Collective Voice is a collaboration of eight of the largest voluntary sector providers of Drug and Alcohol treatment in the country, responsible for more than half of the treatment provided in England.
The population who experience drug or alcohol conditions is diverse. At one extreme are individuals with lengthy work histories and sought after skills, who have stumbled into addiction as a consequence of unexpected crises in their lives. At the other are a significant minority who are, characterised by fragile mental health, disrupted childhoods, lengthy criminal records, limited experience of the formal economy, unstable accommodation, inadequate social skills, little or no family support, and declining physical health.
The likelihood of achieving sustained recovery including employment for either end of this continuum is starkly different. Not everyone with high levels of social capital will sustain recovery and employment, but many will. Not everyone from the most challenging cohort will fail to escape, but the prognosis for most is poor.
Of the 200,000 individuals in drug treatment, 160,000 have a history of heroin, or heroin and crack use. The typical heroin user is now aged between 35 and 50, their addiction began 20 or 30 years ago, and they will experience a number of the complex overlapping problems described above. One of the consequences of this is that their treatment careers will be lengthy, often many years, interspersed with periods of drop-out following relapse, custodial sentences, and false dawns of short lived treatment “success”.
A proportion of the alcohol treatment population will have similar experiences but for many, particularly those with high levels of social capital, alcohol treatment will be over a much shorter timeframe, with greater likelihood of success. Treatment for cannabis dependency, powder cocaine and NPS will follow a similar pattern to alcohol, although a significant minority of the cannabis using population will also have mental health problems which inhibit recovery.
The current system does not deliver well for the majority of this population. The work programme is ineffective for individuals with multiple needs as it is not in providers’ commercial interests to engage with them in a meaningful way. Despite isolated examples of excellence, ETE services provided by drug treatment providers struggle to sustain productive relationships with both JCP and Work Programme providers. Some providers have detected a de-prioritisation of drug and alcohol issues within JCP and DWP following the Work Programme’s implementation.
Drug addiction tends to dazzle JCP and WP staff, blinding them to the other problems in service users’ lives, particularly mental health, which tends to be ignored despite being at least as big a barrier to employability as their drug or alcohol use. This compounds the lack of trust many service users have in JCP staff and inhibits full disclosure.
The lifestyle and behaviour of those experiencing multiple problems, and the reluctance of many in the NHS to engage with a population they experience as “challenging”, results in their health needs being consistently underserved. In particular, they are often excluded from mental health services. Of those in treatment, 70% have mental health problems but only 20% will be receiving help. Physical health will also be poor as a consequence of exclusion from GP services, smoking, poor diet, poverty and homelessness .This is exacerbated by the population ageing as the cohort who began using in the 1980s and 90s move into middle age. This leaves them increasingly vulnerable to overdose, evidenced by recent increases in drug related deaths, and the long term consequences of their overlapping problems.
Drug and Alcohol Treatment
The government set out a clear ambition in the 2010 Drug Strategy to maximise service users’ opportunities to recover from addiction.
Drug and alcohol services currently provide huge benefit to society in terms of reduced public health risk, significantly reduced crime, improvements in the health of service users, and improving rates of recovery, judged by the National Audit office to yield £2.50 worth of benefit to the taxpayer for every £1 invested. However, services have not always prioritised improving employability as part of their routine engagement with service users. In the past, services have too often allowed legitimate concerns about service users’ capacity to sustain employment, and the risk this would pose to hard-won stability, to drift into collusion with a life on benefits supplemented by income from the informal economy.
There is as yet no systematic review of employment-based interventions with this population that could form the basis of a “what works” methodology. Successful completion of treatment in itself only results in a small increase in employability. The work programme is only successful with 8% of individuals with mental health or behavioural difficulties. ETE schemes offer a range of different models with varying levels of success. Outcomes from some are encouraging but it is difficult to identify a compelling model for national implementation, in part because outcomes are more determined by who participates and the characteristics of the local labour market than they are by the content of the intervention. This is not unique to this population; the Criminal Justice System has experienced very similar challenges, and lack of success over the last 40 years.
The Royal Colleges and NHS providers are united in believing mandation to be ethically unacceptable and in breach of the NHS Constitution. Collective Voice is unaware of compelling evidence from other jurisdictions that this approach will actually deliver the outcomes sought, which appeared to be DWP’s view in 2010.
However, treatment ordered by courts for drug misusing offenders has been able to navigate these challenges. Over the past 15 years, it has provided routes out of addiction and offending and withstood initial resistance from clinicians to become an established part of the treatment system. The key to this has been to create incentives to participate in the system rather than sanctions for non-cooperation. Offenders are willing to disclose drug misuse because court mandated treatment usually constitutes a lesser punishment than would be imposed on a non drug using offender for the same offence. Similarly, easing of compliance and sanction regimes following disclosure to facilitate treatment uptake offers a painless and ethically acceptable way to promote disclosure and maximise treatment access among the treatment resistant population claiming benefits.
Over one million people live in families affected by addiction and over half the adults who are receiving drug and alcohol treatment live in households with dependent children. The parenting experienced by these children will vary dependent on the stability of the adults involved over time. Many drug misusing parents and non drug misusing partners provide well for their children. Others provide variable care. Employment has the potential to promote and sustain recovery and as such can represent a significant improvement in children’s life chances. However, work also presents risks of destabilisation, which may impact negatively on children and other family members. This does not argue against engagement in the workforce but reinforces the need for appropriate support to be in place to manage risks of relapse and its consequences.
Employers are reluctant to employ current or ex-drug users and are also reluctant to employ ex-offenders. Those with a good work history and/or marketable skills may be able to overcome this, particularly if they live in areas with a strong economy and skill shortages. However, many of this population struggle to maintain a work routine, have poor self-discipline and few skills. In the current labour market, particularly in the north of England where the greatest concentration of heroin users lives, they are unlikely to be able to compete for scarce jobs.
The projected increase in the minimum wage may further inhibit employers from recruiting those furthest from employment. Ultimately, unless employment is subsidised employers cannot be expected to pay individuals more than their labour is worth to their business.
The employers who currently demonstrate commendable commitment to social responsibility by providing employment for this segment of the treatment population emphasise the significant additional costs of providing supportive working environments to nurture vulnerable people. Without this level of support failure is very likely. This not only means a return to welfare dependency but also risks destabilising progress in treatment and may result in relapse and a return to previous patterns of chaotic use accompanied by prolific offending.
This would suggest that simplistic calculations assuming that routes to employment will yield significant savings may be flawed. The costs of supporting such a vulnerable population in employment, for years in some cases, needs to be offset against any projected savings.
Addiction: Cause or Consequence
There is a powerful cultural assumption that addiction is the unique or primary cause of dysfunctional behaviour. Policy makers assume is that if addiction is associated with, for example, offending, poverty, worklessness and mental health problems then it must be the cause of these.
In reality, for most heroin users the other problems that cluster around their addiction were part of their lives even before they became drug users, and certainly before they became addicted. Low levels of social economic and personal capital is one of the reasons why people are more prepared to engage in risky behaviour with short term rewards and long term negative consequences, “when you’ve got nothing, you’ve got nothing to lose”. It also means you have less support and less reason to change behaviour once addiction takes hold and a more difficult recovery journey because of the multiple barriers you face. Conversely, those with high levels of social capital have personal, economic and social supports to prevent their use spiralling out of control and easier routes out if it does. Crucially, they also have real prospects of sustaining a fulfilling life to sustain them in overcoming the challenges faced by anyone in recovery.
This review is an opportunity to overcome the policy inertia which has undermined efforts to improve the employability of excluded groups for many years. This is an opportunity Collective Voice is keen to support in any way we can.