How Was It For You - A Drug Policy Review of the Year (Part Two)
Friday/04/Jan 2008 Filed in:
Publications and
News
In
JULY the Government published
the long awaited Drug Strategy Consultation
homeoffice.gov.uk…drugs-our-community-consultation?view=Binary
This was a somewhat surprising document. Rather than containing a series of proposals about which government sought our views, it was more of a brochure. Presenting the past ten years somewhat idiosyncratically, only the good news appears in the key facts and figures sections. The targets that haven't been met are not discussed. The evidence base for the use of the proxy indicators is not analysed in the light of new evidence. Its a very positive, very glossy, and ultimately unsatisfying document.
Also in July the NTA published two pieces of guidance. The first is The Guide to Needs Assessment for Adult Drug Treatment which if somewhat prescriptive and frankly unlikely to win any awards for plain English should prove a useful starting point for local discussions about need. Most useful are the sections on using mainstream data to investigate unmet need. The second publication is the Guide to Good Practice in Care Planning. Based on the results of the Joint Improvement Reviews lead by the Healthcare Commission with the NTA this report one of the interesting observations of this report was the very positive correlation between a "healthy DAT partnership" and good practice in care planning. When you think about it though, an area that brings open and honest dialogue, a genuine focus on local need, system wide opportunities for engagement is also likely to be one where services operate more effectively. Good communication by and with commissioners should lead to good communication with service users.
nta.nhs.uk…nta_needs_assessment_guidance.pdf
nta.nhs.uk…nta_good_practice_in_care_planning_gpcp1.pdf
In July the NTA also published the draft of the tier 4 commissioning guidance for consultation. I've been unable to find the finalised copy or a publication date for it, however the draft might still be useful for people exploring cluster and regional commissioning options.
nta.nhs.uk…improving_tier_4_quality_and_provision_consultation_draft.pdf
The Joseph Rowntree Foundation published a fascinating report through their housing committee into the impact of enforcement on street users. Among the reports conclusions was that reducing the visibility of street activity (ie rough sleeping, street drinking/drug use) through enforcement had no discernible benefits for street users. The authors said:
"The impacts are potentially very negative for some street users, such as diversion into more dangerous activities or spaces and the possibility of lengthy prison sentences. Enforcement is therefore a high-risk strategy, only to be used as a last resort, and never with very vulnerable street users such as those with severe mental health problems."
Read the report here: The impact of enforcement on street users in England
On July 15th, the Drug Education Forum published the findings of their survey of DATs. Key issues that came up were about reductions in funding, the reliability or otherwise of the Healthy Schools Framework as a performance management tool for drug education and the general disappointment about the lack of central leadership. drugeducationforum…DAAT%20Survey%20Report%202007.pdf
The Conservative party published their Breakthrough Britain paper on Addictions in July. Despite a few flashes of sharp and pragmatic policy analysis this report largely consists of ill-informed commentary based on anecdotal evidence and a hatred of harm reduction - which is a real shame given that the Conservatives remain the only Government to have ever significantly invested in harm reduction.You can read it here centreforsocialjustice.org.uk…addictions.pdf . Or for a similar experience you could just rub some tin foil over your fillings.
Also in July, NICE (The National Institute for Health and Clinical Excellenece) published its guidelines on the use of psycho-social interventions with drug users. Universally lauded, the publication cut down a number of myths around interventions like cognitive behavioural therapy and motivational interviewing, identifying the appropriate intervention for the appropriate circumstance. The guidance also looked at new ideas like contingency management which would become big news later in the year. Highly recommended reading. Alongside this they also published guidance on opiate detoxification, again extremely useful guidance from a body with a broad role to improve practice in every area of Healthcare in the UK.
CG51 Drug misuse: psychosocial interventions: NICE guideline
CG52 Drug misuse: opioid detoxification: NICE guideline
Many of us felt hopeful that AUGUST was going to be a quiet month. Time to get through the consultation and make a meaningful response. However the roller coaster was not about to stop and right at the begining of the month the NTA announced we were heading for a "new era for young people's substance misuse treatment".
31/07/07 New era for young people's substance misuse treatment
Calling for a better co-ordinated response to meet the need for clinical treatment of young people with substance misuse issues the NTA also opened a consultation on Young People's Commissioning Guidance. Surprisingly the consultation was to end on the 20th August - giving people just 14 days, right in the middle of the summer holiday period to respond to a critical new piece of guidance. Following protests from people in the field, the consultation period was extended to 11th September. The abbreviated timetable for consultation was no doubt in part at least due to the fact that the NTA and DCSF had publicly committed in the memorandum of agreement they published in May to issue a suite of guidance for young people's services in September/October
nta.nhs.uk…MoU_joint_letter_stakeholders_250607.pdf
If you have a copy of the full finalised guidance I'd be really interested in seeing it as it doesn't seem to be available anywhere. However, maybe events have overtaken us - as the NTA are now requiring all DATs to complete a Young People's Treatment Plan and a Young People's Needs Assessment covering treatment only and relating to the top sliced portion of the Pooled Treatment Budget. Other young people's work is covered through monitoring at Government Office or through the Children's Trust structures.
Also in August, Transform Drug Policy Foundation released "Tools for the Debate". This is essentially a guide to how to argue for drug policy reform - what arguments to use, what to say to whom about what, when. No strangers to hubris ("There’s a place for modesty, but it’s not here – we really do know what we are talking about"), Transform claimed that
" ... the ideas in this book have the power to bring about truly transformational change across the world. It shows, for the first time, how to conceptualise and articulate the arguments for reform in such a way that they are unassailable... "
In his review for DrugScope magazine, Peter McDermott said:
"Harm reduction, originally, was about challenging the shibboleths and unexamined truisms that the abstentionists and anti-prohibitionists held dear. However, we’ve started to develop a whole raft of similarly magical principles ourselves, and will often don the blinkers in precisely the same way as the previous generation .... I do believe that it’s possible to bring both sides of this discussion together, to examine the principles that are reliable and well supported by the data, and jettison those that are simply articles of faith. I also believe that further progress is unlikely on these issues without doing that. Disappointingly, this book promises steps in that direction, but completely fails to deliver. No thumbs up"
Make your own mind up at:
tdpf.org.uk…Tools_For_The%20Debate.pdf
Later on in the month, the NTA published the findings of its 2006 user satisfaction survey. With a return of 8,765 questionnaires out of the 72,000 sent out, the survey showed that the majority of the clients who responded were highly satisfied with the treatment they were receiving.
You can read the report at
http://www.nta.nhs.uk/publications/documents/nta_2006_survey_of_user_satisfaction_in_england.pdf
Published alongside this piece of work, its sister publication Survey of User Satisfaction in Pharmacy Needle Exchanges is far more interesting. The reference to pharmacy needle exchange in the title is slightly misleading as this report actually looks at the types of harm reduction information available to drug users in a number of different environments - including within mainstream drug treatment. The work took place as part of the 2006 survey of individuals accessed via treatment services with an additional smaller sample coming from a specific survey of people who were using pharmacy exchanges. Its a really interesting piece of work and tells us that while some harm reduction work is going on for some people in some areas -
".. that the harm reduction needs of substantial percentages of respondents were not being addressed by the treatment system; substantial percentages of respondents reported that this advice or these interventions were relevant to them, but that they had not received them."
When I was first working in the drugs field, I was a street based outreach worker attached to a clinical drugs team in North Liverpool. At the peak of our work, myself and my colleague were distributing in the region of 6000 works a week - a number of them to people who were already in treatment. In addition to our work, the CDT itself had a popular needle exchange that clients of the service and others accessed. There were occasional debates among staff at the drug team about the appropriateness of people who were scripted getting works, but this being the early 90's and Liverpool, we were all pretty clear that harm reduction was about preventing or reducing whatever harm you could. If a script stopped someone scoring for 5 out of seven days, but then at the weekend they had a dig then while that wasn't ideal, at least it meant that they were only injecting two days a week rather than seven. Move on ten years to the early part of this century and I'm working in London. To my amazement it feels like we've gone back to the dark ages - clinical drug treatment services that won't do needle exchange, commissioners who believe siting a clinic in the vicinity of a pharmacy that delivers needle exchange is "asking for trouble" and outreach services working in areas where stimulant injecting is endemic limiting their clients to ten 1ml monoject needles a visit.
As this NTA research shows us people who are in treatment will still inject. This does not mean treatment is having no impact. Most people who are in treatment report far lower rates of use and of injecting than those who are not. However much we work to discourage illict drug use and injecting we also have a moral responsibility to make sure that people who do inject do so as safely as possible. As the researchers conclude
"... needle exchange facilities and harm reduction support must be available and signposted to all drug users, regardless of treatment status or opioid substitution treatment. Indeed, more than 35 per cent of respondents on a prescribing regime were injecting at the time of the survey."
http://www.nta.nhs.uk/publications/documents/nta_2006_harm_reduction_survey.pdf
In SEPTEMBER the latest figures for smoking, drug and alcohol consumption among young people were published by The Information centre for Health and Social Care. The report which was based on a survey of 8200 11 to 15 year olds in England showed that while overall substance use among young people was falling, over half of all the children surveyed had used alcohol at some point and that 21% of them had drunk in the previous week. In the same week DrugScope published their annual Street Drug Trends Survey. This indicated an increasing market for cocaine and concluded
”The current drug strategy has focussed on breaking the links between drugs and crime with most resources dedicated to tackling the use of heroin and crack cocaine. We are concerned that we may be entering a new era of ‘problem drug use’ relating less to heroin and crack and more to the misuse of alcohol, cocaine, cannabis and ecstasy. The longer term public health impacts of such a shift should not be underestimated.”
Read it here: DrugScope | Press releases | DrugScope street drug trends survey 2007: two tier cocaine market puts drug in reach of more users
On 28th September, the NTA published a major and important piece of work - the updated "Drug Misuse and Dependence: Guidelines on Clinical Management" - or the "Orange Book" as its affectionately known. Critically it is UK wide. This means that people across all the devolved administrations should be assured of the same standards of clinical practice. One of the big focusses of these new guidelines is the emphasis on indiviodualised treatment and interventions in the context of a jointly owned care plan. You can read it here
http://www.nta.nhs.uk/areas/clinical_guidance/clinical_guidelines/docs/clinical_guidelines_2007.pdf
In
OCTOBER the Government Drug
Strategy Consultation closed.
Among the published responses the one that is based on the largest independent consultation is DrugScope's, available at www.drugscope.org. uk - or for your convenience in the reports and articles section of this website - homepage.mac…response.pdf - as I was commissioned by DrugScope to undertake this work and the consultation that informed it. (The consultation took us all over the country and was great fun- hello to all who came along)
A number of other responses were published - among them
The Drug Education Forum
drugeducationforum…drug%20strategy%20consultation%20response.pdf
UKDPC
ukdpc.org.uk…Drug_Strategy_Consultation_Response.pdf
The RSA
rsadrugscommission
The Drug Health Alliance
DHA ::Submission to Drugs: Our Community, Your Say (Drug Strategy Consultation Paper 2007)
The Children's Society
http://www.childrenssociety.org.uk/NR/rdonlyres/10F1BAA3-EFA2-463F-B818-6BD78B762897/0/0710DrugsOurCommunityYourSay_final.pdf
The Association of Directors of Social Services
http://www.adss.org.uk/publications/consresp/2007/drugs.pdf
Also in October we had the Comprehensive Spending Review (CSR) . The CSR is the process through which the treasury and the government departments agree how much money will go to what areas of work and what will be done with it. The outcomes of the process are called Public Service Agreements (PSAs). What usually happens is that the departments have agreed what they're going to do by formulating strategy in response to the needs they identify, and then they bid to and lobby and bully and cajole the treasury for resources and after a big bun fight it all gets agreed. The strategy is pretty critical to this process - to agree what you're going to measure and what will be paid for you kind of need to know what you're going to do. Drugs was at a disadvantage in the Comprehensive Spending Review because we had no new strategy. That's why PSA 25 - the drug and alcohol PSA only has new outcomes for alcohol and why all the drugs outcomes are the same ones that have been so widely criticised for the past 5 years. (The New Policy Institute commented in the recent report looking at the PSAs that they were "broadly the same outcomes, but less specific"). The next step was for the LGA (Local Government Association) and DCLG to sit down with the PSAs and decide what the targets should be for local partnerships - the local authorities and PCTs etc who agree local strategy. More of this later on in the year ...
If you want to find out more about the Comprehensive Spending Review and the PSA process have a look at The Guide to the Local Implementaion of the National Drug Strategy that I rote for the LDPF - also published in October last year.
Sara McGrail - National Guide
If you'd like to know more about the PSAs for drugs themselves here they are - see if you can spot how the outcomes from the National Alcohol Strategy have got themselves in here - and the real difference between them and the treatment measures. Its worth noting though that the blurb around the PSA says all of this can be amended once the National Drug Strategy has been written. Fingers crossed eh?
2007 Pre Budget Report and Comprehensive Spending Review: Public service agreements index
(you're looking for the section on Stronger Communities and a Better Quality of Life. PSA 25 is the main one, but PSA 14 covers the young people's issues and PSA 23 much of the Criminal Justice stuff))
On the 18th October, Paul Hayes, CEO of the NTA appeared on the Today Programme in a less than positive interview about the effectiveness of the current approach to treatment. You can listen to the interview here (you need REALAUDIO installed)
bbc.co.uk…today4_addicts_20071018.ram
or read about the story here
BBC NEWS | UK | Drug 'rewards' given to addicts
The report focussed on two issues. Firstly the use of contingency management techniques - with prescription drugs including antidepressants and diamorphine being reported in an published NTA document being used as "rewards" for clean urines. The second half of the interview looked at the purpose and value for money of treatment - and the statistics that back up claims of effectiveness. It was a media disaster for the NTA - truly car crash radio. Some in the field felt it was a well placed intervention by the BBC. Others felt - as one contributor to a newsgroup stated - that "to attack the NTA is to attack the very basis of drug treatment". I guess I'm not particularly sympathetic to either position - but I do think its a shame that the only opportunity we get to begin a proper critique of our work and political and social attitudes towards drug users ends up in another tired debate about abstinence versus maintenance. However if all the interview did was engage the new Minister for Public Health in discussions about Drug policy then it was probably worth the temporary embarrassment for the NTA who issued this response early in November (although the letter is no longer on the NTA news pages, its reproduced below thanks to those nice people at DrugScope
DrugScope | Current News Pages | NTA response to BBC story on treatment efficacy
In NOVEMBER the New Performance Management Framework for Local Partnership was published. Unsurprisingly given the PSAs (of which this is the local expression) the substance msiuse indicators contained in this document were poor. You can read more about this in my Blog Drugs Forgotten in New Government Agreement
Unit costing of treatment was a big issue throughout 2007 - with some of the rationale for placement of cuts in the Pooled Treatment Budget early in the year being based on findings from initial work on unit cost. In November the NTA announced they were delaying the new unit cost process (based on a web based system rather than a spreadsheet) until the end of the financial year 2007/8. This may prove problematic for the NTA and Department of Health should they decide to use units costs as the basis of distribution of the Pooled Treatment Budget this year as is widely rumoured. Watch this blog for more information about this.
The Health Protection Agency (HPA) published and update to their report "Shooting Up" - a look at blood borne viruses among injecting drug users. In it they noted the increased risk of infection related to homelessness, the increased prevalence of groin injecting and also the injection rather than smoking of crack cocaine. Unsuprisingly they reported that around 1 in 75 injecting drug users have HIV and that 50% have hepatitis C. On the brighter side, they noted an increase in the numbers of at risk drug users reporting Hep B immunisation.
HPA | Injecting Drug Users
Also in November the NTA sponsored a copy of Network - the Substance Misuse Management in General Practice (SMMGP) newsletter - looking at the new clinical guidelines. This is a really useful read for those who are looking for an overview of the publication's reception in general practice. You can read it online here:
SMMGP - Library - Newsletters - Network 20 (Nov 2007)
Those nice people from NICE were at it again in November, this time publishing their guidance on school based interventions around alcohol. The publication looks at best practice in interventions that aim to encourage children not to drink, delay the age at which young people start drinking and reduce the harm it can cause among those young people who do drink.
School based interventions on alcohol
In November the Home Office published 8 new reports on Drug POlicy and interventions. In some ways it would have been really useful to have had this information before the strategy consultation. You can read more about this in my blog
8 Home Office Reports Partially Digested
In DECEMBER both the Government's own Statistics Commission and the Advisory Council on the Misuse of Drugs (ACMD) were publicly highly critical of the Drug Strategy Consultation. The ACMD introduced their response to the consultation thus:
"... The ACMD found the consultation paper self-congratulatory and generally disappointing. It is of concern that the evidence presented, and the interpretation given, are not based on rigorous scrutiny. It is not acknowledged that in many cases the information is uncertain and sometimes of poor quality. "
drugs.homeoffice.gov.uk…acmdconsultresponse.pdf?view=Binary
and the Statistics Commission in a letter to Sir David Normington, Permanent Secretary at the Home Office said:
"Where a target has been met or exceeded, as is the case with the target to increase participation of problem drug users in treatment programmes, this is highlighted: "the Government has achieved huge success in delivering treatment services - a national treatment target [... ] has been exceeded two years early". But where a target has been missed, or seems likely to be missed, the relevant information is presented in a low key way, without acknowledging that a target exists.... "
statscom.org.uk…Letter0407.pdf
The issue was reported in the Guardian as follows:
http://www.guardian.co.uk/society/2007/dec/24/drugsandalcohol.publicservices
The Government announced their replacement for the Neighbourhood Renewal Fund. Its called the Working Neighbourhoods Fund - and you can find out more here Work Works
December for DATs usually means treatment planning time, but this year it proved rather tricky. Not only is the guidance "currently being refreshed and unavailable" according to the NTA website, but also no one has been told how much money they're getting. Despite this, DATs are required to submit a summary document and financial forecast by the middle of January. Presumably its going to Mr F. Kafka, C/O The Castle.
Finally December brought us the annual review by the New Policy Institute of the extent of Poverty and Exclusion in the UK. This report tells us that overall poverty levels in 2005/06 were the same as in 2002/03 and that
Monitoring poverty and social exclusion 2007
Its a really interesting report, but reading it, you know, you start to wonder. Yes we can talk about drugs and drug treatment and the rights and wrong of methadone, needle exchange, the NTA, the Home Office, Neil McKeganey and Mike Trace and the Swedes and all until the sun burns out and the world closes down, but actually its probably not going to make a lot of difference to most of our service users if we continue to make so little progress on tackling poverty and exclusion.
We know that drug use impacts on poor people and their communities far more problematically than it does on the better off or wealthy. We know that work and decent housing and aspiration are the things that make a real difference to someone's chances of recovery. Yet we also know that people who are affected by drug use find it harder to access work and decent housing, and find it harder to get the kinds of interventions from mainstream services that foster aspiration and make people feel they can achieve.
So I reckon our New Years Resolution across the field for 2008 should be to help our colleagues in those services tackling poverty and exclusion understand that drug use is not a reason to exclude people from employment or housing but an imperative to INCLUDE them - even if that means with a greater investment in support and staffing. Because only by tackling poverty and social and economic exclusion will we ever really get to the root of what makes substance use such a problem for us still.
Happy New Year.
homeoffice.gov.uk…drugs-our-community-consultation?view=Binary
This was a somewhat surprising document. Rather than containing a series of proposals about which government sought our views, it was more of a brochure. Presenting the past ten years somewhat idiosyncratically, only the good news appears in the key facts and figures sections. The targets that haven't been met are not discussed. The evidence base for the use of the proxy indicators is not analysed in the light of new evidence. Its a very positive, very glossy, and ultimately unsatisfying document.
Also in July the NTA published two pieces of guidance. The first is The Guide to Needs Assessment for Adult Drug Treatment which if somewhat prescriptive and frankly unlikely to win any awards for plain English should prove a useful starting point for local discussions about need. Most useful are the sections on using mainstream data to investigate unmet need. The second publication is the Guide to Good Practice in Care Planning. Based on the results of the Joint Improvement Reviews lead by the Healthcare Commission with the NTA this report one of the interesting observations of this report was the very positive correlation between a "healthy DAT partnership" and good practice in care planning. When you think about it though, an area that brings open and honest dialogue, a genuine focus on local need, system wide opportunities for engagement is also likely to be one where services operate more effectively. Good communication by and with commissioners should lead to good communication with service users.
nta.nhs.uk…nta_needs_assessment_guidance.pdf
nta.nhs.uk…nta_good_practice_in_care_planning_gpcp1.pdf
In July the NTA also published the draft of the tier 4 commissioning guidance for consultation. I've been unable to find the finalised copy or a publication date for it, however the draft might still be useful for people exploring cluster and regional commissioning options.
nta.nhs.uk…improving_tier_4_quality_and_provision_consultation_draft.pdf
The Joseph Rowntree Foundation published a fascinating report through their housing committee into the impact of enforcement on street users. Among the reports conclusions was that reducing the visibility of street activity (ie rough sleeping, street drinking/drug use) through enforcement had no discernible benefits for street users. The authors said:
"The impacts are potentially very negative for some street users, such as diversion into more dangerous activities or spaces and the possibility of lengthy prison sentences. Enforcement is therefore a high-risk strategy, only to be used as a last resort, and never with very vulnerable street users such as those with severe mental health problems."
Read the report here: The impact of enforcement on street users in England
On July 15th, the Drug Education Forum published the findings of their survey of DATs. Key issues that came up were about reductions in funding, the reliability or otherwise of the Healthy Schools Framework as a performance management tool for drug education and the general disappointment about the lack of central leadership. drugeducationforum…DAAT%20Survey%20Report%202007.pdf
The Conservative party published their Breakthrough Britain paper on Addictions in July. Despite a few flashes of sharp and pragmatic policy analysis this report largely consists of ill-informed commentary based on anecdotal evidence and a hatred of harm reduction - which is a real shame given that the Conservatives remain the only Government to have ever significantly invested in harm reduction.You can read it here centreforsocialjustice.org.uk…addictions.pdf . Or for a similar experience you could just rub some tin foil over your fillings.
Also in July, NICE (The National Institute for Health and Clinical Excellenece) published its guidelines on the use of psycho-social interventions with drug users. Universally lauded, the publication cut down a number of myths around interventions like cognitive behavioural therapy and motivational interviewing, identifying the appropriate intervention for the appropriate circumstance. The guidance also looked at new ideas like contingency management which would become big news later in the year. Highly recommended reading. Alongside this they also published guidance on opiate detoxification, again extremely useful guidance from a body with a broad role to improve practice in every area of Healthcare in the UK.
CG51 Drug misuse: psychosocial interventions: NICE guideline
CG52 Drug misuse: opioid detoxification: NICE guideline
Many of us felt hopeful that AUGUST was going to be a quiet month. Time to get through the consultation and make a meaningful response. However the roller coaster was not about to stop and right at the begining of the month the NTA announced we were heading for a "new era for young people's substance misuse treatment".
31/07/07 New era for young people's substance misuse treatment
Calling for a better co-ordinated response to meet the need for clinical treatment of young people with substance misuse issues the NTA also opened a consultation on Young People's Commissioning Guidance. Surprisingly the consultation was to end on the 20th August - giving people just 14 days, right in the middle of the summer holiday period to respond to a critical new piece of guidance. Following protests from people in the field, the consultation period was extended to 11th September. The abbreviated timetable for consultation was no doubt in part at least due to the fact that the NTA and DCSF had publicly committed in the memorandum of agreement they published in May to issue a suite of guidance for young people's services in September/October
nta.nhs.uk…MoU_joint_letter_stakeholders_250607.pdf
If you have a copy of the full finalised guidance I'd be really interested in seeing it as it doesn't seem to be available anywhere. However, maybe events have overtaken us - as the NTA are now requiring all DATs to complete a Young People's Treatment Plan and a Young People's Needs Assessment covering treatment only and relating to the top sliced portion of the Pooled Treatment Budget. Other young people's work is covered through monitoring at Government Office or through the Children's Trust structures.
Also in August, Transform Drug Policy Foundation released "Tools for the Debate". This is essentially a guide to how to argue for drug policy reform - what arguments to use, what to say to whom about what, when. No strangers to hubris ("There’s a place for modesty, but it’s not here – we really do know what we are talking about"), Transform claimed that
" ... the ideas in this book have the power to bring about truly transformational change across the world. It shows, for the first time, how to conceptualise and articulate the arguments for reform in such a way that they are unassailable... "
In his review for DrugScope magazine, Peter McDermott said:
"Harm reduction, originally, was about challenging the shibboleths and unexamined truisms that the abstentionists and anti-prohibitionists held dear. However, we’ve started to develop a whole raft of similarly magical principles ourselves, and will often don the blinkers in precisely the same way as the previous generation .... I do believe that it’s possible to bring both sides of this discussion together, to examine the principles that are reliable and well supported by the data, and jettison those that are simply articles of faith. I also believe that further progress is unlikely on these issues without doing that. Disappointingly, this book promises steps in that direction, but completely fails to deliver. No thumbs up"
Make your own mind up at:
tdpf.org.uk…Tools_For_The%20Debate.pdf
Later on in the month, the NTA published the findings of its 2006 user satisfaction survey. With a return of 8,765 questionnaires out of the 72,000 sent out, the survey showed that the majority of the clients who responded were highly satisfied with the treatment they were receiving.
You can read the report at
http://www.nta.nhs.uk/publications/documents/nta_2006_survey_of_user_satisfaction_in_england.pdf
Published alongside this piece of work, its sister publication Survey of User Satisfaction in Pharmacy Needle Exchanges is far more interesting. The reference to pharmacy needle exchange in the title is slightly misleading as this report actually looks at the types of harm reduction information available to drug users in a number of different environments - including within mainstream drug treatment. The work took place as part of the 2006 survey of individuals accessed via treatment services with an additional smaller sample coming from a specific survey of people who were using pharmacy exchanges. Its a really interesting piece of work and tells us that while some harm reduction work is going on for some people in some areas -
".. that the harm reduction needs of substantial percentages of respondents were not being addressed by the treatment system; substantial percentages of respondents reported that this advice or these interventions were relevant to them, but that they had not received them."
When I was first working in the drugs field, I was a street based outreach worker attached to a clinical drugs team in North Liverpool. At the peak of our work, myself and my colleague were distributing in the region of 6000 works a week - a number of them to people who were already in treatment. In addition to our work, the CDT itself had a popular needle exchange that clients of the service and others accessed. There were occasional debates among staff at the drug team about the appropriateness of people who were scripted getting works, but this being the early 90's and Liverpool, we were all pretty clear that harm reduction was about preventing or reducing whatever harm you could. If a script stopped someone scoring for 5 out of seven days, but then at the weekend they had a dig then while that wasn't ideal, at least it meant that they were only injecting two days a week rather than seven. Move on ten years to the early part of this century and I'm working in London. To my amazement it feels like we've gone back to the dark ages - clinical drug treatment services that won't do needle exchange, commissioners who believe siting a clinic in the vicinity of a pharmacy that delivers needle exchange is "asking for trouble" and outreach services working in areas where stimulant injecting is endemic limiting their clients to ten 1ml monoject needles a visit.
As this NTA research shows us people who are in treatment will still inject. This does not mean treatment is having no impact. Most people who are in treatment report far lower rates of use and of injecting than those who are not. However much we work to discourage illict drug use and injecting we also have a moral responsibility to make sure that people who do inject do so as safely as possible. As the researchers conclude
"... needle exchange facilities and harm reduction support must be available and signposted to all drug users, regardless of treatment status or opioid substitution treatment. Indeed, more than 35 per cent of respondents on a prescribing regime were injecting at the time of the survey."
http://www.nta.nhs.uk/publications/documents/nta_2006_harm_reduction_survey.pdf
In SEPTEMBER the latest figures for smoking, drug and alcohol consumption among young people were published by The Information centre for Health and Social Care. The report which was based on a survey of 8200 11 to 15 year olds in England showed that while overall substance use among young people was falling, over half of all the children surveyed had used alcohol at some point and that 21% of them had drunk in the previous week. In the same week DrugScope published their annual Street Drug Trends Survey. This indicated an increasing market for cocaine and concluded
”The current drug strategy has focussed on breaking the links between drugs and crime with most resources dedicated to tackling the use of heroin and crack cocaine. We are concerned that we may be entering a new era of ‘problem drug use’ relating less to heroin and crack and more to the misuse of alcohol, cocaine, cannabis and ecstasy. The longer term public health impacts of such a shift should not be underestimated.”
Read it here: DrugScope | Press releases | DrugScope street drug trends survey 2007: two tier cocaine market puts drug in reach of more users
On 28th September, the NTA published a major and important piece of work - the updated "Drug Misuse and Dependence: Guidelines on Clinical Management" - or the "Orange Book" as its affectionately known. Critically it is UK wide. This means that people across all the devolved administrations should be assured of the same standards of clinical practice. One of the big focusses of these new guidelines is the emphasis on indiviodualised treatment and interventions in the context of a jointly owned care plan. You can read it here
http://www.nta.nhs.uk/areas/clinical_guidance/clinical_guidelines/docs/clinical_guidelines_2007.pdf
Among the published responses the one that is based on the largest independent consultation is DrugScope's, available at www.drugscope.org. uk - or for your convenience in the reports and articles section of this website - homepage.mac…response.pdf - as I was commissioned by DrugScope to undertake this work and the consultation that informed it. (The consultation took us all over the country and was great fun- hello to all who came along)
A number of other responses were published - among them
The Drug Education Forum
drugeducationforum…drug%20strategy%20consultation%20response.pdf
UKDPC
ukdpc.org.uk…Drug_Strategy_Consultation_Response.pdf
The RSA
rsadrugscommission
The Drug Health Alliance
DHA ::Submission to Drugs: Our Community, Your Say (Drug Strategy Consultation Paper 2007)
The Children's Society
http://www.childrenssociety.org.uk/NR/rdonlyres/10F1BAA3-EFA2-463F-B818-6BD78B762897/0/0710DrugsOurCommunityYourSay_final.pdf
The Association of Directors of Social Services
http://www.adss.org.uk/publications/consresp/2007/drugs.pdf
Also in October we had the Comprehensive Spending Review (CSR) . The CSR is the process through which the treasury and the government departments agree how much money will go to what areas of work and what will be done with it. The outcomes of the process are called Public Service Agreements (PSAs). What usually happens is that the departments have agreed what they're going to do by formulating strategy in response to the needs they identify, and then they bid to and lobby and bully and cajole the treasury for resources and after a big bun fight it all gets agreed. The strategy is pretty critical to this process - to agree what you're going to measure and what will be paid for you kind of need to know what you're going to do. Drugs was at a disadvantage in the Comprehensive Spending Review because we had no new strategy. That's why PSA 25 - the drug and alcohol PSA only has new outcomes for alcohol and why all the drugs outcomes are the same ones that have been so widely criticised for the past 5 years. (The New Policy Institute commented in the recent report looking at the PSAs that they were "broadly the same outcomes, but less specific"). The next step was for the LGA (Local Government Association) and DCLG to sit down with the PSAs and decide what the targets should be for local partnerships - the local authorities and PCTs etc who agree local strategy. More of this later on in the year ...
If you want to find out more about the Comprehensive Spending Review and the PSA process have a look at The Guide to the Local Implementaion of the National Drug Strategy that I rote for the LDPF - also published in October last year.
Sara McGrail - National Guide
If you'd like to know more about the PSAs for drugs themselves here they are - see if you can spot how the outcomes from the National Alcohol Strategy have got themselves in here - and the real difference between them and the treatment measures. Its worth noting though that the blurb around the PSA says all of this can be amended once the National Drug Strategy has been written. Fingers crossed eh?
2007 Pre Budget Report and Comprehensive Spending Review: Public service agreements index
(you're looking for the section on Stronger Communities and a Better Quality of Life. PSA 25 is the main one, but PSA 14 covers the young people's issues and PSA 23 much of the Criminal Justice stuff))
On the 18th October, Paul Hayes, CEO of the NTA appeared on the Today Programme in a less than positive interview about the effectiveness of the current approach to treatment. You can listen to the interview here (you need REALAUDIO installed)
bbc.co.uk…today4_addicts_20071018.ram
or read about the story here
BBC NEWS | UK | Drug 'rewards' given to addicts
The report focussed on two issues. Firstly the use of contingency management techniques - with prescription drugs including antidepressants and diamorphine being reported in an published NTA document being used as "rewards" for clean urines. The second half of the interview looked at the purpose and value for money of treatment - and the statistics that back up claims of effectiveness. It was a media disaster for the NTA - truly car crash radio. Some in the field felt it was a well placed intervention by the BBC. Others felt - as one contributor to a newsgroup stated - that "to attack the NTA is to attack the very basis of drug treatment". I guess I'm not particularly sympathetic to either position - but I do think its a shame that the only opportunity we get to begin a proper critique of our work and political and social attitudes towards drug users ends up in another tired debate about abstinence versus maintenance. However if all the interview did was engage the new Minister for Public Health in discussions about Drug policy then it was probably worth the temporary embarrassment for the NTA who issued this response early in November (although the letter is no longer on the NTA news pages, its reproduced below thanks to those nice people at DrugScope
DrugScope | Current News Pages | NTA response to BBC story on treatment efficacy
In NOVEMBER the New Performance Management Framework for Local Partnership was published. Unsurprisingly given the PSAs (of which this is the local expression) the substance msiuse indicators contained in this document were poor. You can read more about this in my Blog Drugs Forgotten in New Government Agreement
Unit costing of treatment was a big issue throughout 2007 - with some of the rationale for placement of cuts in the Pooled Treatment Budget early in the year being based on findings from initial work on unit cost. In November the NTA announced they were delaying the new unit cost process (based on a web based system rather than a spreadsheet) until the end of the financial year 2007/8. This may prove problematic for the NTA and Department of Health should they decide to use units costs as the basis of distribution of the Pooled Treatment Budget this year as is widely rumoured. Watch this blog for more information about this.
The Health Protection Agency (HPA) published and update to their report "Shooting Up" - a look at blood borne viruses among injecting drug users. In it they noted the increased risk of infection related to homelessness, the increased prevalence of groin injecting and also the injection rather than smoking of crack cocaine. Unsuprisingly they reported that around 1 in 75 injecting drug users have HIV and that 50% have hepatitis C. On the brighter side, they noted an increase in the numbers of at risk drug users reporting Hep B immunisation.
HPA | Injecting Drug Users
Also in November the NTA sponsored a copy of Network - the Substance Misuse Management in General Practice (SMMGP) newsletter - looking at the new clinical guidelines. This is a really useful read for those who are looking for an overview of the publication's reception in general practice. You can read it online here:
SMMGP - Library - Newsletters - Network 20 (Nov 2007)
Those nice people from NICE were at it again in November, this time publishing their guidance on school based interventions around alcohol. The publication looks at best practice in interventions that aim to encourage children not to drink, delay the age at which young people start drinking and reduce the harm it can cause among those young people who do drink.
School based interventions on alcohol
In November the Home Office published 8 new reports on Drug POlicy and interventions. In some ways it would have been really useful to have had this information before the strategy consultation. You can read more about this in my blog
8 Home Office Reports Partially Digested
In DECEMBER both the Government's own Statistics Commission and the Advisory Council on the Misuse of Drugs (ACMD) were publicly highly critical of the Drug Strategy Consultation. The ACMD introduced their response to the consultation thus:
"... The ACMD found the consultation paper self-congratulatory and generally disappointing. It is of concern that the evidence presented, and the interpretation given, are not based on rigorous scrutiny. It is not acknowledged that in many cases the information is uncertain and sometimes of poor quality. "
drugs.homeoffice.gov.uk…acmdconsultresponse.pdf?view=Binary
and the Statistics Commission in a letter to Sir David Normington, Permanent Secretary at the Home Office said:
"Where a target has been met or exceeded, as is the case with the target to increase participation of problem drug users in treatment programmes, this is highlighted: "the Government has achieved huge success in delivering treatment services - a national treatment target [... ] has been exceeded two years early". But where a target has been missed, or seems likely to be missed, the relevant information is presented in a low key way, without acknowledging that a target exists.... "
statscom.org.uk…Letter0407.pdf
The issue was reported in the Guardian as follows:
http://www.guardian.co.uk/society/2007/dec/24/drugsandalcohol.publicservices
The Government announced their replacement for the Neighbourhood Renewal Fund. Its called the Working Neighbourhoods Fund - and you can find out more here Work Works
December for DATs usually means treatment planning time, but this year it proved rather tricky. Not only is the guidance "currently being refreshed and unavailable" according to the NTA website, but also no one has been told how much money they're getting. Despite this, DATs are required to submit a summary document and financial forecast by the middle of January. Presumably its going to Mr F. Kafka, C/O The Castle.
Finally December brought us the annual review by the New Policy Institute of the extent of Poverty and Exclusion in the UK. This report tells us that overall poverty levels in 2005/06 were the same as in 2002/03 and that
- Child poverty in 2005/06 was still 500,000 higher than the target set for 2004/05.
- The unemployment rate among the under-25s has been rising since 2004, while the rate for those over 25 stopped falling in 2005.
- Half the children in poverty are still in working families.
- The number of children in working families where earnings and Child Benefit are insufficient for them to escape poverty goes on rising.
- Overall earnings inequalities are widening.
- At least a quarter of 19-year-olds lack minimum levels of qualification.
- Not all those who want to work can do so, and disability rather than lone parenthood is the factor most likely to leave a person workless.
- The value of social security benefits for working-age adults falls ever further behind earnings.
Monitoring poverty and social exclusion 2007
Its a really interesting report, but reading it, you know, you start to wonder. Yes we can talk about drugs and drug treatment and the rights and wrong of methadone, needle exchange, the NTA, the Home Office, Neil McKeganey and Mike Trace and the Swedes and all until the sun burns out and the world closes down, but actually its probably not going to make a lot of difference to most of our service users if we continue to make so little progress on tackling poverty and exclusion.
We know that drug use impacts on poor people and their communities far more problematically than it does on the better off or wealthy. We know that work and decent housing and aspiration are the things that make a real difference to someone's chances of recovery. Yet we also know that people who are affected by drug use find it harder to access work and decent housing, and find it harder to get the kinds of interventions from mainstream services that foster aspiration and make people feel they can achieve.
So I reckon our New Years Resolution across the field for 2008 should be to help our colleagues in those services tackling poverty and exclusion understand that drug use is not a reason to exclude people from employment or housing but an imperative to INCLUDE them - even if that means with a greater investment in support and staffing. Because only by tackling poverty and social and economic exclusion will we ever really get to the root of what makes substance use such a problem for us still.
Happy New Year.