Over the past year I've been working with the London Drug Policy Forum on a project supported by the Home Office that looks at the current and future roles of local partnerships - and how the resources they currently receive or are able to generate locally are used to deliver the outcomes of the 2008 National Drugs Strategy. 

In particular the report explores

• The robustness of local partnerships
• To what extent they are able to deliver the new national drug strategy 
• What Government needs to do to help partnerships work better
• How local Scrutiny can work as part of performance management and support implementation

Both Sides of the Coin is a project I'm working on with the LDPF with support from ADFAM and KCA. We want to explore the relationship between financial exclusion, poverty and substance use and find ways of tackling it. Our focus is not just on developing responses within the drugs field but also to support and encourage mainstream agencies to work more effectively with drugs users, their families and communities.

Inclusion and Exclusion
Financial inclusion is an increasingly important issue for the Government, with the Treasury and the Financial Inclusion Task Force leading on a range of actions to enable more people to become financially included and provide greater security for themselves and their families. Financial exclusion is not the same thing as poverty, but it is often a significant factor in poverty. Transact - the National Forum for Financial Inclusion - define it as follows:

Transact use the following definition to define financial inclusion: "A state in which all people have access to appropriate, desired financial products and services in order to manage their money effectively. It is achieved by financial literacy and financial capability on the part of the consumer, and access on the part of financial product, services and advice suppliers"

Those who are unable to access basic financial services pay more to manage their money, find it difficult to plan for the future and are more likely to become over-indebted. In the words of the Treasury Select Committee: "Too many people cannot gain access to appropriate financial products and services at present: they struggle to obtain affordable credit or helpful financial advice and face barriers in opening and operating bank accounts. Financial exclusion blights the lives of many millions of people; it increases the costs they bear for basic services; it makes them vulnerable to illegal or highcost lending; it reinforces social exclusion."
(Transact, IN BRIEF: FINANCIAL EXCLUSION)

The Problem
We know there is a strong correlation between poverty and problematic substance use. People affected by drug use - families, carers, people who use drugs or who are in drug treatment often experience financial exclusion. In the last drug strategy, Government made a commitment to tackling some related issues - for example the cost for Grandparents of looking after children affected by parental substance use. They also have prioritised issues around employment and inclusion, mainstreaming and reintegration. In our preliminary research and discussions we have found that many people who access treatment services or experience problems related to substance use also experience financial exclusion at levels that seriously impact on their quality of life - and recovery.

As part of our development of the Both Sides of the Coin project I met with a group of service users in January at the Birmingham DDN/Alliance conference. For them there was no denying the links between their economic situation and their drug use. One told the story of how on being discharged from rehab he got a grant to help him set up his new life. Unfortunately he had no bank account and no passport so he couldn’t cash the cheque anywhere but at one of those high street “Pay Day Loan” shops that seem to be springing up everywhere. This meant he lost just over 10% of his community care grant. Another woman spoke about how one of the things that had made a huge difference to her was being in her local credit union – it meant that although her income went down when she went into treatment (as it does apparently for a lot of people) she was able to manage her money better and even save a little bit. Other people have spoken to us about real difficulties they have got into with "Doorstep Credit" (take a look at Debt on Our Doortep for more about this) and loan sharks - stories that will be familiar to workers and services users across the drugs field.

Tackling Drugs Means Tackling Multiple Problems
I was recently speaking at an event where I was describing one of the impacts of the recession on drug use. People who currently feel they are managing their drug use might find that use becoming less controllable if some other areas of their life become more pressured. For example, the person who knows they have to moderate their weekend drug use because on Monday they have to be in work might find the weekends “spilling over” into the week if they lose their job. The challenge I asked the people I was talking with to consider is how we could get help and support to these people. The answer came back “Well it depends when they turn up at treatment services”. This seems fairly logical when you think about it. Job one is drug treatment, so people need to come for drug treatment before we can help – right?

Wrong! Our business is to reduce the community, individual and social harms related to drug use and help people achieve better health and a better quality of life. It’s an aim that should cut right across all our work wherever we are in the drugs field. That certainly does mean we need to continue to resource and support treatment services. Ensuring free, equitable access to high quality drug treatment is a critical part of any effective approach to drugs. But does the work begin and end there? I remember sitting in on a meeting with Mike Ashton a year or so ago when he posed the question why do we have to wait until someone hits a crisis point before we intervene?

I think we need to begin to develop ways of supporting people to deal with their drug use before it becomes problematic, to enable people to be aware of and develop tactics to reduce the potential harms of their own use. We also need to explore further what social and economic factors can help prevent use of drugs and alcohol escalating to problematic levels. Work to ensure we invest in measures to protect vulnerable people and communities from the worst impacts of recession may be of equal value to good treatment services in the medium and long term. Within specialist treatment as well, support around issues to do with housing and employment is recognised as important – but support around money, benefits, and debt can make a real difference too.

Both Sides of The Coin
The Both Sides of The Coin project grew out of the second Goodenough Drug Strategy and a series of informal discussions between people working in the field of financial exclusion and people from the drugs field looking at how the multiple problems of financial and social exclusion, worklessness, stigma and poverty might affect people who experience problems with drugs. One of the things we have noticed since we've begun this work is the level of prejudice and exclusion even organisations working in the area of social inclusion display towards drugs users and their families. I cannot count now the number of times we have been told by organisations "Oh no, we don't work with people like that". Alongside this however we have also found that people working in substance use services often know that money and financial inclusion are big problems for their clients but don't feel they can offer any help. What we hope to initially achieve through Both Sides of the Coin is a raised awareness of how the issues of financial exclusion affect people's chances of getting their lives back on track - and how problems related to drug use affect people's ability to sort their finances out.

The Both Sides of the Coin project will report in the early summer making a series of recommendations for both the financial and the drugs sectors about how we can improve the current situation. We also hope to be able to establish a network of individuals and organisations across the field who will help develop the work in the long and medium term too. To help take the project forward, on the 23rd April in the City of London, the LDPF with ADFAM and KCA are running a conference for users, carers, policy makers, professionals, commissioners and communities to look at the impact of money and debt on people affected by drug use – users, family, carers and communities – and how we can work to improve the situation. At the conference we will be trying to scope the problem and its impact - looking at problems of debt and poverty. But the main focus will be on learning about initiatives like credit unions, debt counselling, savings clubs and community finance schemes which we might be able to adapt and use over the coming years to help people get back on their feet.

Both Sides of the Coin is - ironically perhaps - being undertaken on a shoestring and so while we have a limited number of free places sponsored by our partner organisations - KCA and ADFAM - we are having to charge a small fee (£75.00) to delegates to cover costs. If you’re interested in being part of this new initiative, you can find out more by downloading the PDF here.

A shorter version of this article appeared in this weeks Drink and Drug News

It might as well be for Mr. Kite as it's hard to see exactly who the Welfare Reform Bill's sections on drugs are meant to benefit. Certainly not drug users - for while there is potential for it to improve the lot of some, the design, implementation and administration of the initiative looks likely to be mechanistic and dehumanising. Not the wider community as the likelihood is that the main thrust of the proposals - that is benefit sanctions - can only lead to greater hardship, problematic drug use and crime for the most vulnerable communities. Nor can it, in anything but the short term thrill of seeing themselves looking "tuff" in the Daily Mail, benefit the government, as the paucity of talent and insight evident in the documentation before parliament in relation to this only demonstrates how far from intellectual rigour - or even common sense - those involved in policy making centrally have come.


Leaps and Assumptions
Lets start off by taking the single underpinning assumption of the approach - that is, that there are many numbers of people whose ability to work is only limited by their drug use, or their "propensity" (more of this later) to misuse drugs. The main piece of evidence used by government to support this is a DWP Working Paper published in July 2008 - Population estimates of problematic drug users in England who access DWP benefits. The researchers estimate that there are in the region of 267,000 drug users claiming the main benefits in England (not many really out of a total working age benefit claiming population of around 5 million). Essentially, what the researchers did was take some data from DTORS areas about how many of the in treatment population claimed benefits and then applied this to the estimated national figure of "problem drug users" (eg people using heroin and Crack). The estimate is based on a number of assumptions. Firstly that people in treatment claim benefits in pretty much the same way as people who use drugs but who are not in treatment. Secondly the authors assume that the uptake of benefits by PDUs isn't subject to any local or regional variation - so that people in rural Sussex claim benefits in much the same way as people in Knowsley or Salford regardless of local employment variations. Thirdly, the report assumes that the widely contested and ever changing prevalence estimates from the University of Glasgow that have dogged the sector for some time, are accurate. Two of the three data sources used to build this estimate are themselves estimates - the authors themselves are very honest about the limitations of the research, saying -

"This study has provided some preliminary estimates of the extent of benefit uptake by problematic drug users in England. Its findings point to the need for further research in a number of areas. In particular, the results suggest the need to test some of the assumptions included in this study through a more detailed exploration of the experience of PDUs in accessing benefits."

Far from looking to find out more about the issue however, Government decided to go one stage further, and base policy on it. In the Green Paper "No One left Out - Reforming Welfare to reward Responsibility", drug users were singled out as a group who required special treatment within the benefit system. There were, the authors told us, some 100,000 drug users claiming benefits who were not in treatment (this estimate once again based on the estimates based on estimates based on a finger in the air in the Working Paper). These people, we were told, need to be brought into treatment, as it is obviously their drug use which stops them working. The Green Paper proposed a system to deal with this. Criminal justice agencies - who its worth remembering already share information with treatment agencies - and treatment agencies themselves, would now start to share information with Job Centre Plus. This would mean that people being discharged from prison and sentenced to DRRs would be referred via the job centre into treatment. One could be accused of thinking this was a duplication. After all weren't people coming out of prison and being sentenced to DRRs already being referred to treatment by DIP? The Green Paper however was clear that this would make a major difference - though it never quite got round to explaining why. The Green Paper also explained that Government would be providing new guidance to Job Centre Plus staff to enable them to identify problem drug users, and asked for views on the practicality of requiring everyone who claimed benefits to declare whether or not they were a problem drug user while ruling out universal drug testing.


A Propensity for Nonsense
Come the White Paper "Raising Expectations and Increasing Support: reforming Welfare for the Future" - published in December - and some of these ideas were fleshed out. By the time we reached the publication of the Welfare Reform Bill itself in early January, it became clear what intentions were. The proposed system will look something like this.

Criminal Justice Agencies will share information about people coming out of prison and being sentenced for drug related offences with Job Centre Plus. This will enable Job Centre Plus staff to identify those new and existing claimants who use drugs and require them to attend an assessment. Job Centre Plus staff will also be expected to identify at the time of claiming, people who have what is referred to throughout the proposed legislation as people with "a propensity for drug misuse". Neither the bill nor the schedules are clear about treatment agencies requirements to information share, but the NTA initial guidance for partnerships and providers (published in January) suggests that they will be involved as well, if only in terms of relaying information about compliance back to Job centre Plus staff. The people identified as PDUs or as "having a propensity to misuse drugs" will also be required to attend an assessment. The assessment will look at whether the person is or is not a problem drug user or "has a propensity to misuse drugs", whether their condition requires or may be susceptible to treatment and whether it is a factor affecting their prospects of obtaining or remaining in work.

From a brief examination of the new Schedule to the 1995 Jobseekers Act we find out that those individuals identified as a PDU or as having this "propensity to misuse drugs" who fail to take part in this assessment or who refuse -

"... can be required to undertake one or more drug tests to ascertain whether there is or has been any drug in the person's body to help determine whether they are dependant on or have a propensity to misuse, drugs" - House of Commons Research Paper 09/08, Welfare Reform Bill - Social Security Provisions referencing the proposed new Schedule 1a of the 1995 Jobseekers Act

Those who refuse to be tested (bog standard urine testing rather than the more draconian approaches originally reported!) will face benefit sanctions. Or to put it another way, no sample, no income.

Lets just detour for a minute to look at this business of "propensity".

The OED defines a propensity as "a natural inclination or tendency". The 2009 Welfare Reform Bill does not define it at all. Having a "propensity" for misusing drugs, if you think about it, could mean any number of things. It could mean that you are currently misusing drugs or that you once misused drugs and now don't. It might mean you have an environmental or familial connection to drug use. It could mean that although you might be tempted sometimes to use drugs, you don't, or it might mean that you're bang at it, 24/7 and the monkey only gets off your back when you go under low bridges. It might even mean you're a bit like Tony McNulty, now Minister of State for Employment and Welfare reform who in 2007 said he had "encountered and smoked" cannabis at university. Whichever way we define the word, its clear that the group of people who may have a "propensity to misuse drugs" (including alcohol, as the bill explains) is a pretty wide group. And this in turn makes those who could be subject to a drug assessment and being drug tested when they go to sign on a pretty wide group too. And who is going to make this judgement? well initially the Job centre Plus member of staff who registers or reviews your claim.

Those who are assessed as being PDUs or as having a "propensity for drug misuse" will be referred to the new programme. Curiously detail here is sparser, with what people will actually get at the end of the ordeal of testing and assessment, described simply as

"a personalised programme of support until they are ready to move onto the mainstream Flexible New Deal or Pathways to Work programme".

We do know that individuals brought into the programme will have their JSA converted into what's called a "Treatment Allowance" which will have different conditions mandating compliance with the individual treatment regime - or "personalised support programme". Those on Treatment Allowance will not be required to fulfil the job-seeking conditions of JSA. It is not clear whether a move to the Treatment Allowance off JSA will represent a break in claim and require the individual to make a new claim under new conditions when treatment finishes.

A joint NTA Job Centre Plus letter that went out to partnerships on the 5th January describes the Treatment Allowance as

"an appropriate ‘safety net’ of support, to which other claimants would be entitled, for drug users in treatment"

Which itself implies that drug users - and presumably "those with a propensity for drug misuse" are by fact of being in treatment, unable to comply with the requirements of the JSA, namely seeking work. This rather turns on its head the idea that work and inclusion are critical parts of the treatment process, rather describing treatment as an essential precursor to employment support. It is clear from even a preliminary reading of the documentation that the issue of maintenance has been barely - if at all - understood by those who have drafted these proposals. The White Paper explained that

"While the ultimate goal must be abstinence, we understand that many problem drug users need additional help such as substitute medication to become drug free. The approach that we adopt will support that"

But support it how? Take the case of Barry. Barry spent large parts of his twenties involved in pretty heavy opiate use, but got into treatment in 2001. At the point he got stable on his script, Barry got a job as a labourer for a house-building company. He has done pretty well - being in work more or less constantly since 2003. He's still on his script and though its sometimes a problem picking it up because of his working hours, he manages pretty well. In two weeks time though Barry reckons he's going to get laid off. The job he's working on is finishing and it doesn't look like there's much more work in house-building at the moment. When Barry goes to sign on, he won't declare his drug use, because he doesn't have to. Barry will simply sign on and start looking for work or retraining, and he'll carry on with his script cos that's what he does.

Under the new regime, Barry would be required to declare he was a drug user. He'd then be referred for an assessment, presumably mandated to stay on his script with maybe some additional requirements about attending drug specific services (though stable as he is that might be a waste of time - and money). Is Barry going to be moved onto the Treatment Allowance? Maybe - after all he hasn't reached the "ultimate goal". On the other hand Barry has been stable and working for 5 or 6 years now - so shouldn't he be trying to get back into work.? It seems that at the heart of this piece of legislation is a real confusion about the nature and effectiveness of drug treatment and the experience and ability of those who benefit from it.


Compulsion, Coercion and Sanctions
The proposals for tackling drug use and dependency in the ways suggested, have met with widespread criticism. Last week Addaction challenged the whole premise of a sanctions based approach to increasing opportunity for people affected by drug use. DrugScope too have been critical. The Scottish Government have refused to engage with the proposal, with Scottish ministers pointing out that taking benefits from drug users will simply lead them to engage in more criminal activity. This is a view that was borne out in discussions with drug users at last weeks DDN/Alliance conference in Birmingham and has been expressed by pretty much every drug charity and non statutory body since the proposals were first made.

But increased crime is only one part of the problem with a sanctions based approach. Unemployment and worklessness are not just the responsibility of the individual jobseeker. They are complex phenomena, that involve multiple factors - some structural and accordingly not controlled by the individual. A number of things impact on the ability of anyone to get a job. Firstly there is the state of the local, regional and national labour market. Secondly, the marketability of a type of individual and their skills, and finally the situation and motivation of the individual. Of all of these factors, a sanctions based approach is purely targeted at the motivation of the individual to get work, with some knock on impact, if the right programme is mandated, of improving their skills so that they become more marketable.

Sanctions do not expand shrinking labour markets, they do not make economically struggling regions and towns more successful and they do not make employers more likely to employ people with less experience or who are for other reasons less desirable as employees. The sanctions regime proposed by this legislation will do nothing to tackle the root causes of worklessness in some of our most vulnerable communities - which are also those where the social harms of problematic substance use are felt most keenly.

The 2004 DWP Research Report on the Evaluation of the Community Sentences Sanctions Pilot (where benefits were cut if people did not comply with community sentences) in 2001 found that sanctioning offenders benefits led to an increase of only 1.8% in compliance with sentences. Offenders reported that sanctions had little or no effect on their behaviour - with some reporting increased hardship and increased criminal behaviour as a result of being sanctioned.

Benefit sanctions themselves have been shown to have a significant effect however when applied to people who experience multiple disadvantage. They make their lives worse. In a 2004 Social Exclusion Unit (SEU) Report from the Office of the Deputy Prime Minster the efficacy of applying benefit sanctions to people with multiple disadvantages was examined. The report argued that sanctions can lead to increasing marginalisation, possibly pushing some into criminality and having a detrimental effect on health. It was clear that

"There is evidence that compulsion – in the guise of benefit sanctions – are not effective at engaging clients with a number of disadvantages ... the use of sanctions on people with multiple disadvantages results in increased social exclusion and participation in the informal economy... some are pushed into criminality. The side effects of compulsion and sanctions push those who are already marginalised further from the reach of employment organisations. (Social Exclusion Unit Report 2004: 76).

Value for Money
The use of sanctions and compulsion with people who experience problems with drug use has a chequered history. While undoubtedly a useful tool in working with some groups, when applied across systems they have rarely yielded results. When we aver with such bombast that people coerced into treatment experience broadly similar outcomes to people who enter voluntarily, maybe we should be asking ourselves why we feel its necessary to coerce people into treatment at all in that case? As Judith Rumgay said in her presentation at the 2005 National Drug Treatment Conference

"... all this expansion of coerced treatment, with its accompanying costs, has taken place with little thought as to whether we are making good enough use of the existing mainstream treatment opportunities. An attraction of the coercive approach arose from early American evaluations that found an association between coercion and time spent in treatment. Time spent in treatment is itself associated with successful outcome. It was all too easy to conclude that ‘coercion works’. Wrong – it is engagement with treatment that works. The very high drop out and breach rates of DTTOs and all the effective practice pathfinder programmes demonstrate the damaging naïveté of privileging coercion over engagement,"

Progress to Work has against the odds been a surprisingly successful programme - as far as we know. The final evaluation report of this costly initiative has not been published - nor does it look as though it is likely to be. However anecdotal reports suggest that the practice of working intensively with people affected by drug use, to help the retrain and get back into the labour market can be effective. However no one associated with progress to Work - either at a local or national level has talked about sanctions, no one has said, "this was good, but it would have been better if we'd been able to force more people in".

The most widespread coercive scheme we've employed in drug treatment in the UK has been the Tough Choices element of the DIP programme. In this, various channels compel the drug user into assessment and treatment and in principle keep them there with prison as the ultimate sanction. 3 years on from its inception, we are now looking at a prison system swelled to beyond its limits with breaches and a DIP portal to treatment characterised by repeated admissions and assessments and referrals. For something which when applied widely makes so little difference to engagement , coercion is an expensive business. Commissioners and stakeholders are already beginning to ask serious questions about the value for money of DIP schemes and their usefulness above and beyond the expansion of the treatment system. To take the DIP approach of coercion and testing and to apply it wholesale to the issue of worklessness and benefit dependency is likely to be expensive. Investment in treatment and support for people affected by drug use is falling per head of the anticipated community of beneficiaries at the moment. Is this really the right time to see resources and worker time drain away from much needed services towards a scheme the need for which is unproven and the approach to which risky and marginalising?

Job Creation ... In Administration
The fact is that we know and have known for some time that getting and keeping a job makes a real difference to people affected by problems related to drugs and alcohol. Working, making a contribution and earning money are really positive reasons for someone to maintain their own recovery and stick with what at times can be a difficult process - whether they are maintained or abstinent.

Despite the difficulties of its timing - right at the start of what looks to be the hardest recession in generations - The Welfare Reform Bill itself has some interesting proposals that are about making real efforts to help people who are currently excluded from opportunities for employment get work. There's an emphasis on introducing flexibility and personalisation to the benefits regime so that people can find the approach to work that helps them. There is also greater support for employers prepared to give disadvantaged people an opportunity - and greater expectations that employers will make more efforts to support people in work. Above all there was an increased focus on ability rather than disability - and a step towards valuing people for what they can achieve.

Its unclear though how many of these opportunities will be open to people who have experienced problems because of drug or alcohol misuse. Its likely that the approach that has been taken - to single out drug users and those with "a propensity to misuse drugs" and coerce them into complying with treatment - will put at risk any gains around inclusion that might be made. The sheer sprawling expense of the system that is proposed is extraordinary.
The reporting system - like the DIP one - is evidently to be as cumbersome and involved as the central fetish for information management demands - with £9 million already ringfenced for the establishment of 62 new roles in Job Centres. It looks like they'll have lots to do

"Jobcentre Plus will be seeking evidence from affected clients that they have indeed attended that appointment... Jobcentre Plus may ask the treatment provider in question to independently verify attendance of specific clients ... Where service users are engaged both in treatment and working towards employment, Jobcentre Plus may retain responsibilities for the case management of their clients in relation to seeking and gaining employment, acquiring skills and accessing training... Drug treatment services retain responsibility for their clients’ treatment and care planning in line with existing clinical guidelines. Services will need to agree arrangements for the co-ordination of care in these cases, clarifying key worker roles, information exchange for the purpose of case reviews, treatment completion and loss of contact by either service. The identity and role of key-working care co-ordinators will need to be specified. "

A mass of new reporting lines and monitoring is likely to simply overburden the existing treatment system. More importantly, as those who have spent any time mapping a service users journey lately will note, a proliferation of new assessments and case management responsibilities risks losing the individual in the system. Reading through the initial guidance, for all the talk of individualised support, you sometimes struggle to remember that this is about people at all -

"The NTA is in discussion with Jobcentre Plus regarding the possible matching of anonymised client attributors in order to monitor the robustness of referral pathways between Jobcentre Plus and drug treatment providers. This information may also support requirements within the Memorandum of Understanding for Jobcentre Plus to report progress of the effectiveness of local pathways to the Department for Health (DH) and NTA. If, and when, anonymised matching is agreed to be possible and desirable, further communications will be issued. ..."

We don't have long to wait until we see how some of the changes bed in. Whereas the Bill and its associated documentation suggests that all the approaches will be piloted in advance of implementation and that the programme will start properly in 2013, the NTA guidance tells us that some of the changes will happen much more quickly than we originally believed.

"... from 1 April 2009 benefit claimants in receipt of Jobseeker’s Allowance (JSA) and individuals in receipt of Employment Support Allowance (ESA) who disclose, respectively, at their 13-week interview and via their Personal Capability Assessment that opiate and/or crack cocaine use is a barrier to work will be mandated to attend an initial appointment with a local drug treatment provider..."

The sheer numbers who will soon be entering the jobseekers programmes will make reform and change even harder to manage in the benefit system. In addition the recession may be the trigger for some people to move from non problematic to problematic substance use - affording your coke habit with a salary is one thing, keeping your head above water on benefits is quite another. Employers, who have mostly been unwilling to take drug users onto the workforce knowingly, may be even less reluctant to do so when there will be so many other people in the market - some with considerable experience. It seems that this is a bad time to try to bring about the changes Government wants to see, and worse of course, the wrong approach to achieve them. For as the group of people experiencing problems with substance use grows, and the labour market contracts we run the risk of creating a permanently sidelined population, who with their Treatment Allowance and their separate status, are excluded even from the mainstream job seeking population.

At a time when there is a widespread recognition that treating disadvantaged people as individuals with different needs and expectations is important; where mainstreaming the public service experience of people affected by substance use is the priority, this approach makes no sense. Defining a problem based on estimates and over exaggerating its importance to meet political goals, then carving out a separate system for a group of people defined simply in terms of their drug use (or propensity to misuse drugs), and establishing a series of involved and complex administrative procedures in order to manage it also seems pointless and wasteful. Still, I guess it'll keep a lot of people in work - if only in administrating the system.








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January brought the extraordinary announcement of an increase in the Pooled Treatment Budget that was in fact a three year shrinking budget nationally and a real decrease for many areas. Largely redistributing funding from deprived inner city boroughs to the more well-to-do suburbs and shires, the overall national budget for drugs was set at £358 million and essentially required "efficiency savings" of £50 million to achieve a standstill. While undeniably many areas had been significantly underfunded for years, the argument that others were over funded was possibly less well founded. Most controversially, a new funding formula was announced that recast the pooled treatment budget as largely a per capita allowance per drug user - with crack and heroin users yielding up twice as much money for local budget holders as people who experienced problems with cannabis, methamphetamine, benzodiazepines or any other drug. Possibly the most significant aspect of this new funding allocation was the implicit shift from a commissioning framework that recognised issues like blood borne viruses, aftercare and support and community services to one which for the first time incorporated the principles underpinning the output based performance management system in the local allocations formula. This, if you like, squared the circle - ensuring for the first time a direct link between NTA performance management and funding. Either a very good thing or a very bad thing depending on your perspective, if DATs were in any doubt about the purpose of their commissioning receipt of the Pooled Treatment Budget was also for the first time made contingent on submission of a treatment plan to the NTA and adherence to NDTMS reporting requirements.

Sharp eyed commentators could be forgiven by being a little confused therefore to read in February's New National Drug Strategy Drugs: Protecting Families and Communities that Government was committed to supporting local areas to deliver a strategy that moved away from central control. The new strategy recognised the importance of meeting the specific needs of communities, emphasised life after treatment and promised enhanced support for people in terms of housing and employment. It also focussed on the needs of the children of people affected by drug use and their carers and prioritised the needs of communities to identify the measures they believe will help them effectively tackle their drug problems. For the new strategy to be operationalised there needed to be an effective, comprehensive and comprehensible structured approach to enabling local areas to develop their responses and for government to monitor the impact of this work in delivering the broad strategic aims of the strategy. What we got instead was disappointing -

Firstly, a set of local indicators which both failed to provide sufficient local levers to ensure drugs got onto the mainstream local agenda and retained a reliance on outdated and inappropriate performance management information, or which were based on fag packet estimates and fallacy while retaining a complexity heretofore only seen in flatpack furniture diagrams. Then a national performance management framework for local areas focussed on delivery of the treatment strand of the 2002 strategy and the still unevaluated DIP programme,(£150 million invested and no clear idea of impact beyond a few snapshots) with no effective performance management of anything other than numbers in treatment, 12 weeks retention, numbers of required assessments and drug tests after arrests. Then finally an action plan from the Home Office within which there's little action and not much that looks like a plan - certainly if one tries to identify what has been achieved against the timetable to date. This in fact is an incredibly interesting exercise to undertake prior to Christmas dinner - maybe a sort of disappointment bingo, where the first person to identify an action set for 2008 that's actually been fulfilled gets to make a wish.

Also in February the London Drug Policy Forum published an updated version of the second edition of its Guide to the National Drug Strategy - including ideas about how to use the non drug specific local indicators to reflect some of the themes of the national strategy.

March brought a plethora of reactions to the new strategy from Drugscope, Addaction, Transform, EATA, and a very curious one from the LGA (Local Government Association) warning of creating a carved out treatment system if criminals were allowed to jump the queue in this new-fangled DIP stuff. The unifying factor about most of the responses - including my own - was a desire to give the Home Office some breathing space to catch up with the critique of the numbers based treatment dominated approach of the past ten years and bring us what the strategy promised - a locally focussed strategy inspired by a strong vision and lead from government informed by an ongoing dialogue with communities, people who use services and the drugs field itself. accordingly responses soft pedalled on policy disasters like benefit sanctions (as if eh?), cannabis reclassification and the Daily Mail language in which much of this was written and concentrated on the positives. The test for government would be how long this détente could last.

In April the drug strategy was debated in parliament - coincidentally in the very same week it was leaked that the ACMD would recommend no change to the classification of Cannabis. Drugs Minister Vernon Coaker indicated he wait to receive the advice of the ACMD before making his decision about cannabis classification:

"We must be confident that we have the right position on classification, which is why the Home Secretary asked the Advisory Council on the Misuse of Drugs to review its position. The ACMD is continuing its review and will submit it and its advice to the Home Secretary at the end of this month. A decision about the reclassification, or not, of cannabis will be taken at that time, when we have received that evidence from the ACMD."

Drugscope launched its Great Debate series, picking up on the rumblings across the field about the purpose of methadone maintenance and the rising concerns about the lack of abstinence focussed options for people in treatment (often expressed in a series of increasingly aggressive statements from the residential sector as they noticed that the trough was getting smaller and they hadn't yet had what they considered their fair share). You can read Mike Ashton's article that kicked the series off here and my own contribution to the debate at Birkbeck College in London here.

Also in April, The MOJ published Matrix's evaluation report on the two Dedicated Drug Court (DDC) pilots in Leeds and West London. The report identified some significant methodological difficulties including poor data collection, lower than expected numbers of drug misusing offenders moving through the Dedicated Drug Courts in the period of the evaluation and - rather astonishly - no available information about the nature and extent of drug treatment people engaged with as part of the DRR. The report concluded that there were some significant operational and practice issues that would need to be taken into account if, as was planned the DDC system was to be expanded. These include having sufficient capacity in treatment and aftercare services to recieve the people from the drug courts, effective partnership working and information sharing, and adequate resources in the court itself - like the ability to field enough magistrates and have enough courtrooms. The report was unable to identify whetehr or not the DCC's represented value for money.

Alcohol Concern published one of the more interesting reports of the year in April. The Poor Relation looked at the state of alcohol treatment commissioning within a localist agenda. Despite poor levels of returns from PCTs (who from the report seemed to have been somewhat bamboozled simply by being asked what they were doing about alcohol), Alcohol Concern concluded that separating out alcohol and drug commissioning was highly problematic for those seeking to increase access to effective alcohol treatment and that the lack of central targets within a local framework hindered success. They identified a massive variation in investment in treatment services across the country as well - and reflected on the low level of commitment to solid needs analysis. One can understand the motivation here - after all, what PCT is going to want to uncover a need they have no capacity to address? Depressingly of course PCTs and their partners are often meeting much higher - if hidden costs - in terms of dealing with the results of alcohol related disorder, accidents and emergencies and the long term health consequences of chronic problem drinking - often evidenced in huge costs for gastro-enterology.

May opened with the spectacular piece of political irresponsibility that was the announcement of the decision by Gordon Brown to reclassify cannabis as a class B drug. This was in the face of reduced levels of use by young people and increased levels of help seeking behaviour since downgrading, and as predicted contrary to the explicit recommendations of the ACMD and the responses to the governments own consultation where of 639 responses received only 121 supported reclassification. This decision at a stroke identified a clear new path for government in terms of drugs. For the first time since 1998, the reduction of harm was not the aim of policy. Government interventions were now to be about "sending out a strong message" - regardless of the impact that had on young people.

The Healthcare Commission and NTA review of commissioning and harm reduction was published. The main surprise in this was how positive the press release was in relation to the report itself. Harm reduction services were revealed as poorly developed - a finding that seems to underpin the publication of new statistics about the prevalence of blood borne viruses in October (more of which in part two). I'd blogged earlier in the year about the lack of followthrough on the Department of Health's 2007 Action Plan for Reducing Drug Related Harm, so it was salutary to see just how much ground needed to be made up as indicated in this report. Worryingly, needle exchange within treatment services was one of the worse developed areas of provision - along with services outside normal working hours. In terms of commissioning, the picture was also mixed - with areas doing well at filling in the forms and developing the strategies, but less well in terms of forging genuine local partnership. You can look at my more detailed analysis here. However, just in case we became too pessimistic, a quick look at the IHRA publication ‘Global State of Harm Reduction 2008: Mapping the response to drug-related HIV and hepatitis C epidemics’ also published in May reveals just how much has been achieved in the UK - particularly in terms of HIV infection - simply through the expansion of treatment services.

Watch out for part 2 of my Drug Policy Review of the Year 2008 - including a look at the political (and that's a very little 'p') battles fought over the terminology and definitions of recovery through the summer, the new look Scottish Drug Strategy, fears of the impact of the recession and the legislative bean feast that brought us not one, not two, but three White Papers that could radically alter the shape of things to come for the drug policy field in 2009 ... until then

Merry Christmas

And a very Happy New Year

The Tory Centre for Policy Studies Daily Blog on the 13th November was quite extraordinary, even by their standards.

In it, Kathy Gyngell comments at length on the murder of Baby P in Haringey. This murder, she says, happened because of reliance on systems and structures, which she lays directly at the door of government - "because government apparatchiks have been indoctrinated by the higher demand of process at the price of humanity". In this the blog differs very little from what's been written about this tragedy in most of the national papers and on any number of other blogs.

But then the blog goes on to do something extraordinary. For two paragraphs the emphasis shifts from the tragedy in Haringey, to the matter of drug dependant parents and specifically what Gyngell calls "the state sponsored drugging of some 200,000 adults with the prescribed opiate substitute, methadone". What relationship this bears on the awful death of Baby P the blog doesn't explain. As far as we know neither of the parents was prescribed methadone or in touch with any drug treatment service. What this is in fact is one of the oldest spin-tricks in the book. She seems to be seeking to create, by proximity in this piece, a connection between methadone prescribing and the death of this child. I think its shabby and its unpleasant and its misleading.

It seems Kathy Gyngell is no stranger to this sort of lobbying. In the early 90s along with a group of other women, she set up a campaigning organisation called "Full Time Mothers" which aimed to promote stay at home mothers and lobby for among other things a reduction in spend on childcare and increased spending on tax breaks for traditional families. Jessica Asato on The Progressive blog comments: Their website asks visitors insightful questions such as “Are you tired of seeing your family's taxes diverted towards encouraging more childcare and absentee parenting?” According to a document put together by Hazel Blears, Kathy Gyngell has said that "When a child's mother dies, that is a terrible tragedy. But we impose that tragedy on every child when we leave them to go to work".

In 1993 Jamie Bulger was killed by two children. Just a month later in the media storm that followed, the Mail on Sunday published an article by Kathy Gyngell entitled "The Price of Feminism". In it she implicitly drew a link between the recent tragedy and the feminist movement. In their essay in the 1999 book "Changing Family Values" Kirk Mann and Sasha Roseneil picked up on this - A photograph of a 1970s march showing women carrying placards reading 'women demand equality' was placed next to a photograph of a young boy, wearing a balaclava helmet, pointing threateningly at the camera in 1993. The headline above them read 'Did this…lead to this?' In the article Kathy Gyngell argues that feminism, by encouraging women to take paid employment, is responsible for juvenile crime and moral and social decline. Echoing theories of maternal deprivation from the 1950s, she claims that children are being neglected by their absent mothers, and draws upon essentialist notions of maternal instinct: 'Feminists may complain that it is unfair that mothers are primarily responsible for the upbringing of their children. But it is an unavoidable fact of life. Nature provides women not only with the body to bear children, but the instinct to foster their emerging sense of morality.' (The Mail on Sunday 7 March 1993) Social policies to encourage women to stay at home with their children was the solution suggested by Gyngell.

So what is this about? Why would a fairly respectable blog site stoop to such low tactics to make its points? I guess the answer must lie in their fervent belief in the justice of the cause - that of shifting policy away from harm reduction towards a drugs policy that focuses primarily on encouraging abstinence and prioritising prevention. Kathy Gyngell's commitment to ending harm reduction is obviously such that spinning news stories - even ones as upsetting and important as this - must seem in some way a valid approach. Its quite saddening really, but in many ways typical of those on both sides of this manufactured debate. Like I said its turf wars - and no one is the winner here. No one.

Please note this blog was not carried by the Daily Dose so please forward to any friends or colleagues who would otherwise miss it.



Photograph: Copyright Jim Young

Anyone studying the recent debate on drugs and drug treatment in the media could be forgiven for thinking we've all gone mad. Drug use, we are told, is an illness that can be cured as long as we are willing to pay for the right treatment. The right treatment is residential rehabilitation and the way we need to pay for it is to take all the investment we have in methadone maintenance services and needle exchange and spend it on residential services. Because as Melanie Reid put it in the Times -

"Two months is usually sufficient to get most people off drugs. Abstinence programmes are proved to be seven times more effective than methadone."

Simple Solutions
You see, its simple. Our drug problems can be solved, we can all breathe a huge sigh of relief and be confident that the past 20 years of harm reduction have just been a brief delusional nightmare on the righteous road to a drug free society.

Kathy Gyngell in her blog on the tory Centre for Policy Studies website says:

"They could simplify and reform funding arrangements under one roof. They could reallocate resources from Tier 3 ‘prescribing’ to Tier 4 rehab. "*

So why aren't we doing just this? If residential rehabilitation IS the answer to our problems why aren't we commissioning it ? Last weeks "Addiction Today" in its piece questioning whether the NTA were "fit for purpose" said:

"Medically invested DATs and Primary Care Trusts are diverting people to methadone maintenance and other harm reduction …bad practice dominates with people treated as statistical units to serve political targets. "

So its political? This is a bit of a strange one, because politicians tend to go for the populist angle and as the same article points out, the public are pretty much overwhelmingly convinced of the benefits of abstinence focussed treatment and the value of residential services. One would have thought that if there were some quick political wins to be safely made by moving investment to residential rehabilitation they would have done it.

Kathy Gyngell's view is simply that "past record shows NTA upper management simply not wanting to".

So that's the NTA taking a principled stand against a simplistic populist and politically appetising solution? Ok …

In fact most of those who are espousing a retreat from harm reduction seem incapable of either making a case for this approach to strategy or a rationale for why our current administrative masters find it so unappetising. The closest we've come is Melanie Reid's citation of a "powerful methadone lobby" but as this is the woman who reckon's that "Britain's Got Talent is a model for a competitive, compassionate, cohesive, colour-blind society" we may be well advised to take her ramblings with a pinch of salt.

I wonder if the current furore is more a case of turf wars than anything else.

Variable Quality
With the exception of things involving aliens, black boxes or Nancy Reagan, in the world of treatment lots of different things have some impact on some people sometimes. Residential treatment is a really important option to be able to offer people, but its not without problems and its neither goose, nor golden egg.

Quality across the residential sector is highly variable. The Commission for Social Care Inspectorate (CSCI) is responsible for the main part of the drugs residential sector (with a small number of specialist clinical services being inspected by the Healthcare Commission), it achieves this largely through self inspection, with only a very few unannounced visits to services of concern. While inspections are pretty good at assessing where a service is at, they tend to be less effective at making sure services improve. They look at whether a therapeutic regime is in place, but not at its quality or effectiveness . The NTA guidance issued recently - Improving The Quality and Provision of Tier Four Drug interventions is a useful start, but one does have to wonder why its taken so long to arrive and while it provides a framework, does not solve some of the problems about regulation and improving standards.
The lack of a rigourous inspection regime or much commitment on the part of a number of providers to do anything other than find imaginative ways of side stepping what regulation there is has done little to build confidence.

De-registration, for example, is where a residential treatment provider declares themselves no longer a social care service, applies to be removed from the CSCI Register and redefines themselves as providing housing with additional support. This is a canny way of finding a different funding for residential treatment - using housing benefit to cover the accommodation costs and elements of Pooled Treatment Budget funding and Supporting People to support the interventions. But what it also does is enable the residential provider to sidestep what little regulation of residential services there is and run pretty much completely un-inspected by and unaccountable to anyone. This is particularly frightening when you find some providers offering detox and other clinical interventions through this type of service.

I've noticed a number of residential treatment services that now claim to be “regulated by QUADS” (that is Quality in Alcohol and Drug Services). QUADS is little more than a tool for self audit and inspection and does little to provide guarantees of the quality or safety of a service. DATs don't regulate residential services because, with a very few exceptions, residential services aren't funded by any one DAT. The NTA don't regulate residential services because the NTA regulate commissioning not provision.

In many ways the most accurate regulation we have of these services is the old one of "bums on seats". That makes it worth asking the question if people aren't using residential services is it because many of those residential services aren't very good?

Why They Don't Want To Go To rehab
There are some excellent residential facilities. I would defy anyone to visit an establishment like Clouds House for example and fail to be impressed by the degree of care and intelligence they bring to their work and the tremendous respect with which they treat the people who use their service - which would put many community drug services to shame. However the majority of residential services I have visited in the past 20 years are places I'd reject as a boarding option for my dog, never mind as a treatment option for a vulnerable person. Like the service I visited 12 months ago where the manager called one of the residents over, lifted his jumper up, patted his bare belly and said

"There, look how well we feed them here - he's turning into a little fat boy".

This was a man in his late 30's, who she subsequently introduced me to. Then there was the detoxification service where not a single risk assessment had been undertaken for any of the residents, and staff had been appointed and employed without either references or CRB checks (this was operated by a major drugs charity and these flaws were repeatedly reported by CSCI, but nothing was done over a three year period to correct them). Or the rehab where community meetings bore more resemblance to a denunciation meeting in Mao's cultural revolution than any form of treatment - with residents routinely humiliated and degraded in the interests of "improving their motivation for recovery".

Many service users I have worked with have attended residential treatment not just once, but on many occasions and on many occasions have dropped out or been kicked out. As one old colleague of mine used to say "I've done my full 6 months in rehab. Or at least I've done one month in 6 rehabs - and that's nearly the same"

We know that residential treatment works for some people some of the time but we also know that for a lot of people its a disaster. Premature referral, referral to the wrong type of residential care, referral without regard to family circumstance or worries about childcare all impact on the likely success of the treatment. Many of the people we have in treatment now, have been in treatment before and many of them know that going away and living in Somerset for 6 months didn't prepare them particularly well for coming back to inner city Birmingham or Manchester. A lack of aftercare does not predispose either referrer or referred to choose the residential option - but that's not the only reason. The majority of drug users have lives, families and jobs. They don't always want to give them up and go away - particularly if there's a risk their job won't be kept open and their flat won't still be there for them or worst of all they'll be separated from their kids.

Additionally, the expansion of community treatment is bound to hit the residential sector. If people have an option of treatment at home that enables them to keep their jobs, homes and families together, why wouldn't they choose it? The ongoing gnashing of teeth on the part of some elements of the residential sector about the closure of tier four services may be motivated by a desire to open up treatment options to people who need them. I'd bet its also equally motivated by a desire to keep the wages bill paid and the wallet full.

Target Culture
What's interesting about much of the commentary about the lack of investment in residential services is the volume of it generated by the sector itself. In this of course they are no different to any other part of the drugs field. Those involved in community treatment services by and large defend community treatment. Those in the residential sector defend the residential sector. The difference is that over the past ten years Government has chosen the community sector as beneficiaries of much of the new investment available. With that investment has come a vast expansion in treatment availability and a reduction in waiting times for treatment - the type of volume expansion that would have been neither practical nor affordable using the residential sector alone. In return for that investment, the treatment sector was told to prioritise the things that were important to Government. These things and their relative importance were expressed through targets.

Setting numerical targets has dangers – particularly when continued investment is predicated on reaching or appearing to reach them. Instead of the target being something that measures what we do, the target becomes what we do, and somewhere in there, we lose the client. Services get built not to improve people’s quality of life, but to deliver targets. You see this again and again when you look at treatment systems like those developed in the early years of this government for acute healthcare. Targets distort healthcare systems. In the case of drugs treatment, we created a sausage machine that met the proxy indicators of success identified by the Government. So for example it was identified that treatment episodes that lasts 12 weeks or more get better outcomes in terms of reducing criminal activity, and improving health and social functioning. This enabled us to set a target for treatment to last 12 weeks or more, but what we didn’t do was set a target for reduced criminal activity or improved health and social functioning. The focus for the service and the DAT became the length of time someone was in treatment, not their improved quality of life.

In the end proxy indicators like this don’t deliver outcomes, they just deliver spreadsheets. While you may meet the targets you’re set, you don’t know that you’re going to get the results those targets should indicate, but that doesn’t matter because you’re meeting the target. However without the focus on the outcome rather than just the target, the promises made to the public and politicians about the targets aren’t fullfilled, and sooner or later people begin to feel conned.

Its against this background that the residential sector, fired up by a media able to smell government failure a mile off, are baying for that investment to be redistributed "Choose us," they cry, "We make people better". According to reports of a recent meeting in Manchester which while identifying that polarization in the drug treatment field was a bad idea, ran an oppositional debate entitled “Maintenance Is for Quitters – Rehabilitation Is For Survivors”, some people are now calling for an "Abstinence Target". This echoes Mark Easton’s attacks on the NTA where he repeatedly questioned why there is no target for people leaving treatment drug free.

So how would a target for abstinence work - and what would it achieve? Despite the claims of those lobbying for this kind of new orientation, its unlikely that residential rehab would be able to provide everything to everyone from day one. Despite assertions that all it would need is a simple reallocation of funding from community to residential services, residential rehabilitation on demand for all is unlikely to be practical or affordable. Community services would probably still provide the majority of treatment. Presumably with an abstinence target, those community services would be directed to increase the number of people being discharged drug free. Services would need to develop new strategies to work towards that target - both official and unofficial. Officially services would talk about stabilisation (probably on as low a dose of methadone as possible), support and counselling and gradual reduction. But if you've got a target you have to meet as we’ve seen in the recent past, you’ll move heaven and earth to meet it. If it gets to January 1st and you’re meant to have 50 people out of the door, drug free by April 1st, but so far you’ve only got 10, then you’re going to have to get 40 extra people drug free and discharged in the next 3 months. That’s 40 people drug free and discharged regardless of personal circumstances, regardless of health status, regardless of family commitments – because you have to meet your target. But its ok really, because although you’ll detox and discharge them now, they can come back in May and you can sort them out all over again. In his August 2008 article, A Flag in the Breeze, Mike Ashton reminded us of similar attempts to move away from long term maintenance provision in the States:

"When in the late 1990s New York’s mayor Rudolph Giuliani moved to curtail methadone treatment, to predict what might happen, researchers trawled through the back catalogue of studies of discharge from the treatment. They concluded that as things stood, it would be “unwise to structure methadone programs and their financing so as to discourage or impede long-term maintenance, and at the same time to pressure patients overtly to accept abstinence by heralding its supposed desirability or superiority”. Post-discharge relapse was the norm and with it death, disease and social deterioration."

The Great Divide - Public Investment, Individual Recovery
So what should government choose to invest our money in? Services that get people off drugs? Services that keep people on drugs? Maybe services like the ones we used to have in the good old days which kept people on drugs, then took people off drugs and then got them on them again in that lovely thing we used to call the revolving door, before we learned to refer to it as the 12 week retention target.

The truth is, it shouldn't be government's job to choose what kind of treatment we invest in, but to make sure that there are a range of treatment options available to suit the different needs and choices of people who experience problems with substance use (and yes, I know its trendy to say "addicts" again, but I've never liked name calling). It is not government's job to identify whether abstinence or maintenance is appropriate to help someone achieve recovery. "Recovery" can only be defined by the individual concerned. Government is responsible for minimising the harm caused by drugs and putting in place initiatives that maximise the protective factors for communities and individuals so availability need not turn into problematic drug use. This means investing in things like employment support, housing, decent education and community policing. Government is also responsible for making sure that the provision of a wide range of treatment is adequately prioritised, funded and regulated, subject to scrutiny regarding clinical effectiveness and of a decent quality. Beyond that, choices around treatment type need to be made by the individual seeking the treatment and their family and friends if they choose to involve them. These choices can be informed by a strong relationship with a key worker and by involvement with the criminal justice, mental health or children's services. But the decisions need to be made by the individual concerned, not by a mandarin in Whitehall, not by a lobby from either side of the treatment industry and certainly not by the media.

Its said that the biggest divide in the drugs field is between those who believe in abstinence and those who believe in maintenance. I don't think that's true. Melanie Reid and those who espouse similar views often barely disguise their intolerance, lack of compassion and essential dislike of their fellow human beings behind a veneer of phoney outraged morality -

"Street drugs are a lifestyle choice. Being a taxpayer is not; and its harder to be tolerant of the rotten choices of others when one's hard earned money is spent subsidising them long term"

I wonder what she'd like us to do about those people who make rotten choices if they don't do what we say? Does she really believe if we shut down the needle exchanges (what's left of them) and the methadone clinics that the people who use these services will simply look around and stop using? Surely its obvious by now that we will achieve nothing by screwing up our eyes, putting out fingers in our ears and pretending that no one will ever use drugs if we tell them not to? We'll achieve less still by sifting people into categories of those who deserve our support and compassion (and tax!) and those who don't.

I remember having a conversation about the importance of client choice with a colleague, about 4 years ago, as we were driving at breakneck speed around the Lancashire Yorkshire borders.

"But Sara" he said, "you know as well as me that there are people who can't make those kinds of decisions, people who've got in so deep, who've become so chaotic that we have to do something".

And I agree with him. We need to make sure that we have adequate provision of good quality open access services in which people can - if need be – get patched up, helped towards some stability and supported and motivated to make some decisions and choices about their future. As we support people to access the interventions that make sense to them - whether that's residential rehab., community maintenance or detox., or a combination of these options, we keep the safety net in place. We need to help people stay as safe as possible for as long as possible so the harm experienced by them, their children and families and the communities in which we live is minimised.

We do that through rational, humane and pragmatic approaches to substance use. This is what harm reduction is about. Not stifling individual aspiration in order to meet political objectives, and not creating a system so dogmatic in its push towards one particular type of treatment that it cannot accept the validity for other people of different approaches.

And that is where for me the divide in drug treatment lies - not between maintenance and abstinence or between needle exchange and needlework or 12 steps and harm reduction. The real divide is between those who want to impose solutions on people and refuse support to those who don't fit into their narrow view of treatment (who perpetuate these turf wars) and those who want people to be able to access a full range of support that addresses their individual problems. Or to put it more simply, those who believe in people's right to define their own recovery and those who don't.


(please see also LDPF response and DrugScope Response to Melanie Reid's article)



* At the risk of being churlish, this actually wouldn't be that easy. You'd need to develop a new system of regulation for the residential sector, a new commissioning structure - possibly sub regional or possibly based on individual brokerage against a regional or local pot. You'd also need to disaggregate the current drugs spend from local Community Care budgets and reallocate it to the new commissioning structure. This would probably need to be undertaken at a departmental level.

1757

I've been asked on so many occasions now where people could get copies of Ian Smith's old magazine Monkey from, I've decided to make the links available directly from this website*. Monkey was produced from a drug service in Greater Manchester by Ian Smith with a team of service users and colleagues. Some editions are a polemical tour de force and others simply polemical, but its never boring. It was aimed at delivering treatment and harm reduction advice alongside user self organisation and opening up a world of policy - locally and nationally - to street drug users.

When Monkey first came out people either loved it or hated it. Mainly drug users loved it and DATs hated it. You can see why. Some people felt it was too focussed on harm reduction, others that it stirred up too much unrest among the in treatment population. Although some of the pieces are now out of date, many are still relevant and interesting - particularly for an anorak like me - because they show us how far we've come over the past few years. Sadly some of this 'movement' seems just a slight sideways shift in position out of the shade and into the warm sunshine of government funding. Then as someone far wiser that I once said, all that stands between ourselves and and endless repetition of the same mistakes, is a study of our own history. Monkey sometimes appeared to have a psychic eye - and with articles on a rocketing prison population as the war on drug users gathers force, massive profits for drug testing companies and benefits cut backs for those not in treatment, you could sometimes be forgiven for thinking it was hot off the press.

There have however been undeniable advances. Except in Scotland and Northern Ireland where I understand the shame that is treatment rationing still prevails, the days of long waiting lists and poor access to treatment that so taxed Ian and his colleagues seem to be passed. whether we've made quite as much progress in getting away from punitive discriminatory treatment service practices and an over reliance on the criminal justice system is for you to judge for yourself. Follow this link .... Monkey Business

What is it?

This area of work the NTA tells us, sets out to

"... provide partnerships with a powerful aid for considering whether any changes may need to be made to the design of the treatment system so as to optimise outcomes, taking into account their own local needs assessment or other relevant local factors ... "

Apparently its been developed in response to recent "increases" in the Pooled Treatment Budget (that would be the £50 million worth of spending cuts announced in January)
The model works like this:

First you identify what proportions of different kinds of drug users comprise your local drug using population. You can choose from a number of different varieties handily demarcated by the drug they use rather than by anything irrelevant or transient like gender or economic or social status, or mental health issues or ethnicity or age or housing status or health status and certainly nothing as stupid as choice. So the categories are -

• People who use opiates in the community
• People who use crack in the community
• People who use opiates and crack in the community
• People who use opiates and who are in prison
• People who use crack and who are in prison
• People who use opiates and crack and who are in prison
• Young Users of any other drug other than opiates and crack
• Adult users of any drug other than opiates or crack

• Following detoxification, it is estimated that 20 per cent of clients need structured psychosocial interventions (usually one-to-one) in addition to ongoing keyworking
• It is assumed that these psychosocial slots last for 12 weeks on average
• A 12-week psychosocial slot costs £480 on average

• All those in structured treatment will receive drug related aftercare following completion of all structured community or residential treatment interventions
• It is assumed that aftercare lasts for twelve months with intensity tapering off after six months
• Aftercare costs £1,338 on average per six-month slot

• An Employment & Support Allowance (ESA) to replace Incapacity Benefits (IB, DLA etc) by 2013
• An extension of the concepts of individualisation and personalisation of employment support (including individual budgets) for people experiencing barriers to work through health or social care need (but not people who have/are experiencing problems with drug use.)
• Requiring people who have claimed Jobseeker's Allowance (JSA) for two years to undertake mandatory community work in return for benefits
• Contracting out many of the Job Centre Plus functions to the private, voluntary or third sectors.

1. That the relationship between poverty and drug use is complex, but that helping someone out of poverty saves money in terms of expenditure on drug treatment and crime and healthcare (you know I think it might just be something like "every £3.50 we spend on poverty helps us save ..... " ah no, we've been somewhere like this before haven't we?)
2. That treatment on its own doesn't in fact "work" in terms of helping people out of poverty, but that its just the first step. And that poverty itself can undermine the gains and the stability that people get from treatment.
3. That employment and housing and support for families and communities are all critical - but that they cost money and no one anywhere is putting their hands in their pockets to fund it. New initiatives will be funded by efficiencies elsewhere in the system.

• Focus on people rather than services.
• Monitor outcomes rather than performance.
• Emphasise strengths rather than deficits or dysfunction.
• Educate people who provide services, schools, employers, the media and the public to combat stigma.
• Foster collaboration between those who need support and those who support them as an alternative to coercion.
• Through enabling and supporting self-management, promote autonomy and, as a result, decrease the need for people to rely on formal service and professional supports.

You'd be forgiven for missing it in the hoo-haa about cannabis reclassification, but on the exact same day as the ACMD published their report into cannabis and the powers that be said "so what", the Healthcare Commission and the NTA published their latest Improvement Review report.

Although the report is a single document, it actually refers to two themed reviews within the same programme - one of Harm Reduction Services and one of Commissioning Systems.

The process works like this ... First of all supported by an expert group, the NTA builds an assessment framework that looks at what the key features and outcome of the theme area should be - you can find them here. Local partnerships and service providers submit their responses to the assessment through an online tool. In addition data from NDTMS, the 2006 NTA survey of services users and the 2006/7 treatment plans is also used to assess performance. Local areas are then marked "Weak", "Fair" "Good" or Excellent" across a range of criteria.

Following the review the weakest 10-15% of areas are required to prepare and implement an improvement action plan.

This type of process is obviously only as good as the questions that are asked and the honesty of the replies by service providers and local partnerships - and it is clear that while efforts have gone into assuring quality, this research relies on self assessment, uses a number of data sources of variable quality and is based on some assumptions about effectiveness which are not necessarily as robustly 'proven' as they might be. That said, this is an ambitious piece of work of which the originators - the NTA and the Healthcare Commission - should be proud. Its probably the best we're going to see for some time as a snapshot of harm reduction across the country and will help us direct other pieces of work around commissioning systems and partnerships (like that by the NAO and the Cabinet Office) more effectively.

The Commissioning Systems Review looked at 6 key areas:

• Strategic Partnership
• Needs assessment
• Compliance with national frameworks
• Competent contracting
• Performance management
• Competent commissioning

• The extent to which harm reduction services are embedded in the whole treatment system
• Prompt and flexible access to interventions like needle and syringe exchange
• Action by providers to reduce drug related deaths
• Competence around harm reduction in drug service staff

• The key areas against which there has been achievement have been the Healthcare Commission Inspection of Harm Reduction Services , the placing of a greater emphasis on improvement in harm reduction services and the NICE reviews including the one of Needle and Syringe Schemes that is ongoing. This - while obviously not being the same thing - may lead to the minimum standards for needle exchange and harm reduction for inclusion in contracts promised for December last year.
• In terms of the publication of new guidance for local enquiries into drug related death (due March 2008) I can find hide nor hair of it anywhere. At the moment all that's out there is the 2003 guidance from DH .
• The inclusion in TOPs and NDTMS of data regarding injecting behaviour should improve our understanding of risk activities among the in treatment population and is welcome. However the questions remain around public health surveillance of the not-in-treatment population.
• I can't find out how much progress has been made towards the improvement of prison harm reduction and healthcare - this is a key focus of IDTS. Someone told me that Hep B immunisation in prisons is moving along at the moment, however official information on the current state of play is thin on the ground. No news is .... well, no news.
• I can't find much at all that indicates the competency based training has been taking place but the module may be developed by now (it was due January) even if its not yet published.
• Unless I am mistaken there was no campaign to reduce BBVs and DRDs among at risk groups - though as I am not a member of an at risk group, this may have been so well targeted that I missed it. Similarly I'm not aware of any ongoing centrally co-ordinated or funded peer education pilots.
• We don't have figures yet for Hep b immunisation - lets hope it has met the target. Oh hang on, there wasn't one.

I've just taken part in the Drugscope and Conference Consortium Great Debate looking at the issues around the resurgence of the abstinence vs maintenance arguments.
You can download Mike Ashton's article, 'The new abstentionists', here.

A number of people have asked for a copy of my speech, so I’m blogging it for them and anyone else who's interested.

Comments below or email me using the "get in touch" link on my homepage

• 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.

• The overall volume of offending by a cohort of 7,727 individuals was 26 per cent lower following DIP identification.
  
• Around half of the cohort showed a decline in offending of around 79 per cent.
  
• Rates of entry into treatment for DIP referrals were higher than for previous arrest referral programmes.

• There were higher rates of attrition before 12 weeks after 'Tough Choices' was introduced

• There was a large increase in the number of "Low Crime Causing Users" (LCCUs - people with 0 - 3 convictions over the past three years) getting "gripped" by  DIP but a reduction in the proportion of "High Crime Causing Users" (HCCUs - people with 9 or more convictions over the past three years) coming into DIP
• There was a small increase in the number of HCCUs coming into DIP after the introduction of 'Tough Choices'
• Referrals into tier three and four treatment reduce from 47% to  41% after the introduction of 'Tough Choices'