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.

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