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 Although some of the pieces are now out of date, many are still relevant and interesting - particularly for an anorak like me - because they show us how far we've come over the past few years.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

The new NTA consultation on Value Improvement for drug treatment systems was published last week. It is a remarkable and extraordinary document. I suggest you start at the end - because that's the only place you get to comment on the purpose of this peculiar tool.

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

Next you apply the NTA model of treatment system usage (or sausage machine) to this population. This will tell you what services people will use for what amount of time and in what configuration. This is the bit of the model we've currently been asked to comment on. You see these calculations of treatment system usage are based on a series of assumptions and estimates made by the NTA about how people use the drug treatment system and how the system responds. Of the 114 separate assumptions on which the model is based, 55 of them are estimates which appear to have no clear evidence base at all, are not referenced in any way, and could almost have been scribbled down on the back of a beer mat. (This seems somewhat ironic given the requirement to those responding to the consultation to base their assertions on a clear evidence base!). As the authors themselves suggest:

"Where the existing evidence is perhaps ambiguous, we need to make some informed decisions which can influence the model. These assumptions have been developed within the NTA and shared with the relevant government departments."

So that's ok then. The rest are referenced to either the controversial unit cost exercise from 2006, the fairly solid NICE guidelines and new Orange Book, the self reported HCC inspections of the past three years and Offender Health Statistics from the Department of Health. So for example the NTA estimates that:

• 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

Then we have the aftercare estimates:

• 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

I'm sure by now you've got the idea. We estimate the numbers of people who might need treatment, we define in advance what that treatment will be and then by comparing what the NTA model says a local treatment system in that area should look like work out if the system is providing value for money. Local partnerships will be able to use this tool to identify whether their providers and services are delivering the right interventions to the right people at the right cost with the right results. So a commissioner in say inner city London will be able to identify if they are providing drug treatment in the same way and at the same cost as the commissioner in rural Dorset.

What's it For?

The NTA state that this tool will simply be an extra bit of kit to help commissioners and that the real work will be in meeting local needs assessed through a local process. However, given the change in status of the Pooled Treatment Budget from an allocation to a fund applied for by areas who meet NTA requirements for treatment planning, and given the somewhat complex new formula for area allocations, its hard not to be sceptical about these claims. If this "tool" is not to be used by the NTA to monitor local spending and local systems then why on earth has it been developed?

The NTA is keen to get our views on the assumptions underpining the formula but only ask one question about the approach itself. While we are being asked to comment on whether its 15 0r 20% of young people

"... who engage with a treatment service will have low-severity drug or alcohol use, a low risk of harm and high protective factors"

or if its really true that

" for each hour of a multi-agency intervention, the keyworker will need to do an additional three hours of preparation"

we're in danger of missing the main game. Maybe when we approach this lengthy and complicated consultation we should start at the back where the 93rd question out of a total of 98 - which I understand was added on as an afterthought after comments by initial workshop participants - asks:

Are there any possible unintended consequences of developing the model or are there any other issues which should be taken into account during the development of the model?

Unfortunately, while this allows us to comment about the dangers of this approach, it does not get to the key questions we need to be asking. For example can and should we generalise on treatment system access patterns for such non homogenous communities of drug users? Are the costs of providing treatment really the same nationwide? Is the information we have about our drug using population such as prevalence statistics reliable enough to enable us to map our populations in such a way that a model can have any practical application at all? This reminds me of nothing more than the parlour games that ask us to think of a number, take us through a complicated set of calculations and then ask us to take away the number we first thought of. It appears that the approach we saw to measuring the impact of interventions on drug related crime that I highlighted last week, that of basing our measurement on an estimate built on an assumption, based on another estimate, prevails here.

Complex and Personal

The authors of this work are clear that complexity is missing and offer some blandishments that it may be incorporated in the future, but without an understanding of the complexity and diversity of people who use drugs and an accommodation of their different needs, can a model like this have any validity? If it doesn't reflect what's actually happening but just what someone thinks might be happening in an "average" world then is there any point in using it? Furthermore, can we be sure that the interventions people need to help them reach their own recovery can be identified solely by reference to the drugs they use rather than to the person they are an the experience they have had? Is the 21 year old man who's got caught up in a bit of heroin use over a 6 month period really going to use the treatment system in the same way as a 38 year old woman who's been using for 7 years with bi-polar disorder, 4 children and a dependant partner? No. Is the system going to respond in the same way to them? Well, one would hope not, but programmes like this have to make you consider if what's been called the "Macdonaldisation" of treatment is just around the corner. How can this possibly be reconciled with a drug strategy that states:

"We will therefore work to develop more personalised approaches to treatment services, which have the flexibility to respond to individual circumstances. We will examine how we can best support those leaving and planning to leave treatment with packages of support to access housing, education, training and employment."

So where is the support to access housing, education, training and employment in this model? Well, apart from a brief mention under keyworking, they simply don't feature in this document, these are not things which are part of this "average" treatment system. Yet surely its become clear over the past few years that one of the real drags on the value for money of treatment is the lack of integration with other services? Housing support, good primary healthcare, employment and training are exactly the kind of services that we know not only improve outcomes for drug users, but that also in doing say improve value for money for the public purse. This model focusses commissioners on a treatment system newly defined not just to exclude mainstream services and support, but even GP support and social care.

Missing Pieces

One of the dangers of a model like this is that as it reinforces rigid specialist treatment systems, it discourages engagement in local treatment systems of generic mainstream health and social care services. While in the introduction the authors say: "Interventions and costs that fall outside the drug treatment system such as brief interventions provided by generic health and social care services, such as GPs and A&E, and alcohol treatment are not included in the model."

They later say - "It is assumed that all interventions provided by drug treatment systems have been included. Have any interventions been excluded?"

What are we to infer from this? That interventions provided by GPs and and social care services are no longer part of the drug treatment system? That we are not interested in drug users being able to access the support they need from outside specialist services? This is possibly one of the most significant dangers of this model. In focussing so much on the services and the specialisms it has completely lost sight of the human being who should be at the centre of our concept of treatment. It is not how we set out the care pathways that matters in terms of service design, it is how people use them. And that's why a task like this, seeking to translate the help seeking behaviour of a hugely disparate group of people into a series of standardised transactions based on average but not optimised interventions seems not only pointless and self indulgent, but also quite dangerous.

Of course this is not to say that a tariff shouldn't be set for interventions for people who experience problems with drugs, but that if it is to be set it should be set on the basis of real experiences across a range of services - both inside and outside the specialist medical silo. It also needs to reflect the patient's rather than the bureaucrat's journey. The divisions between health and social care, between statutory and voluntary sector, between services that provide employment support and services that provide access to services that provide employment support belong to us not our clients. When we work within and reinforce these silos we define our own experience of the services as more important than those of our clients. The principles of recovery and the principles of effective person centred services are the same - that the delivery of health and social care must be understood primarily from the patient perspective and that this must be at the heart not just of how we provide services, but also of how we commission them.

Ideal or Just Average?

One unintended consequence may be of this tool being treated as an ideal system against which local areas will be measured. Certainly it appears from an earlier draft that this was the original intention. However these assumptions are not ideals at all but simply the way things are on average now. For example : "It is assumed that ten per cent of opioid users who are receiving substitute opioid maintenance medication attend intensive day programmes (NDTMS)" or "It is assumed that residential rehabilitation lasts for three months on average" or "It is assumed that keyworking takes place once a month on average for an hour on average". That may be how it is now as recorded by NDTMS or as much as funders are prepared to fund, but is that the way it should be? Embedding this sort of thing in the model against which partnerships are invited to compare themselves will not get us to the point where the government wants to get to - where many more people are stably recovered and reintegrated into mainstream society.

It may be that this is a clumsy and ill thought out attempt to preserve specialist treatment services in the face of the current onslaughts of the ideologues who claim the only worthy aim of a drug service is to move people towards abstinence rapidly without regard to personal choice, circumstance or risk. If so its pretty depressing that this is the best that can be done. It is as wrong for the NTA to seek to impose their own predefined solutions to individual problems within a ring fenced specialist system that protects a section of the treatment industry as it is for the evangelical abstinence brigade to do so. The way to challenge the current ill founded attacks on maintenance programmes and harm reduction services is not to reinforce the role of specialist treatment by placing it at the heart of our systems of interventions. Rather we need to open up treatment, to democratise it, to make it more not fewer people's responsibility, to provide more choice, locating more services in primary care, putting the individual patient at the centre of a range of integrated personalised services. Only in this way we can ensure that drug treatment is no longer left behind the rest of health and social care and that it begins to meet the demand for personal and individual care that is at the heart of the move to World Class Commissioning and central to Lord Darzi's NHS Next Stage Review

This tool and it's accompanying model of treatment systems reinforces the ringfence around drug users and introduces a complexity to treatment commissioning that appears not to be simply another bureaucratic fetish but actually a destructive and damaging new philosophical approach to treatment itself. One which indicates that all that is necessary is a pocket calculator, a nurses uniform and a prescription pad to get it right. Oh and a pair of blinkers - apparently that's the key must-have accessory for our commissioners from now on .


Many thanks to Mike Ashton from Findings - the repository of all things bona fide and reliable in terms of drugs research on the web for his help in analysing the potential impact of this model and exploring some of the assumptions underpinning it.


(The Photograph above is from the "Office Collar" series of body architecture designs by Simone Brewster)

Some news for those who followed last years setting of the new Public Service Agreements and 198 Local Government Indicators with as much nerd-like interest as I did. You'll recall that apart from the obvious difficulties entailed in setting up an evaluation framework before a strategy has been written, the somewhat naive faith in proxy measures of treatment throughput to measure the effectiveness of national and local approaches to recovery and the seeming absence of any measures related to reintegration, employment or housing, that some of the indicators actually hadn't been defined yet.

National Indicator 38 which sets out to measure improvements in levels of drug related crime is one of the indicators whose methodology for measurement is included in a new publication out for consultation last week from the Department for Communities and Local Government.

The new metrics for this indicator are interesting. What is proposed is to measure the effectiveness of partnerships efforts to reduce drug related crime by comparing the actual criminal activity of a DAT level cohort of people who test positive for class A drugs and people identified through OASys (the criminal justice individual database - Offender Assessment System) with the estimated or forecast criminal activity of that cohort. Essentially what this means is that someone somewhere will be looking at the likelihood of a certain group of people known to police and services offending in the next year. If less than the expected number offend (or are caught offending) then the local partnership is deemed to have done a good job. If more, then the local partnership will have done a bad job.

I am not a criminologist, and me and statistics have at best a love-hate relationship, but this seems a bit of a shaky basis on which to measure the effectiveness of our approach to tackling drug related crime. First of all, as we know not everyone who commits a crime is caught. Secondly, many things other than drug use and treatment affect peoples propensity to commit or not commit offences - so any change in performance against this criteria may not be attributable to the responses of the partnership. Thirdly, the process used to estimate the offending rate of the cohort - the figure that provides the "baseline" for the measure - is 'Response Surface Methodology' - which uses a range of variables to identify a likely outcome. This means that we will be basing our measurement on a proxy built on an estimate based on a series of assumptions informed by a narrow perspective on the relationship between drug use and crime . I'd be very happy to hear others views on this and would like to be convinced it is of more value that it appears at first sight ... please do get in touch if you think you can make this make more sense for me.

The fact that this indicator does not require any additional local data collection is a plus. I'm also grateful to the authors of the work for giving me one of my favourite phrases in any government document so far this year - the priceless and almost poetic "breach is an expression of CJS grip".

You can find out more about this consultation by downloading the new definitions and responding to the DCLG consultation. Responses are due in by 31st October.