New Government Drugs Strategy for England; One and a half Cheers

The Government has released a new Drugs Strategy for England, along with one or two other documents . This strategy needs close reading by commissioners and a range of stakeholders. There is some good stuff in it, but also some disappointments. This is my take. Right now I’m feeling  8/10 for aspiration, 6/10 for clarity and 5/10 for action.

Government says that the economic and social cost and changing population drug trends means a new strategy needed. Fewer drug users are coming into treatment and those under 25 who use opiates entering treatment for first time has fallen substantially. By contrast they say, there are more adults leaving treatment successfully but rates vary between best and poorest performing local authorities, and rates have levelled off in recent years with a decline in opiate users leaving treatment successfully.  The increase in drug related deaths requires action, but some are still working out what.

The aim is “to reduce all illicit and other harmful drug use, and increase the rate of individuals recovering from their dependence” and  they will be “taking a smarter, coordinated partnership approach;“  What’s not to like?  Well, this is a mixed document. Some great and welcome stuff, some areas where it remains to be seen what will change and some areas where, frankly, they could have done much better, even without funding. The question I have had in my mind throughout is “will this strategy serve people better?”  In some cases, undoubtedly yes. In other cases, much more could have been done.

The logic model of this strategy is an implicit one.  Joined up responses and local stakeholders with greater transparency. It is a massive missed opportunity that that significant and positive logic remains poorly, if at all, articulated across this document.

The legitimate role of the state in drugs

There is a debate to be had on what the interest of the state in drugs is. Indeed, there are lots of people who think they’re having that debate. Some of them though, seem to be longer on rhetoric than evidence. The influence of this debate, including the recent (and for my money patchy and inconsistent) report by FPH and RSPH on drugs is conspicuous by its absence.  My interest is harm. Where there is harm or potential for harm to people or communities, then we need to act. Where there isn’t, I’m not sure I, personally, have a role.  If people are using drugs without any harm or potential for harm, then that’s much less of a priority for me than those who really are harming themselves and others. I’m aware that this varies across government; customs and police have different as well as shared interests to me, and reducing supply remains important even if we only see that as a way of reducing crime. It’s important. But this strategy could have done a basic network analysis of those to guide us all on what we should focus on. That is left to local areas, if it is done at all. And that’s an omission.  All of that suggests to me that the policy agenda on this continues to remain short on the joined-up thinking we need to be mirrored at national, regional and local levels.

Responses from the people who will end up doing the work

The Association of Directors of Public Health (ADPH) and the Local Government Association (LGA) have both responded to the strategy.  The ADPH statement points out:

  • “The local response will require Directors of Public Health to continue to play a central role and we can no longer avoid the fact that cuts to the Public Health Grant are damaging to government’s ambitions. There is no long-term vision in this strategy to ensure services are adequately funded.”
  • “The pressure on Directors of Public Health and Local Authorities could have been easily addressed by reversing the cut to the Public Health Grant; the announced cuts total £531M while additional expectations continue to be created.”

Meanwhile the LGA response, while affirming that “Local government will continue to play its part in working with national government to deliver on our shared ambition to support those individuals and their families devastated by the harm caused by drug misuse” points out that  “we have long argued that reductions by central government to the public health grant in local government that is used to fund drug and alcohol prevention and treatment services is a short-term approach and one that will only compound acute pressures for criminal justice and NHS services further down the line.

It concludes “Leaving councils to pick up the bill for new national policies while being handed further spending reductions cannot be an option. Pressure will be placed on already stretched local services if the Government fails to fully assess the impact of their funding decisions.”

Key things for a Director of Public Health to do

For all the lack of mention of Directors of Public Health (not once in over fifty pages), there are numerous mentions of Local Authorities, and the document implies the system role we have will continue. The key challenge is to turn this strategy from paper to opportunity. That is just not going to happen without Directors of Public Health, local authorities more widely, police, voluntary sector and a range of other stakeholders working together locally. So the lack of even a basic acknowledgement of this beyond the repeated use of the word partnerships is at best, disappointing.  At worst, it suggests a lack of ability to think about systems approaches, despite the fact the strategy implies – and here I fully support it – we need whole systems approaches on this.

The key action for DsPH is to identify what we need to do to build effective local partnerships across reducing demand, supply and building recovery and work on this.  We should welcome the focus on partnership, evidence and transparency, as well as the lifecourse approach.

We should also recognise that no single agency will in reality be well placed to deliver most of this, it requires comprehensive action by a range of stakeholders.  But the role of local authorities and Directors of Public Health needed a somewhat better elucidation than is in the strategy, and to be honest, the role of national government gets little explanation. This document is long on ambition, short on conceptualisation and patchy on action. It will be important for local leaders to fill in these gaps if the ambition and opportunity the document rightly tries to set us towards is to be realised.

At best this document is welcome clarity and focus with very little specific commitment.  PHE will face new demands to support. We need to hold PHE to account to deliver this well and effectively, and to add value in the system. That varies by region and Centre, if PHE’s own stakeholder survey views are anything to go by.

Drug related deaths, lifecourse approach, recovery, prescription drug use, chemsex, NPS, working with police, better offender management, drug testing on arrest and more are all on my agenda. Some of this document helps, some of it still leaves us on our own to sort it out. It’s a shame that the leadership role of local authorities in this is mentioned more implicitly than explicitly.

Background

The strategy is owned by the Home Office, but it’s clear this has been significantly influenced by Public Health England.

There is no new money but several re-announcements of existing or previous money. While there is not a single mention of the Director of Public Health, it seems existing funding through Public Health Grant (until 2019) and the commissioning responsibilities of the Director of Public Health will remain.

There are lots of good intentions on partnerships which seem to boil down to a national strategy board to hold local areas and other work to account.  While one can see where concerns of different stakeholders have sometimes got through, this strategy feels written close to the chest of government, and what feels like lack of concrete commitments in some places, vague promises of support and work in others shows that. In a time of austerity, why did we not get the system together to work out what we could do without money. I think we would have had a better product.There are a number of things to be welcomed but this could have been a much better document with that approach.

The commitments on Families, for example, are spread across the document but beyond saying PHE will work with drug and alcohol family courts , produce a toolkit for local authorities and an exhortation that “evidence based psychological interventions which involve family members” should be available, there is often not much to go on.

Much of this gives PHE a significantly enhanced role of support or guidance, though some will argue that this is what they should have been doing anyway, and there is little in the way of detail on what will actually happen. The use of “support” occurs 150 times throughout the strategy and “work with” 17. But there is precious little detail and some will wonder about PHE’s ability to deliver.

The strategy seems to verge between a deficit approach “local areas need support” while recognising and exhorting local partnerships to do better at other times. This feels like it could have been better thought through.  Its really good they want local areas to be more effective but the relationship set out in here feels extremely one sided.  Will local commissioners have representation on the new national Board? If not, why not?

For all their talk on partnership and integration, the model still feels like it veers towards national doing to local and holding them to account.

Measuring outcomes gets various mentions with, on page 36, its strongest statement, a framework of measures and outcomes from treatment to recovery. A homelessness and housing measure, and measures for crime, mental health and employment will be added.  Without the impetus or requirements for agencies to work together though (and this never gets beyond exhortation in the strategy), this will be more difficult to achieve if local relationships and co-ordination don’t prioritise this. Good idea by government, but have they really thought through how to make this drive change?

A section on governance is perhaps most disappointing of all.  Given everything that could be done locally to address some of the aspirations of this strategy, there is only a commitment to a national strategy board (fair enough, that will be useful) which will “ use greater transparency and data on performance to support action by local services to deliver the best possible outcomes and monitor progress.” The old National Treatment Agency’s obsession with performance management by another name perhaps?

There will be a National Recovery Champion who will sit on the Board, provide leadership, support collaboration, seek to address stigma and act as a ministerial envoy. Well, as a change tool, this has mixed reviews. Has government learned little from the mixed experience of Tsars, Czars and Tzars across clinical areas, public sector transformation and drugs among other areas since 1994?

The statement that “the Care Quality Commission will play a vital role in assuring quality” is very welcome, provided CQC does better at understanding what it is we are all trying to achieve. The document talks about quality in an encouraging way. That’s good. But we need to work together to recognise it, and there is little concrete here to go on. Take for example what good looks like for specific populations. There are sections on specific populations across the document. These range from really welcome but could be stronger (dual diagnosis issues) to tokenistic and feels like government doesn’t actually know what to do (chemsex.)  The phrases “good practice” appear throughout. What this looks like across any area remains to be seen.

I’m not going to cover the global action chapter which feels more like its relevant to people other than local commissioners.

 

Reducing Demand – adopting a lifecourse universal approach

I count at least 20 commitments in this and other chapters on this:

  1. PHE will help local areas by providing professional guidance for midwives, health visitirs and school nurses under health child programme
  2. Providing support and guidance to LAs including systems to support integrated commissioning and delivery from 0 to 5
  3. Supporting school nurses, youth workers and community services to work together
  4. Providing information through child health profiles
  5. Encouraging schools and teachers to “develop their practice”
  6. Encourage prevention strategies in schools
  7. Develop resources and share them, and monitor existing programmes
  8. Specialist substance misuse services should link with wider childrens’ services
  9. Govt says they will support youth offending team to work with individuals
  10. Action on families : PHE will wotk with Family Drug and Alcohol Courts and local public health teams to improve outcomes and the existing Troubled Families programme. No mention of Family Safeguarding. The strategy later commits that PHE will develop a toolkit for LAs to support response to parental substance user
  11. Vague and unsatisfactory commitment on intimate partner abuse (page 12)
  12. In depth research on sex work
  13. Homelessness work will be done through the Homeless Prevention Programme (but nothing specific on drugs)
  14. Expectation to continue to work together on veterans drugs issues nothing concrete other than provide tailored pathways
  15. On Older People Advisory Council on Misuse of drugs looking at evidence on older people
  16. On new threats they talk about novel psychoactive substances (NPS) and will establish a new clinical network of experts and clinicians.
  17. In prisons NHS England has carried out a review of its commissioned provision and will increase focus on NPS
  18. Neptune II – an NPS programme, will be promoted more widely across the field
  19. Chemsex – PHE will support areas by providing guidance on close collaboration between sexual health services and community groups
  20. Misuse of prescription medicines – “we will support local authorities and CCGS so people dependent on medicines can access suitable treatment”

Some of this is good, some feels like a litany of “things we must mention” rather than a coherent set of strategically thought through concentrations of effort. Little of this seems to have much in the way of strong evidence base and the strategy seems to assume beyond pilot areas mentioned that it isn’t happening already. Some of this may be useful but this feels like doing for the sake of doing. Phrases like “encouraging” schools, seems to have little in the way of teeth given how government feels this is urgent. Some encouraging noise about universities’ role are given, for example, but no clear action. There is an incredibly weak statement on prescription medicine use especially given what others are doing about it

Restricting Supply Chapter

There are some new actions but mostly targeted at national level.  Some specific commitments to be welcomed include:

  1. Govt will look at options to make improvements to drug driving regime including remedial courses
  2. Look at how anti social behaviour legislation can be used to tackle drug related offending

Sub chapter on Drug Related Offending

This section  is mixed. There are some good things in here and if we work on them we could make the system work better. Some things need greater elucidation, though.

  1. Encouraging wider user of drug testing on arrest.
  2. push for drug testing to be more consistently available in the community so it can be part of a community or suspended sentence (feels like a backwards move for some areas)
  3. Early intervention for offenders through “better integration” with community mental health and substance misuse services
  4. Increase use of treatment as part of a community sentence including a protocol for drg rehabilitation
  5. Considering what to do following the pilots on out of court disposals
  6. Against the background of prison reforms, do more to restrict supply in prisons including testing and treatment. A specific list of actions and committments
  7. Some vague statements about local partnerships
  8. They will work with integrated offender management arrangements to share practice
  9. Continue to support heroin and crack action areas

We need to turn some of the very vague statements like “we will work with” into concrete actions. This section of the strategy seems strongest on the national enforcement and supply restriction work and work in prisons.  Buzzwords like better integration and vague words about local partnerships are welcome signs of intention but we need to turn these into action. The National Strategy Board will not achieve this unless it develops strong local relationships.

Building Recovery

This is, sadly,  probably the weakest chapter, even given the welcome but weak  lifecourse section.  There is a very welcome reminder of support after people finish treatment and a useful (page 31) and a list of points on things to enhance recovery. I like this checklist.   A good highlight is an emphasis on working from custody to community and actions to reduce drug related deaths.

But other than one or two pieces of action, it feels largely like most local commissioners are left on their own with the promise of PHE “support.”  All in all a missed opportunity for government to play its part much more synergistically with local commissioners.

A section on commissioning starts by saying nobody should be left behind, confirms the extension of the ringfenced public health grant to 2019 and says there will be greater transparency through building on the Public Health Outcomes Framework to “hold local areas to account” and then talks up the £30m Life Chances Fund and £10m payments to homelessness prevention programme. While the latter is very welcome, this section seems to say little of any use.  Again, some useful pointers but it’s up to local areas to make of this language of intention what they can.

Later in the strategy they commit to expanding the measurements of outcomes and treatment indicators (page 36), which could be very useful for commissioners and local stakeholders. Transparency is good.

I support recovery as part of response to drug and alcohol use. I really do. But evidence for recovery approaches is still building and in some areas is patchy, so the statement that  ACMD has been looking at the commissioning of drug treatment and recovery services and the impact this can have on recovery outcomes for individuals and communities is really welcome.  We need much more evidence and improving practice. But they could have recognised here that actually some of the providers around the country are doing amazing work. The commitment to “carefully consider any recommendations to inform future policy” from this while welcome, feels a let down given how important this area is. We need to be even more dynamic as a field on building and implementing evidence of what is effective.  Government’s leadership role in this alongside the rest of us is not well articulated here.

Commissioning

A re-iteration of need for local partnerships contains no specific commitments on doing anything to support them.  The 2007 guidelines on commissioning have, however, been updated, which is welcome.  PHE will support and share guidance and there will be a broader set of indicators (feels like they’ve already said this several pages earlier.) Commissioners “should” develop quality governance structures for drug treatment linked to safeguarding procedures for children and adults. (page 30.) The advice that we address quality in rehabilitation and detoxification is welcome .  But there is no indication of what quality looks like and this strategy is not going to give us it.  The proof will be in how agencies work together.

Workforce

This is a major issue in our field. There is a welcome statement on ensuring we continue to have the right workforce including working with HEE and Royal Colleges.  What will the National Strategy Board to do support this is my question back?

In particular I welcome the statement that Government will “work with Health Education England and other stakeholders, in line with the Five Year Forward View for Mental Health recommendation, to support development of an appropriately trained and competent workforce to meet the needs of people with co-occurring substance misuse and mental health conditions. “

If these commitments happen, it will be all to the good and it’s good the strategy recognises that.

Perhaps one of the most long awaited announcements has been the outcome of the Dame Carol Black work on drug use and employment.  Nothing really new here. Universal Credit will still roll out, JobCentres will have a “transfored roled” and a new “Work and Health Programme” will provide support to people who are long term unemployed and give early access to people with drug issues.

Finally, I strongly welcome the recognition of user engagement but this could have been better phrased. The section on peer-led recovery, by contrast, feels weak and beyond a mutual aid toolkit for peer support exhorts local areas to “support community based initiatives which promote and sustain recovery”

 

 

 

 

 

 

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