Injecting Rooms: Have we progressed since the 1970’s

As the debate heats up in Brighton over the introduction of injecting rooms it is worth reflecting that this contentious discussion has taken place over the last 40 years.  At its heart is the concern between condoning illicit drug use pitched against reducing the very real risk of death, overdose, serious injury and infection that can come with poor injecting practice and hygiene.  It is a debate between a morale high ground and a pragmatic non-judgemental response to the risks injecting drug users face.

As we watch, hear and feel the passion from those involved in the debate about the possible introduction of injection rooms there is a feeling of déjà vu at Blenheim and our long history documents similar debates in the 1960’s and 1970’s.

In the late 1960’s until the mid 1970’s Blenheim (CDP operating in South London) provided clients with places they could inject safely and in private.  This was 15-20 years prior to the development of needle exchanges.

As now this practice was subject to heated and often angry debate.  The practice was even more controversial now as attitudes to drugs and those injecting illicit drugs were far less tolerant than they are today.  For most people the idea that people using heroin and other drugs should be given special facilities in which to take their drugs was seen as actively condoning and encouraging drug use and conferring a social acceptability.  It was not just the public at large this view was also widely held by many working in the substance misuse sector.

The running of injecting rooms was not without its practical difficulties as services ran on a fraction of today’s resources.  In the 1970 CDP annual report records that:

“Limiting the hours that the injecting room is open may well increase the instance of addicts injecting themselves in public, and stir up once more public opposition.”

This suggests a real concern to move injecting off the streets in part to reduce local opposition to CDP and to remove the practice from the public eye. This was indeed the case.  “You are actively encouraging and condoning an illegal and destructive activity” was a typical comment recorded in the 1970 CDP annual return documenting public feedback.  The 1970 document goes on to starkly record that:

“The mounting of a public campaign with protest meetings and accompanying press coverage poses a threat to the continued existence of our project (CDP).”

Doubts about the practice were not just coming from the community in South London within CDP there were also doubts about the validity of injection rooms. Concerns were documented that injection rooms could be;

“Seen to run counter our therapeutic aims, perhaps reinforcing a drug using culture and protecting the addict from the realities of life, however unpleasant.”

As an organisation CDP in the 1970’s was a community organisation torn between the needs of injecting drug users and its responsibility to the local community which it could not afford to alienate.

This tension was articulated in the following quote from an annual report:

“These are problems facing anybody who attempts the difficult task of reconciling the communities interests with those of a group that society fears and finds so hard to accept.  In declaring our interest with both we perhaps assume, and are ascribed, the role of King Soloman, yet lack the necessary wisdom.”

Debbie Lindsey, Chief Operating Officer Blenheim, is disappointed about progress:

“With the considerable changes across the drugs misuse sector over the last 20years and the mainstreaming of services including needle exchange, the tangible developments such as evidenced best practice, policy and guidance, recording and data collection, recovery focus, and workforce competence to name but a few, it is disappointing that the stigma of drug dependency is still increasingly present, and as a society we have not developed a collective wisdom that removes the role of King Soloman.”

The world has moved on, what was a reasonable debate and tension in the 1970’s pre HIV and the national availability of state funded needle exchange provision seems completely illogical to me today.  If we accept the need to provide needles, syringes and safer injecting equipment to drug users it seems to me outrageous not to be able to provide a safe place for people to inject where there is a need.  The debate remains whether we should provide needle exchange equipment or not, injecting rooms are simply a logical extension of existing service provision.

It seems that safe injecting rooms remain a particularly contentious issue for the UK but many Canadian  and European cities report, in line with Blenheim CDP’s experience in the 1960’s and 1970’s that injecting rooms have had a positive impact by minimising drug use in public and providing a safe place for users to go.  It is sad that in the UK even a relatively liberal place such as Brighton, struggles to come to terms with the issue.

Government needs to stick by its commitment to introduce minimum alcohol pricing

It is time to regulate the supply and price of alcohol to encourage a reduction in alcohol consumption particularly by those who drink more alcohol than is recommended in health guidelines. Listening to the views of the alcohol industry is the same as consulting drug dealers on the regulation and legality of heroin or asking turkeys to vote for Christmas.

Along with many others Blenheim is concerned about Government ’still evaluating’ the plan for minimum alcohol pricing.  As this step acknowledges the clear relationship between price and the consumption of alcohol and associated harms, which is supported by substantial and robust evidence and modeling. Minimum unit pricing is particularly important in helping to address alcohol consumption’s contribution to chronic disease and will primarily target harmful and hazardous drinkers, with comparatively little impact on the spending of moderate drinkers. Evidence shows that it is the cheapest alcohol that is causing high levels of harm—in the UK on average, harmful drinkers buy 15 times more alcohol than moderate drinkers, yet pay 40% less per unit.

Modelling conducted by the University of Sheffield found that increasing levels of minimum pricing show substantial increases in effectiveness (see Figure 1 below). Blenheim supports the introduction of a minimum unit price of at least 50p per unit, which the modeling suggests would reduce total alcohol consumption by 6.7%, saving around 20,000 hospital admissions in the first year and 97,000 a year once the policy has been in place for 10 years. This would result in direct costs saved in relation to health, crime and workplace impacts in England of £7.6 billion over 10 years.

Figure 1

Banning multi-buy discounts – Blenheim also calls on the Government to ban multi-buy promotions. The University of Sheffield modeling shows that increasing restrictions in off-trade discounting (i.e. through multi-buys) does have increasing effects in a similar way to minimum pricing. Restrictions to 40%, 30%, 20% and 10% discounting give estimated consumption changes of −0.1%, −0.3%, −1.6%, −2.8% respectively. A 2.8% reduction in consumption is similar to the change estimated for a 40p minimum price (see Figure 1 above).

It’s time to stand together to protect the best drug and alcohol treatment system in the world

At a recent conference I was asked to speak on what the biggest changes to the public sector for a generation felt like at the coal face for an organisation like Blenheim.

These changes include;

• Re-organisation of the NHS
• Establishment of Public Health England and the transfer of public health funding and responsibilities to local authorities
• Death of the National Treatment Agency as it is swallowed by Public Health England
• Localism agenda
• Police and crime commissioners
• More procurement lead commissioning structures
• Payment by Results
• Increasing role of CQC in our work

I took a straw poll of staff at head office on what the changes felt, looked and smelt like and the consensus answer was uncertainty, the unknown and a leap into the dark.

Uncertainty is the mother of anxiety and this certainly describes how it has felt over the last year as we worried about whether some Hitchcock like Politician with a knife would make cuts in services and funding without rational thought about the consequences for our service users.

I spent much of the last year campaigning with others to ensure that money was not disinvested from our sector and against the evils of the Works Programme and Payment by Results.

There remains huge uncertainty about what the changes will look like going forward,  in the end I have decided to keep calm and pretend I know what Blenheim is doing and what the changes will mean for us as we approach April 2013, which feels like the great millennium bug fears of 2000. As I speak to managers, commissioners, CEO’s, Politician’s and senior civil servants it is clear they are all doing the same.

The good news is that central government allocations to local authorities for public health seem to be generous, particularly in the age of austerity.  For now everyone is getting to grips with new structures, roles and relationships and I see little appetite or capacity for major change in 2013/14.  However over time we will start to see some real changes in what is commissioned as we move to local agenda’s and a whole population rather than a complex need focus, with the needs of the many outweighing the needs of a few.  We must embrace these changes with open arms whilst continuing to advocate for the needs of those with whom we work.

We have the greatest treatment system in the world but if we are to keep it we need to fight for it, love it, protect it; and embracing change, innovation and new priorities; develop it.

Perhaps the biggest threats are competitive tendering processes and the culture of competition it forces on agencies, who otherwise, would work together collaboratively in the interests of service users. There is little evidence that current commissioning and procurement processes improve service delivery and lots of evidence that they do the opposite.

The drug and alcohol treatment sector has in my view a clear mission to end dependency by enabling people to change and along the way we also have a duty to help people improve their health, quality of life and reduce their involvement in risky behaviour and criminal activity.

Excellent services and staff work tirelessly up and down the country making a positive impact that not only improves the health of the individual’s drug and alcohol users but has a positive impact on their families and friends. People using our services are not just people with drug and alcohol problems they are partners, fathers, grandmothers, children, brothers, sisters, friends, work colleagues and carers.  Helping them beat dependency helps put the joy back in so many lives.  The ripples of the work undertaken by staff and agencies up and down the country spread out across every community. It’s worth every penny of the £billion that is spent on it and its worth fighting for.

It is time for us to collaborate and come together as a sector to fight for what we believe is important ending dependency, enabling recovery, hope, and better lives for those with whom we work.  It’s time to challenge the damaging commissioning and procurement culture imposed on us by European procurement rules which is damaging our capacity to do this.  Of course commissioners should have the right to re-tender and re-commission services but this should not be arbitrary process and should be needs lead.  There is a need to develop and explore concepts of co-production between local authorities and the third sector.

Government should stick by its commitment to introduce minimum alcohol pricing

It is time to regulate the supply and price of alcohol to encourage a reduction in alcohol consumption particularly by those who drink more alcohol than is recommended in health guidelines.  Listening to the views of the alcohol industry is the same as consulting drug dealers on the regulation and legality of heroin or asking turkeys to vote for Christmas.

Blenheim strongly supports the Government’s commitment to introduce a minimum price on alcohol in England and Wales. This step acknowledges the clear relationship between price and the consumption of alcohol and associated harms, which is supported by substantial and robust evidence and modeling. Minimum unit pricing is particularly important in helping to address alcohol consumption’s contribution to chronic disease and will primarily target harmful and hazardous drinkers, with comparatively little impact on the spending of moderate drinkers.Evidence shows that it is the cheapest alcohol that is causing high levels of harm—in the UK on average, harmful drinkers buy 15 times more alcohol than moderate drinkers, yet pay 40% less per unit.

Modelling conducted by the University of Sheffield found that increasing levels of minimum pricing show substantial increases in effectiveness (see Figure 1 below). Blenheim supports the introduction of a minimum unit price of at least 50p per unit, which the modeling suggests would reduce total alcohol consumption by 6.7%, saving around 20,000 hospital admissions in the first year and 97,000 a year once the policy has been in place for 10 years. This would result in direct costs saved in relation to health, crime and workplace impacts in England of £7.6 billion over 10 years.

Figure 1

Banning multi-buy discounts – Blenheim also calls on the Government to ban multi-buy promotions. The University of Sheffield modeling shows that increasing restrictions in off-trade discounting (i.e. through multi-buys) does have increasing effects in a similar way to minimum pricing. Restrictions to 40%, 30%, 20% and 10% discounting give estimated consumption changes of −0.1%, −0.3%, −1.6%, −2.8% respectively. A 2.8% reduction in consumption is similar to the change estimated for a 40p minimum price (see Figure 1 above).

Public Health England national leadership and funding for drug and alcohol services

Removal of ‘ring-fencing’ from the drug budget, the shift of responsibilities from the National Treatment Agency (NTA) to the new public health structures and a more localised approach to service provision is likely to result in the long term disinvestment in drug and alcohol services, with a negative impact on vulnerable individuals, families and communities.

But my real fear is the loss of nearly 20 years of hard work creating the worlds most effective and comprehensive drug treatment system just at the point when it is having a major impact on reducing drug dependency.  I have been proud to be associated with what has been achieved and my small part in it.

I woke last night having had a nightmare that I was back in 1987 when Methadone prescribing was difficult to access and involved a wait of up to nine months to see anyone. Large parts of the country had commissioners and services that did not believe in substitute prescribing so you either detoxed on your own or found a private doctor. If we had managed to get a needle exchange the police would often park outside.

As a drug worker at Release I would regularly put people in touch with private doctors or even more regularly talk them through the process of a home detox on the phone, often from my bed in the middle of the night as I manned the 24 hour helpline. London had 3 street agencies when I started the Hungerford, CDP and The Blenheim.

In the early to mid 1980’s the impact of HIV and AIDS was becoming clear and the dreadful realisation that all those HIV positive would likely go on to develop AIDS galvanised us into setting up needle exchanges and throwing inhibitions about talking about sex out the window. Somehow it was more important to keep people HIV free or do our best to keep those who were HIV positive healthy than worry about the embarrassment of asking people about their sex life, or whether they were still using drugs.

The establishment of Drug Action Team Co-ordinators in all 149 local authority areas in 1995, the appointment of a Drug Czar in 1997 and the later establishment of the NTA along with massive investment have lead to a world leading national system of drug service provision that still reflects local diversity.

In April 2013 the National Treatment Agency will be wound up and the responsibility for drugs and alcohol at a national level will switch to a new body Public Health England (PHE).  Current ring fenced funding for drug services will go into a ring fenced budget given to local authorities to fund new public health responsibilities from 2013.

1^st April 2013 will not be the day the drug and alcohol sector is disembowelled by funding cuts but unless we are careful we will see decades of painstaking work undone as providers, commissioning structures, knowledge and more importantly the capacity to help and support the most vulnerable in our society are re-organised and under-resourced.

To date, in documents circulated concerning PHE, there seems to have been an almost complete failure to recognise that the new Public Health remit includes drug and alcohol services and that drug and alcohol workers will represent the majority of staff working on delivering PHE’s remit.

It would also seem clear that PHE will not be the voice of the drug and alcohol profession, drug and alcohol service users or providers,  a role in any event which it would seem ill equipped to perform. Neither can we rely on PHE to take forward or preserve the evidence base on which the sector sits nor the comprehensive network of services that currently exist.  The NTA, for all its marmite like effect on people, made a credible attempt to advocate within government and to a greater or lesser extent deliver on the above. This vacuum will need to be filled as a matter of urgency if we are to lock in the significant progress as a sector we have achieved over the last 20 years in helping those experiencing dependency.

I would suggest that as a sector we now ask Drugscope to amalgamate with other umbrella organisations and  to take this role in advocate for high quality evidenced based provision for service users and a minimum standard of service delivery nationally.

Within the new localised agenda it has never been more important to ensure a national recognised qualifications framework for the sector to protect service users and ensure that people providing support meet appropriate minimum standards of professionalism and skill. I continue to advocate the need for a regulated title of Drug and Alcohol Worker to ensure the protection of some of the most vulnerable in society.

Directors of Public Health, sitting in the local authority, will be responsible for health improvement at a local level and will be jointly appointed by PHE and local authorities. This will come into being in April 2013 and as part of their new role Directors of Public Health, along with local partners, will be responsible for ensuring that the drug treatment and recovery services, and those for the more severely alcohol dependent, are delivered in line with best practice.

Local authorities will take the lead for improving health and coordinating local efforts to protect the public’s health and wellbeing, and ensuring health services effectively promote population health. Local political leadership will be central to making this work. In return for taking on the responsibilities they will receive a grant, approximately 50% of which is money formally funding drugs services via the Pool treatment budget or DIP.

Local authorities will be responsible for:

• tobacco control and smoking cessation services
• alcohol and drug misuse services
• public health services for children and young people aged 5-19 (including Healthy Child Programme 5-19) (and in the longer term all public health services for children and young people)
• the National Child Measurement Programme
• interventions to tackle obesity such as community lifestyle and weight management services
• locally-led nutrition initiatives
• increasing levels of physical activity in the local population
• NHS Health Check assessments
• public mental health services
• dental public health services
• accidental injury prevention
• population level interventions to reduce and prevent birth defects
• behavioural and lifestyle campaigns to prevent cancer and long-term conditions
• local initiatives on workplace health
• supporting, reviewing and challenging delivery of key public health funded and NHS delivered services such as immunisation and screening programmes
• comprehensive sexual health services (including testing and treatment for sexually transmitted infections, contraception outside of the GP contract and sexual health promotion and disease prevention)
• local initiatives to reduce excess deaths as a result of seasonal mortality
• the local authority role in dealing with health protection incidents, outbreaks and emergencies
• public health aspects of promotion of community safety, violence prevention and response
• public health aspects of local initiatives to tackle social exclusion
• local initiatives that reduce public health impacts of environmental risks

The intention is for the grant to be spent on activities whose main or primary purpose is to impact positively on the health and wellbeing of local populations, with the aim of reducing health inequalities in local communities. Those activities include:

1. improving significantly the health and wellbeing of local populations
2. carrying out health protection functions delegated from the Secretary of State
3. reducing health inequalities across the life course
4. ensuring the provision of population healthcare advice

This does not seem to be a definition that lends itself to the long term support of small populations of heavily addicted drug users currently funded by 50% of the grant.

Although local authorities will receive a single grant that they must then prioritise, the preferred distribution is built up from three components:

• a component to support mandated services;
• a component to support non-mandated services, other than drugs services currently commissioned by Drug Action Team      partnerships (DATs); and
• A component to support drugs services which are currently commissioned by DATs through the Pooled Treatment Budget (PTB) formula. This will also include 2/3rds of the DIP budget which will be distributed using the revised formula set out below. These drugs services  are non-mandated.

The funding for non-mandated services is the ‘health premium’ and ultimately will include both a core allocation, targeted to allow authorities to be responsive to relative deprivation and poor health outcomes and an incentive component.

At this stage both mandatory and non-mandatory components are based on the same formula related to Standard Mortality rates, and when grants are made to local authorities no distinction will be made between these two elements, allowing them as much flexibility as possible within the ring-fence to prioritise spending.

The mandated services component (reflecting spend on sexual health services, the National Child Measurement Programme, the NHS Health Check programme, the provision of public health advice to NHS commissioners and resources required for ensuring health protection plans are in place) is based entirely on the interim formula recommended by ACRA, as is the non-mandated services component.

ACRA felt that, at least in the interim, the allocation of the PTB for drugs treatment should continue to follow the approach currently used and praised as effective by the National Audit Office. This is currently based on a need component and an activity component, which will continue to be followed except for replacing the need component with the SMR<75, as recommended for the rest of the public health formula.

This suggests that the formula for drug allocation from PHE to local authorities will be will be made up of three components;

1. Complexity  of partnership -24% of the  allocation for each partnership based on the SMR<75
2. Activity based on numbers in effective treatment – 56% of the allocation is based on the activity as defined by the number of adult drug users that were in treatment for 12 weeks or more, or who if they left treatment before 12 weeks did so successfully completing treatment.
3. Reward  element based on number of clients successfully completing treatment and  not re-presenting. -20% of the overall allocation is based on the activity as defined by the number of adult drug users that had successfully completed treatment and who had not re-presented to treatment anywhere in England  for at least six months.

The impact of the change to complexity factor and the allocation of the DIP money via this formula will see a redistribution of Drug Allocation between partnerships at a time when the DIP element has been cut by a third and given to Police commissioners who may choose not to invest in drug services.

No mention is made of the guaranteed income based on this year’s allocation promised to PbR drug pilot areas.

The introduction of needle exchange and related services in the UK in the 1980s and 1990s resulted in one of the lowest rates of HIV infection among injecting drug users (at around one per cent) in the world. It is unclear what requirement (if any) it is envisaged there will be for local authorities to provide services such as needle exchange, screening and testing for blood borne viruses and vaccination and treatment for hepatitis and other health problems associated with the use and administration of drugs, or what alternative arrangements are proposed for these vital services. It is unclear what role and/or responsibilities are envisaged for GP Consortia in the provision of harm reduction services, and drug and alcohol treatment more generally.

There is a particular challenge in ensuring the provision for people affected by drug and alcohol problems is given sufficient priority at local level when there will be so many competing demands on public health funding, particularly given the levels of stigma they (and their families) can experience.

This challenge is not helped by the limited reference to drug and alcohol services in the Government’s ‘Healthy Lives, Healthy People’ (HLHP) consultation documents, and in the wider public discussion of health reform. Despite the fact that drug and alcohol treatment and other services will represent a quarter of the national and up to half of the local public health spend, the White Paper contained only a handful of references to drugs and alcohol.  Only two proposed indicators in the consultation document on ‘Transparency of Outcomes’ were directly concerned with drugs and alcohol:  ‘numbers leaving drug treatment free of dependency’; and ‘rate of hospital admissions per 100,000 for alcohol related harm’.

At the 2011 Drugscope conference directors of public health clearly indicated they would be seeking to divert current drugs treatment funding to other public health priorities and in February 2011 Paul Hayes, NTA CEO, expressed serious concerns about the threat to drug service provision resulting from local disinvestment.  Despite the reassuring news concerning PTB arrangements in relation to drugs funding (which could easily be dropped), there are still serious concerns re disinvestment in drug services, particularly for young people where this is already happening.  So concerned are the NTA in April 2012 about local areas disinvesting in alcohol provision they have written to local areas expressing concern about the proposed spending identified by most London boroughs on alcohol services by Partnerships which they regard as significantly under reported.

‘Drugs Worker’ should be a regulated title requiring specific competence and training

Drugs and alcohol workers work with some of the most vulnerable and challenging people in our society, yet we still do not have a legally enforceable minimum level of competence or regulation for those in the sector.  It is extraordinary that the professional drug and/or alcohol worker is still not regulated and recognised in the same way as a social worker, doctor, nurse, counsellor, hearing aid dispenser or art therapist.

The Drug Strategy recognises that ‘developing a competent substance misuse workforce is crucial to ensuring a high standard of service delivery’ and the NTA notes that ‘it is important that commissioners and services continue to work towards a workforce which is fully competent and able to demonstrate its competence’.

But we need more than just people with the ability to do their job; we need a workforce which puts its potential into practice on the ground.

We also need practitioners to work to the highest ethical standards because of the potential vulnerability of our client group.

The first step to a competent workforce is for each person to have a “role profile” identifying:

• The range of competences they require (i.e. the tasks and activities they need to be competent in) to do their job properly
• The knowledge, understanding and skills (know-how) needed to perform each of these to the standard required.

Having identified the competences and underpinning know-how required in a person’s role, we need to ensure that:

• They are regularly assessed against their role profile, to identify any shortfalls in their competence and underlying know-how
• Any such shortfalls are addressed through training, reading, observation and feedback, supervision and so on.

To make sure everyone has a basic set of competences to work in the field all practitioners should either have, or be working towards, evidence of:

• Their core generic competence to work with adults and/or children and young people (depending on their client group)
• Their competence in an agreed minimum of relevant units from the DANOS standards.

Finally, practitioners need regular supervision to ensure they are putting their abilities into practice and acting ethically.

When DANOS was published the following target was set:

• All workers and their line managers/supervisors should have, or be working towards, evidence of their basic competence to work in the field.
• All line managers should be undertaking, or have completed, a training course in line management.

Unfortunately the NTA, a key driving force behind this target, did not monitor our progress against this and removed targets for workforce development from its requirements of local areas. This left the DANOS targets in limbo and open to unscrupulous providers employing people without the competence, knowledge or ability to deliver services on the ground.

Blenheim CDP and a range of other providers have stuck by the DANOS targets because we believed they were important.  Blenheim CDP has been compliant with the training and competence  requirement for a number of years and all our staff are required to sign up to the FDAP code of conduct.

National Occupational Standards (NOS) identify the range of tasks and activities relevant to a particular area of work.

Individual NOS units identify the things people need to do, and the underpinning know-how required, to carry out a task or activity properly.

The Drug & Alcohol National Occupational Standards (DANOS) cover most of the substance misuse tasks and activities relevant to the field.

Competence frameworks like the Knowledge & Skills Framework (KSF) typically include most of the generic competences relevant to drug and alcohol workers, but not the more specialist ones covered by DANOS.

The QCF (Qualifications and Credit Framework) is the national credit transfer system for educational qualification in England, Northern Ireland and Wales. The Substance Misuse Awards and Certificates, on the QCF, are clearly the way forward for verifying the competence of practitioner’s professionalism in our field and the QCF provides the opportunity for on-going assessment of professional development.

Professionally qualified workers (see below) have already demonstrated the generic competence to work with people but not the specialist knowledge required to put this into practice in the drugs and alcohol field. They should at least be undertaking a competency-based substance misuse qualification and the Substance Misuse Award (QCF) is well-placed to address this. While anyone practising as a counsellor or psychotherapist, if not already certified by an appropriate body (like BACP, UKCP, UKRC or FDAP), should also be working towards becoming so.

[A professionally qualified worker is someone qualified to practise in the UK in a regulated health or social care profession (e.g. as a nurse, doctor, social worker), Chartered by BPS as a psychologist, or Certified as a counsellor /psychotherapist by a recognised certifying body (e.g. BACP, UKCP, UKRC or FDAP)].

There is now an urgent need for leadership and regulation of qualification and competence in our field and clear pathways for progression within the wider Health and Social Care sector. The Skills Consortium needs to address this urgently. Or perhaps we just need to wait for the newspaper headlines and the public enquiry about why things went so wrong and were left for so long. We are gifted with committed and highly skilled practitioners; let us give them the formal assessment, qualification and recognition that they deserve and also offer a clear professional career opportunity for the practitioners of the future.

End dependancy by enabling people to change

At the weekend a friend asked me if I thought I made a difference.  This reminded me of a BBC breakfast interview I did in the 1980’s when needle exchanges were being set up for the first time in the UK, despite many aspects of what was being supplied being technically  illegal.  I was asked how can you justify giving people the equipment to take illegal drugs.  My answer was “If providing needles to drug users stops one person getting HIV, blood borne virus, or AIDs it will be worth every penny”.  Harm reduction and the low-level of HIV infection amongst injecting drug users in the UK remains an outstanding achievement of the drug treatment system .  Increasingly, as harm reduction is being airbrushed out of the drug strategy, we will need to continue to defend the concept.

Blenheim CDP’s mission is to end dependency by enabling people to change.  Change is a journey and people will take many routes. Every journey has two key elements the first step and the final destination.  Some of us make the journey faster than others and some never get to the final destination.  Sometimes helping those who never manage to beat their addiction is the best, most meaningful and important work staff at Blenheim CDP do.

In a world driven by targets it’s easy to forget what is important. With the focus increasingly on people completing drug and alcohol treatment drug or alcohol free and not returning to treatment for a significant period it is easy to miss the other impacts we are having as an organisation on people’s lives.

If I said I could help you improve your quality of life by 16% would you be interested?  At Blenheim CDP service users, with our help, achieved the following impact on their lives for people in 2011;

• 33% of heroin users became abstinent.
• 32% of crack users became abstinent.

Arguably more important is the impact service users were able to have on their overall health and wellbeing. On average people changing their lives with Blenheim CDP reported that their:

• Psychological health had improved by 7%
• Physical health had improved by 16%
• Quality of life had improved by 16%

The number of service users who were homeless decreased by 27% between entering the service and follow-up. As an organisation Blenheim CDP needs to work to a target of 100% reduction in homelessness, in the 21^st century no one should be homeless.  If we can spend billions of pounds on the Olympics we can make sure no one is homeless.  My management team will ask if this is realistic to which my answer will be “no but its right”.

Public Sector reorganisation is a threat to sustainable investment in tackling drug and alcohol dependency

At Blenheim CDP we welcome the clear policy shift to a recovery agenda in the 2010 Drug Strategy, its focus on reducing drug use and dependency and its increased focus on community reintegration and service user led provision.  We are concerned, however, that the combined impact of public sector re-organisation will result in a lack of sustainable investment in drug and alcohol services, undermining the recovery agenda and the Governments Drug Strategy with a negative impact on vulnerable individuals, families and communities.

In February 2012 the Recovery Partnership, in a letter supported by Blenheim CDP and all the key provider organisations in the substance misuse sector, wrote to Andrew Lansley, Secretary of State for Health, and Theresa May, Home Secretary, setting out the risk of disinvestment.

It is clear that the abolition of the NTA, the transfer of an estimated £1 billion of drug and alcohol funding into Public Health England, and removal of the specific ‘ring-fence’ around the ‘pooled drug treatment budget’, will result in significant disinvestment in substance misuse services unless action is taken now to prevent this. The current plan is that Local Authorities will initially continue to be funded for achieving current pooled treatment budget targets but there is serious doubt about the future of funding for drug and alcohol services and there is are particular concerns about the disinvestment of expenditure from local NHS and Local Authority budgets which have historically been invested in drug and alcohol services.

This concern is driven by the fact that Local Authorities will be able to spend as they wish in meeting a large number of significant and largely underfunded public health responsibilities. There is a particular challenge in ensuring the provision for people affected by drug and alcohol problems is given sufficient priority at local level when there will be so many competing demands on public health funding, given the levels of stigma they (and their families) can experience. In November 2011, at a Drugscope conference, a number of Directors of Public Health clearly indicated they would be seeking to divert current drugs treatment funding to other public health priorities.

This challenge is not helped by the limited reference to drug and alcohol services in the Government’s ‘Healthy Lives, Healthy People’ (HLHP) consultation documents, and in the wider public discussion of health reform. Despite the fact that drug and alcohol treatment and other services will represent a quarter of the national and up to half of the local public health spend, the White Paper contained only a handful of references to drugs and alcohol.

Paul Hayes, NTA CEO, has expressed serious concerns about the threat to drug and alcohol service provision resulting from local disinvestment.  There are seriously concerns about the potential for local areas to disinvest in alcohol provision and the NTA have written to local areas in London for example expressing concern about the under reporting of spending on alcohol services.

Young people’s drug and alcohol treatment is particularly dependent on local investment.  There has been substantial disinvestment in young people’s services since the 2010 Spending Review and this trend was confirmed in research by the UK Drug Policy Commission in 2011/12.

The removal of the ring fencing of the Drug Intervention Programme money along with the transfer of a third of the money to an elected official responsible for crime and policing at a time of dramatic cuts in police funding raises the significant threat of disinvestment in DIP services to fund other initiatives more attractive to the electorate, or simply to fund existing core policing activity.

This change is also likely to lead to a geographical redistribution of the money as the remaining two-thirds of the money will now be allocated via drug allocation to local authorities using a different formula for distribution.  So in terms of DIP money the Police may choose to disinvest it in drug and alcohol services and the remaining current ring fenced money will come down to Local Authorities via a generic allocation for drug services which they can choose to disinvest in DIP services or indeed drug misuse services in general if they choose.

It is unclear what requirement (if any) it is envisaged there will be for Public Health England to provide services such as needle exchange, screening and testing for blood borne viruses, vaccination and treatment for hepatitis and other health problems associated with the use and administration of drugs, or what alternative arrangements are proposed for these vital services.  Indeed, even within the realm of Public Health, the reorganisation seems at risk of being something of a fiasco. Professor John Ashton, Joint Director of Public Health, NHS Cumbria and Cumbria County Council is brilliant in his condemnation.

It is unclear what role and/or responsibilities are envisaged for GP Consortia in the provision of harm reduction services and drug and alcohol treatment more generally. There is serious concerns that Clinical Commissioning Groups in many areas seem ill prepared to take on their new responsibilities, generally, and particularly around the needs of those with serious drug and alcohol dependency.

The Health and Wellbeing Boards in many areas will not have progressed sufficiently to enable them to effectively manage their public health responsibilities by April 2013.

It is unclear who will monitor standards, quality and investment in drugs and alcohol services in line with the Drugs Strategy following the demise of the NTA.