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.

1st 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.

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