Where is the drugs strategy?

Trying to get a response from Government about when the drug strategy will be published seems increasingly like expecting a sensible response from an Alice in Wonderland character.

Alcohol and drugs cause huge harms in our communities yet the Government has no intention of publishing an alcohol strategy and the drugs strategy, written over a year ago, continues to gather dust on the launch pad as it is postponed again and again.

Meanwhile drug-related deaths in England and Wales have hit record levels, with cocaine deaths reaching an all-time high in 2015 and deaths involving heroin or morphine doubling over three years to reach record levels. The failure to publish the drugs strategy means the Home Office is failing to provide the strategic leadership across Government departments at a time when we are seeing the highest number of drug deaths ever recorded. New drugs are causing significant problems and life threatening issues in prisons, amongst the homeless and in emergency departments. Funding for drug and alcohol services are being cut dramatically and benefit changes are resulting in increased homelessness and deprivation.

In February 2016, the Government said it would shortly be publishing a new Drug Strategy. At the 2016 Christmas adjournment of the House of Commons, Mary Glindon MP reminded the House that, barring an unexpected delivery from Santa Claus, it was still not to be seen. She asked again early this year, and was told that it would be “soon”. So “soon” in Government terms, means months, and “shortly” means more than a year. For a brief few days it looked as if we may see the strategy published prior to Easter but alas; it appears the Easter Bunny, like Santa, will fail to deliver.

Local authority funding for drug and alcohol treatment has been slashed by 42% since 2010. Many clients seeking treatment for addiction lead chaotic lives and many struggle with a whole host of difficulties that go far beyond their addiction. They might be embroiled in the criminal justice system and need advice, they might have housing problems or be struggling with trauma, or they might have been in care and survived institutional abuse.

There are more than 1 million alcohol-related hospital admissions each year, and alcohol is a contributing factor in more than 200 different health conditions. As Chief Executive of a drugs and alcohol charity, I see the harm that alcohol does on a daily basis. I saw the impact as a police officer. I saw the impact as a probation officer. I saw the impact on children and families as a social worker. Despite the huge impact on crime, community safety, children and links to addiction, mental health problems, cancer and liver disease, the Government has indicated it will not be developing a national alcohol strategy.

NHS England has put in place an inefficient system for rationing access to hepatitis C treatment, an illness that mainly impacts on current or former injectors of illicit drugs. Despite effective treatments being available, only 4% of people with the disease are treated annually. Imagine a plane with a hundred seats but security checks that will only let 4 of the hundred passengers fly. Then because of this inefficient system, the NHS says it cannot justify a deal with pharmaceutical companies to provide access to treatment for everyone.

The Government is putting lives at risk by failing to publish a drugs strategy, failing to have an alcohol strategy and discriminating against those needing hepatitis C treatment because most are from marginalised groups. What is particularly sad is that PHE, NHS England and the Government have done some great research into what needs to happen, but what appears to be missing is the strategies and the accompanying resources.

I would love the Government to prove me wrong by publishing the drugs strategy, writing an alcohol strategy, and agreeing a deal to fund hepatitis C treatment for all. Additionally, there would be a need to agree and ring fence resources to ensure equitable access to drugs and alcohol treatment across England, making drug and alcohol treatment a mandatory responsibility for local authorities.

Do this, and I might stop complaining. In fact, I will be first in the queue to offer my congratulations.

There is an urgent need to introduce minimum alcohol pricing and publish English alcohol strategy

A recent review commissioned by the government from Public Health England (PHE) concluded that ministers should introduce minimum unit pricing of alcohol to tackle the grim medical, economic and social toll of drink-related harm. The report leaves little doubt about PHE’s support for the policy, observing that “the financial burden which alcohol-related harm places on society is not reflected in its market price, with taxpayers picking up a larger amount of the overall cost compared to the individual drinkers”.

The study found that alcohol is now the biggest killer of people aged between 15 and 49 in England and is a factor in more than 200 different illnesses. The study predicts that alcohol-related cancer will kill 135,000 by 2035. In 2015 there was an estimated 167,000 working years lost due to alcohol, 16% of all working years lost in England.

It finds that alcohol leads to such huge harm that the loss of economic activity it results in, through early death and disability among workers, is more than that for the 10 most common cancers combined.

The new analysis has examined all the available evidence globally on alcohol harm and the steps which are effective in reducing it.

The report says: “Policies that reduce the affordability of alcohol are the most effective, and cost-effective, approaches to prevention and health improvement … Implementing a minimum unit price is a highly targeted measure which ensures any resulting price increases are passed on to the consumer, improving the health of the heaviest drinkers who experience the greatest amount of harm. It would have a negligible impact on moderate drinkers and the price of alcohol sold in pubs, bars and restaurants.”

It says pricing policies should be updated in line with changes in income and inflation, “in order to retain their relative affordability and therefore be able to impact upon alcohol-related harm”.

PHE makes clear that the pricing of alcohol and the way it is marketed need to be urgently re-examined. It says policies can “address market failures by protecting people from the harm caused by other people’s drinking, deterring children from drinking, and improving consumer awareness of the risks of alcohol consumption.”

The review, carried out by PHE and Sheffield University, found that the economic burden of health, social and economic alcohol-related harm was substantial, with estimates placing the annual cost at between 1.3% and 2.7% of GDP.

The report’s conclusions will pose difficulties for the Department of Health, which asked PHE to undertake the assessment of the latest research. It will now rightly face questions about why the government is not pushing ahead with introducing the policy, given that the evidence suggests it would be effective and that it was a key initiative in the previous coalition government’s original alcohol strategy.

As Chief Executive of a drugs and alcohol charity I see the harm that alcohol does on a daily basis. I saw the impact as a police officer. I saw the impact as a probation officer. I saw the impact on children and families as a social worker. For this reason I would urge the Government to take urgent action to develop a national alcohol strategy based on the findings of this report at a time when the harms caused by alcohol are increasing dramatically. It would be a great show of unity for a concerted approach to this issue across all four UK nations. As always, Scotland and the SNP deserve credit for taking an inspirational lead on this issue rather than the unconvincing approach evidenced by current policy decisions in England.

Finding those most in need of hep C treatment: Injecting Drug Users or Baby Boomers?

I am writing this blog on a train back from an amazing two days in Scotland looking at hep C services and the challenges faced in eliminating hep C. Scotland has a direction of travel and action plan for its hep C services that it has been investing in for over a decade. The maturity of services and the debate on the way forward is significantly more advanced when compared to the overall chaos and lack of clarity or organisation in many services in England. Scottish hep C treatment services face many of the same challenges as the rest of the UK but Scotland has a can-do attitude compared to England’s often reluctant, grudging intervention. The English attitude is best characterised by NHS England’s untrue characterisation of hep C treatment costs as the biggest financial risk facing the NHS and is in stark contrast to the positive approach in Scotland.

The priority in both Scotland and England is to treat those most in need of treatment. This means people who have hep C and significant liver disease are prioritised for treatment. The difference is that in Scotland your disease is prioritised at a lower level of hep C-related illness. In at least one area in Scotland anyone with hep C has the same priority.

Key to this approach in both countries is finding people with hep C who have significant liver disease to meet the required prioritisation criteria. Brainy people have used lots of formulas and inputted data to come up with an estimate that half of those with hep c do not know they have it.

Given that 90% or more will have contracted hep C from injected drug use, it seems sensible to start looking for those in need of treatment in this cohort. So test lots of people injecting drugs and you find lots of people with hep C. Unsurprisingly, this turns out to be true, but it also means that you also find lots of people with hep C who have yet to develop liver disease to the extent that they qualify for priority hep C treatment. Scotland is treating people at a ratio of two-thirds priority to one-third non-priority. Although you may have to wait if you are non-priority, you are at least on a journey towards a cure. In England the picture is far less clear but anecdotally it seems rare for anyone with hep C but no related illness to be treated.

We could find a ready supply of people via drugs services if we wanted to treat everyone with hep C regardless of related disease. This is something I think could be achieved if we did a deal with pharmaceutical companies based on the volume to be treated. However, aside from some areas of Scotland, this is not the position we are in.

So what do we know about people who will have hep C and are likely to have serious related liver disease? It can take decades for hep C to cause liver damage so people will be older and many will have been diagnosed with hep C and told there is no or very unpleasant treatment. Many of these, the ‘lost found’, will not be in touch with services. Those responsible for hep C treatment in Scotland suspect that a sizeable number of people will have dabbled in occasional injected drug use decades ago and it will not even occur to them they may have hep C. They also suspect that many of those who in the past injected drugs migrated to alcohol as a more acceptable addiction.

Based on the opinion of experts and patient groups in Scotland, if we are serious about finding cases we need to systematically target the baby boomers – those born between 1946 and 1964 who are now aged 50-70. Some will be in drugs services; some will be in the recovery community, AA, NA etc. Others may be in alcohol services or they may be working in the drug and alcohol sector. Many will have no contact with drugs and alcohol services and will not in their wildest dreams imagine they are at risk. In Scotland guidelines already state that anyone presenting with abnormal liver function at the GP should be tested for hep C. There is also clear head of steam in Scotland to see hep C testing become much more standard across the NHS.

Not for the first time I find myself wishing England was run from Edinburgh.

The tip of the iceberg

We have just seen the highest drug related deaths figures ever; these figures record deaths from drug poisoning, but services providers know that this is just the tip of the iceberg. There is an alarming increase in the numbers of people dying in treatment as a result of chronic ill health.

An aging population of people with drug and alcohol problems are becoming unwell and often receive a poor service from the NHS in relation to their wider health needs because they struggle to navigate an increasingly complex treatment system and are often treated as undeserving by both our health system and local authorities that are under extreme financial pressure.

Imagine that you are living with a completely treatable infection, that left untreated, can cause a life changing illness (for some ultimately death) and the health service said you had to wait until you developed this life threatening related illness before they would treat you. You would rightly be outraged.

This is precisely what is happening to those who have hep C despite a range of new highly effective NICE approved treatments, with few side effects, that offers a cure for hep C. Only 3-4% of people a year currently get treatment. Unless you have a hep C related illness e.g. cirrhosis you are unlikely to be treated and even then it will have to be serious enough. Many of those with hep C who are not deemed ill enough to deserve treatment do not have their condition adequately monitored.   Sadly many GP’s tell me that they monitor those with hep C who appear to be in reasonable health but then suddenly get ill very quickly, with often fatal consequences.

This discrimination happens because around 90% of those with hep C contracted it via injecting drug use. Although many will have contracted hep C many years ago and have moved away from substance misuse they are often treated with suspicion. They are perceived as unreliable patients on whom expensive treatments are not to be wasted. Alongside this those most at risk of spreading hep C to others are seen as chaotic and thus undeserving or unsuitable.

Naloxone is a drug that saves lives by temporarily reversing the effects of opioid drugs. It costs £18 or less per pack and is recommended by the ACMD, WHO, Public Health Ministers and PHE who actively support its wide provision to those at risk of opioid overdose. Despite this many local authorities, including Liverpool, are still refusing to allow treatment providers to distribute it, denying people access to a life saving tool at a time when we are seeing a significant jump in opiate related overdose deaths. Some years ago Liverpool hosted an international harm reduction conference recognising its historical place in the history of harm reduction in drugs services.

In 2014, (after over 34 years of working in the drug, alcohol and criminal justice sectors, and as Blenheim celebrated 50 years of social action) I committed both Blenheim and myself to do everything in our power to ensure that the worlds best evidenced based treatment system was not destroyed by dogma, localism and cuts to public sector finances. Whilst recovery and ending dependency are hugely important we believe harm reduction is equally as important. Some of our sector’s best work is the daily interventions to keep people alive until they are ready to change.

I was concerned then about disinvestment by local authorities in the drug and alcohol treatment sector to fund a wide range of other equally important and underfunded public health priorities. The subsequent cuts and impending disinvestment have exceeded even my most pessimistic view of the future. We face a return to a post code lottery of underfunded services, ill prepared for the next wave of alcohol and drug dependency or to support those in often chronic ill health.

This year, 2016-17, we are seeing a 30% reduction in funding for drug and alcohol services with local authorities facing often impossible challenges, in the current financial climate, in meeting even their statutory responsibilities. With the ring fence coming off the public health grant and its abolition following the proposed introduction of Business Rate Retention, it will become increasingly difficult for local authorities to justify spending on drug and alcohol services when they cannot adequately fund services they are mandated to deliver. There is an urgent need to make the provision of a full range of drug and alcohol treatment services a statutory responsibility for local authorities.

To quote Collective Voice, an organisation part funded by Blenheim along with other large providers:

“Recent reduction in heroin use has been concentrated amongst the under-30s leaving behind a drug treatment population who are increasingly in frail health because of the cumulative impact of decades of drug addiction, problem alcohol use, poor diet, fragile mental health, and smoking. This leaves them significantly more vulnerable than their age would indicate and places a significant burden on mainstream NHS clinical services.

“Despite this, drug and alcohol treatment is not a natural priority for local authorities, the NHS or public health professionals. This places this area of activity at particular risk from the negative consequences of the proposed replacement of the ring-fenced Public Health Grant with a system of business rate retention.

“Drug and alcohol treatment provides for an unpopular and marginalised population seen by local electors, and politicians as undeserving, particularly in comparison to alternative service user populations such as children and the elderly. Without someone in local systems to champion the agenda there is a continuing risk of deprioritisation and disinvestment.”  

There is growing evidence that local politicians feel that drug and alcohol treatment is an NHS function rather than a local authority public health function. Many are already uncomfortable at the proportion of PHE funding to local authorities that is currently spent on drug and alcohol provision.

At Blenheim we work with a wide range of organisations and government departments to fight for drug and alcohol services and to ensure people in treatment aren’t discriminated against. In doing so we are supported at Westminster, by many hard working politicians from all major parties, who help us hold Government to account.

Elimination

Today is World Hepatitis Day, with the theme of Elimination.

2016 is a crucial year for addressing hepatitis. At the World Health Assembly in May, the World Health Organisation (WHO) Member States endorsed the first ever draft Elimination Strategy for Viral Hepatitis, with the ambitious goal to eliminate hepatitis as a public health threat by 2030.


Hepatitis C is a blood-borne virus that can lead to scarring (cirrhosis) or cancer of the liver if left untreated.

The virus is a serious infectious disease, but with the right early diagnosis and treatment, hepatitis C can be curable.

Hepatitis C disproportionately affects the marginalised groups of people Blenheim works with, including intravenous drug users, prisoners and immigrant populations. Public Health England reported that in 2015 50% of injecting drug users have hepatitis C, up from 45% in 2005.

Therefore, for years, Blenheim has called on NHS England, Public Health England and the Department of Health to make the elimination of hepatitis C a clear priority. We advocate that substance misuse services, the NHS and local authorities must do more to test, treat and cure those with hepatitis C.

In 2014, Blenheim became a member of the Hepatitis C Coalition – along with a group of leading clinicians, patients, organisations and other interested parties, we are committed to the reduction of morbidity and mortality associated with hepatitis C, and its eventual elimination.

To achieve elimination of hepatitis C, we need:

  • greater awareness about the virus,
  • better prevention – including harm reduction such as injection safety,
  • increased testing and diagnosis, and

Greater Awareness, Better Prevention

Injecting drug use continues to be the most important risk factor for contracting the infection because the virus is able to directly enter the blood stream via a needle. Approximately 50% of intravenous drug users are thought to be infected with the virus. Other forms of drug use, like sharing bank notes or straws to snort powders, also pose a significant risk of transmission. More information about risk factors can be found on the Hepatitis C Trust website.

Increased Testing and Diagnosis

You can always go to your GP or GUM Clinic and ask to be tested for the virus. If you are accessing a drug or alcohol service then you should speak to your keyworker or a member of staff about having the test. Services can provide a blood-borne virus (BBV) test for you, but if this isn’t available then they will support you to arrange this with your GP, or another healthcare provider.

Hepatitis C is a ‘silent epidemic’ because it is often asymptomatic in the early stages and can be difficult to diagnose. This means that in most cases, the symptoms are absent, mild, or simply vague. It is important to get tested if you have ever shared injecting equipment, even if it was many years ago, because you may not experience any symptoms. Although there are no set symptoms, common complaints related to the disease can include:

  • Problems with concentration and memory
  • Chronic fatigue
  • Flu-like symptoms, including sweating or headaches
  • Alcohol intolerance
  • Depression or mood swings
  • Digestive problems, including nausea, loss of appetite or weight loss
  • General aches and pains, or specific discomfort in the area of the liver

These symptoms can usually be alleviated with therapy. However, the symptoms people suffer are not necessarily an indication of whether they have liver damage or not.

Better Treatment

Anti-viral therapies have advanced greatly in recent years and are now able to clear the virus, thus preventing the progression of liver disease. These NICE approved treatments cure the virus for around 70-80% of people. Treatment has been shown to reduce both inflammation of the liver and fibrosis. There is also evidence that cases of cirrhosis can sometimes be reversed through treatment.

Decisions about treatment options should be made with your doctor. You can also contact the Hepatitis C Trust’s helpline on 0845 223 4424 for more information.

Blenheim: Test, Treat, Cure

In order to address the low levels of hepatitis treatment amongst our service users, in 2014/15, we introduced a range of initiatives in partnership with PHE, Hepatitis C Trust and the London Working Party on Hepatitis C. We have trained over 100 hepatitis champions throughout the organisation to identify the levels of hepatitis amongst our service users and to support the people affected with accessing treatment.

And progress is being made. Last year, 94% of Blenheim’s new clients that inject drugs or have previously injected drugs, had a Hepatitis C test – an increase from 87% in 2014/2015.

Furthermore, we are currently supporting the I’m Worth… campaign, which has been created to support people living with hepatitis C. It aims to address the stigma that many people with hepatitis C face, encouraging and empowering people living with hepatitis C to access care and services. It emphasises that everyone living with hepatitis C is entitled to the best care.


To find out more about Hepatitis C, please take a look at the factsheet on our website.

Test, Treat, Cure.

Stigma: One of the greatest barriers to employment

If we are to help people into employment we need to remove the stigma around substance misuse treatment, make a real effort to tackle barriers, and provide empathetic education, training and employment (ETE) support to both employees and employers. Local Authorities and other public bodies must take a leading role in providing employment opportunities.

People enter substance misuse treatment with a wide range of health and social needs. These need to be addressed alongside building motivation and aspiration for sustainable change.

Stigma is one of the greatest barriers to employment for those who have completed treatment or who are in treatment for drug and alcohol use. The double whammy of belonging to a group of people that is stigmatised is that those affected begin to believe the messages that they encounter everyday. While two thirds of employers would not employ someone who had a history of heroin or crack use*, many of those with a history of substance misuse believe they would not be employed either. There is an urgent need to develop employment ‘in-reach’** and other initiatives to provide employers with the confidence to employ people with a history of drug and alcohol misuse.

The journey for many people towards good health, recovery and being ready for employment is often slow. New skills need to be learnt and old habits left behind. At the point of accessing treatment for drug and alcohol misuse, people often have a wide range of physical and mental health issues which are often compounded by a myriad of social problems. It may take an extended period of time for people learn or re-learn softer but essential skills such as communication alongside building self-confidence/esteem. This is alongside getting treatment for physical and mental health conditions including their drug and alcohol use.

Some people have either no housing or insecure housing. This alone is a barrier to employment since employers require an address. Conversely housing is difficult to secure without a job therefore a vicious circle operates which continually pushes people further away from mainstream society.

Many people using a Blenheim ETE service were left feeling ashamed and stigmatised when accessing Job Centre Plus. They also reported that “work programmes are too intense” and as a result those who are either “not in treatment and/or subject to easements” struggle to keep up with the rigors of the programme and are therefore at risk of losing benefits. This can result in a return to the old pattern of offending and re-offending. There was a general consensus amongst the groups that the Job Centre wasn’t very helpful and the atmosphere was often poor.

In contrast people using specialist ETE services, felt they were good, offering the opportunity to get onto courses, gave an incentive to change and helped people think about and prepare for employment as they resolved or came to terms with other issues.

We are looking for employers in London to provide volunteer, employment and training opportunities for our service users. If you or know anyone that can help please contact us.


Blenheim has ETE services in Redbridge, Lewisham, and Kensington and Chelsea.

*Getting Serious about Stigma: The problem with stigmatising drug users UKDPC 2010

**In-Reach means where employees starting work with a history of drug or alcohol use are provided with additional support in the work place, as are their employers, to overcome any anxiety they have about employing those with a history of drug and alcohol problems.

How are funding cuts affecting drug and alcohol services?

The State of the Sector report, conducted by the Recovery Partnership, is documenting serious concerns about the declining ability of the substance misuse sector to meet the needs of those it serves.

The first survey, covering 2013, provided a snapshot of the experiences of drug and alcohol treatment services as they entered a new delivery landscape. This landscape was characterised by the closure of the National Treatment Agency (NTA) and its absorption into Public Health England (PHE), as well as the transfer of budgets and commissioning responsibilities for substance use services to local authorities.

While the first report found no evidence of deep and widespread disinvestment, in its second year (2014) the survey found that many respondents were experiencing or anticipating substantial funding reductions. This trend has continued into 2015, with a considerable proportion of both community and residential providers reporting a reduction in funding. Overall, the 2015 report finds that 38% of community drug services and 58% of residential services reported a decrease in funding. Given the announcement in the Autumn Spending Review that public health funding will be reduced by 3.9% per year for the rest of the current Parliament, challenges around resourcing safe and high quality services clearly remain.

Reductions in funding are causing significant disruption to service delivery. In London, reliable sources have indicated that over the last five years up to 50% of the funding for substance misuse services has been cut. The impact of cuts can include; larger caseloads, declining access to workforce development, limited core services, less outreach, less access to employment, training and education provision, and less capacity to respond to complex needs.

Frequent recommissioning is another disruption to service delivery. The 2015 State of the Sector report finds that 44% of services had been through tendering or contract re-negotiation in the previous year and half (49%) expected to go through one of these processes during the year ahead. Furthermore, the income volatility is putting many smaller excellent providers under significant financial strain.

Funding is not the only cause for concern. The challenge of offering effective, joined-up support to service users with multiple and complex needs, and in particular individuals with co-occurring substance use and mental health issues, is a thread which runs through the three reports.

Beyond addressing substance use, the most significant support needs of those using services are: self-esteem, physical and mental health, employment support and financial support and advice. A fifth of respondents in the 2015 State of the Sector report felt that access to mental health services and housing/housing support has worsened over the last year, indicating that better joined-up support for people with dual diagnosis and multiple and complex needs is still required. This is particularly concerning given the documented view in 2014 was that services had got worse. This reflects a worrying downward trend.

I know these concerns are shared by frontline staff, commissioners and providers, and as funds are cut further there is an increasing risk of unmet need and unsafe service models. Unless Local Authorities are careful we may find services being closed as result of serious concerns being identified by the Care Quality Commission. Another risk is Local Authorities are forced to cut substance misuse services to the extent that they can no longer provide community-based alternatives to custody for those with drug and alcohol problems, placing additional pressure on a prison service already in crisis and struggling to cope with drug-use in many establishments.

When the drugs strategy is published this year perhaps the first job should be a long hard look at its affordability.