Drug and Alcohol Worker should be a regulated title

Drug and alcohol workers provide support to some of the most vulnerable people in our society, yet we still do not have a legally enforceable minimum level of competence or regulation for those working in the sector.  It is extraordinary that professional drug and alcohol workers are still not regulated and recognised like social workers, counsellors, hearing aid dispensers or art therapists are.

The 2010 Drug Strategy recognised that “developing a competent substance misuse workforce is crucial to ensuring a high standard of service delivery” and the National Treatment Agency (NTA), before its demise, stated 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 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 to do their job properly
  • The knowledge, understanding and skills needed to perform each of these to the standard required.

Having identified the competences and underpinning skills 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 knowledge
  • Any such shortfalls are addressed through training, supervision and so on.

To make sure everyone has the basic skills required to work in the field, all practitioners should be able to show evidence of their competence in an agreed minimum of relevant units from the Drug and Alcohol National Occupational Standards (DANOS).

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 managers 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, then a key driving force behind this target, did not monitor 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 has stuck by the DANOS targets because we believe they remain important.  Blenheim is compliant with the training and competence requirements and all our staff are required to sign up to the FDAP Code of Conduct.

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 practitioners’ professionalism in our field and the QCF provides the opportunity for ongoing assessment of professional development.

Professionally qualified workers (qualified to practise in the UK in a regulated health or social care profession) have already demonstrated the ability 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.

I welcome Substance Misuse Management Good Practice (SMMGP) picking up responsibility for FDAP. However, 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.

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.

Blenheim offers a wide range of sector-specific training to improve practitioners’ approach, whilst understanding the importance of being responsive to a diverse range of needs and skills. As we continue to await the new drug strategy, I worry that there may be no focus on skills and qualifications for drug and alcohol workers in the near future. It makes me proud to work for an organisation which places such a strong emphasis on training and development.

We are celebrating Volunteers’ Week, and have welcomed a fantastic new cohort of volunteers to the organisation. I know they’ll receive the very best training to bring the best possible benefits to our service users, and look forward to the day when everyone in our sector receives this training and is recognised for it.

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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.

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.

Negative Impact

At Blenheim we have serious concerns about the commissioning, procurement, tendering, payment terms and the application of payment by results in the drug and alcohol sector. We also have great sympathy for the impossible funding environment that Local Authorities have been placed in by Central Government. This is not helped by the latest 6.2% cut in Public Health England (PHE) funding to Local Authorities, a £200 million in year cut. We share the growing concern that cutting £800 million from the PHE budget over the next four years will only be the tip of the iceberg, with some expecting the PHE budget to be decimated by the spending review in November or in subsequent years. Given that drug and alcohol treatment and indeed all PHE services provided by Local Authorities are subject to the NHS constitution it is outrageous that PHE spending, which is mainly invested in services for stigmatised and vulnerable groups is under attack.

It is right that local authorities now responsible for the provision of community based drug and alcohol treatment in England have a process for retendering the work provided to them by organisations such as Blenheim, however there needs to be a level playing field for charities of varying sizes, large private sector companies, NHS and local authorities. More importantly any recommissioning needs to be aware of the impact on service users.

Poor and frequent commissioning and procurement has a number of serious consequences not least of which is the cost. An exercise done by a provider to quantify the costs of tendering services over 10 years ago came up with a figure of £300,000 as the cost expended by all bidders and the commissioning authority per tender. Unintended impacts include deteriorating service provision, poor staff morale, and more importantly the fact that transitions between providers along with early exits from treatment are known factors in drug and alcohol related deaths. For example 1 in 200 injecting heroin users released from prison die within a month of release.

Increasingly charities like Blenheim seem to be in the business of tendering rather than in the business of caring for people in desperate need. In the last two years nearly 100% of drug and alcohol services have been through retendering processes according to a Drugscope survey.

A report, ‘Review of Alcohol Treatment Services’ published in August 2015 by the Recovery Partnership funded by the Department of Health into the state of alcohol services raises serious concerns about the impact of the current commissioning environment as did the ‘State of the Sector’ report, by Drugscope in 2014 into drugs and alcohol services.

Transfer of Financial Risks

The move from NHS to Local Authority commissioning has often seen a switch from payment in advance to payment quarterly in arrears. This has had a significant negative effect on cash-flow within many provider organisations. Many charities are facing increasing delays in Local Authorities paying invoices some waiting up to 6 months for payment in relation to money expended on delivering contracts. There is often little meaningful compliance with new regulations requiring payment of undisputed invoices within 30 days in the Public Contracts Regulations 2015.

Payment by Results (PbR)

Inappropriate poorly designed PbR schemes are a significant financial risk to charities. This is due to delayed payment of the PbR element for lengthy periods of time which impacts on cash-flow and because PbR is usually in our sector set against the cost of service delivery rather than as an incentive above this.

PbR is often set against stretch targets, which is appropriate where PbR operates as an incentive scheme. However almost all PbR schemes operate in our sector as repayment or non-payment schemes with funding deducted from core operating costs when often aspirational/stretch targets are not met.

When used PbR would be better to be clearly separated from core costs in contracts and be an incentive for excellent performance. Where non-payment or repayment conditions apply these we believe should be set in relation to under performance rather than against stretch targets and be clearly labelled as such and linked to processes in the contract related to under performance.

Procurement, tendering and contracts

All providers in the current environment need to accept that the tendering of services is here to stay and that charities like Blenheim will win and lose contracts, however we think there is a case to be made to increase from the standard 3 year contract to a 7-10 year minimum contract length or possibly longer to avoid regular disruption to the treatment of a vulnerable group of people. Such a move would allow providers to invest in equipment, staff training and buildings of the highest quality and build long term community links.

A recent ACMD report “How can opioid substitution therapy (and drug treatment and recovery systems) be optimised to maximise recovery outcomes for service users?” Published in Oct 2015 stated

“The ACMD has early evidence of the negative impacts of frequent re-procurement on local drug treatment systems and service users’ outcomes. It is very concerned that this ‘churn’ in the system, together with significant cuts in resources, is mitigating against stability in drug treatment systems, hampering quality and the implementation of evidence-based interventions (especially if they are deemed ‘expensive’) and may result in negative impacts on recovery outcomes. Furthermore, localism and the lack of ‘levers’ by bodies such as Public Health England and the Local Government Association may hinder government efforts to positively influence local systems.”

Local Authority contracts are often inequitable and allow cancelation by the local authority with three or six months notice, paying little regard to provider infrastructure costs and lease commitments. Often providers are asked to agree to contracts as a condition of being allowed to tender.  We would like to see contracts that are far less easy for Local Authorities to cancel once signed with the expectation that any but the most major changes required are done via contract variation rather than retendering. We fully understand and support contracts enabling cancellation where there are clear performance issues.

Minimum Turnover Requirements

At Blenheim we are concerned about the minimum turnover requirements that increasingly limit the ability of even large and major charities to tender for contracts they currently deliver. This is where to bid for work you have to have a minimum organisational turnover of say £10 million or £15 million. Whilst we realise this is a way of assessing the ability of an organisation to financially manage large contracts we believe it unfairly discriminates against smaller charities many of whom can easily manage larger contracts and that more sophisticated and more appropriate methods of assessing organisations should be applied.

I am aware of many smallish and medium sized charities that have not been able to bid for their existing contracts in their own right. This forces them into shot gun marriages with other charities as sub-contractors. Partnerships have a lot to offer and Blenheim is in many great and highly effective partnerships but they rarely work well when they are marriages of convenience or haste.

Tendering Processes

At Blenheim we are deeply troubled about the many instances of poorly managed tendering processes which create huge wastes of time and effort both at commissioning level and within provider organisations. Issues of concern include;

  • A lack of transparency about the process.
  • The number of tendering processes which have to be suspended due to flaws in the process.
  • A lack of knowledge about tendering and procurement within tendering teams
  • A lack of understanding by many commissioners of TUPE rules
  • A significant pension liability on incoming organisations where NHS or LA is the outgoing organisation particularly where down sizing is managed via a retendering process transferring liabilities for redundancy whilst often hiding cuts.
  • Unworkable specifications
  • Transfer of risk from Local Authorities to providers via Payment by Results with poor data to assess risk and often in relation to performance targets the provider has little control over.

Equally we would reflect that we have seen some excellent examples of commissioning regardless of whether we were successful.

Conclusion

If we want a thriving drug and alcohol sector we need to create a funding and commissioning environment where it can survive. Otherwise we face the risk of a choice of four or five mega charities as all but the largest go the way of the corner shop and the local butcher. Like banks and NHS Trusts these large charities maybe too big to let fail, but get into financial difficulty some will in the not to distant future as cuts in funding and huge public sector liabilities catch up with them.