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.

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.

HEP C SCANDAL – failure to provide treatment or baseline data

National figures suggest 49% of people who inject drugs in the UK are hep C positive, this compares to just 1% who are HIV positive. This group is more likely to have been in prison and been homeless and 47% are unaware of having hep C.

Only 3% of people with hep C get treatment annually despite existing effective treatments being available. This is a scandal.

The rate is far lower for those with drug problems and figures are not kept regularly on people’s access to treatment. This hides an appalling institutional discrimination against drug users and other minority groups. Only 52% of Health and Wellbeing Boards have given any priority to hep C despite many of them having high rates of infection. The numbers dying as a result of hep C infection are rising at an alarming rate despite it being something for which there are effective treatments. The failure to act is shameful.

Substance misuse agencies, the NHS and local authorities must do more to test, treat and cure those with hep C. A first step would be for Public Health England to add a question about whether those hep C positive are receiving treatment to data required from all service providers, to ensure an adequate baseline on which to base an improvement plan.

Why Blenheim is a passionate supporter of the campaign to eradicate Hep C

As CEO of Blenheim I have been concerned for years about the poor access to treatment for drug and alcohol users with hepatitis C. Late in 2013, I read the foreword from The Hepatitis C Trust report “The Uncomfortable Truth: Hep C in England: The State of the Nation” written by Charles Gore. I decided for Blenheim and I that the time for concern was over the time to act had arrived. Please read below the foreword that had such an impact upon me.

“There must be no more excuses for the rising tide of deaths from hepatitis C. Hepatitis C is a preventable and curable virus. The fact that deaths from the virus have nearly quadrupled since 1996 is a scandal. It is absolutely unacceptable that half of those living with hepatitis C are still undiagnosed and a mere 3% of those infected are treated each year.

This report reveals plainly the link between hepatitis C and deprivation. Almost half of patients with hepatitis C who go to hospital are from the poorest fifth of society.

It begs the question: has hepatitis C been overlooked for all these years, resulting in spiralling hospital admissions and deaths, because of the people it impacts? Has it been ignored and under-prioritised because most of the people living with, and dying from, the virus are from the most marginalized, vulnerable, deprived groups of society?

One thing is certain: if the health service is to reduce health inequalities and “improve the health of the poorest, fastest”, hepatitis C must be addressed.

Almost ten years ago a ‘Hepatitis C Action Plan for England’ was published by the Department of Health, recognising hepatitis C as an overlooked condition, a “Cinderella service”. However, the Action Plan did not contain any benchmarks, targets, timelines, monitoring or evaluation measures to ensure implementation of the actions. As a result, implementation was patchy at best and now, almost a decade on, many hepatitis C patients are never assessed for liver damage or offered potentially life-saving treatment.

However, the future could be bright. Treatments for hepatitis C have improved in recent years and new drugs with almost 100% cure rates and very few side effects are expected to be approved in the next few years. Furthermore, the emphasis on addressing public health and health inequalities in the recent NHS reforms should make tackling hepatitis C a priority.

Public Health England, local authorities, NHS England and clinical commissioning groups have a tremendous opportunity to work together to tackle hepatitis C. This report summarises the current ‘state of the nation’ of hepatitis C in England and challenges the new NHS to work together to provide hepatitis C patients with the care they need and deserve and in too many cases have not been receiving.

With coordinated and effective action to diagnose and offer treatment and care to everyone with hepatitis C, The Hepatitis C Trust believes that the virus could be effectively eradicated in England within a generation. Let’s stop talking about it. Let’s do it.”

Charles Gore

Blenheim is fully committed to ensuring this powerful vision becomes a reality and over the next few blogs I will share with you what we have been doing to support The Hepatitis C Trust and others to ensure we eradicate hep C.

Public health ring fenced funding not safe in PHE and Local Authority hands

Blenheim is extremely concerned that Local Authorities are diverting ring fenced funds for public health which includes money for drug and alcohol services to fund other services. Blenheim adds its voice to that of the Faculty of Public Health which has called on Ministers and the National Audit Office to more closely scrutinise how the system is working.

Local authorities across England are diverting ring fenced funds for public health to wider council services to plug gaps caused by government budget cuts a BMJ investigation has found. The BMJ also found that public health staffing in some parts of the country is being scaled back to save money. Professional organisations have warned that public health’s voice may be drowned out in local government and that its workforce is spread too thinly.

The investigation found examples of councils reducing funding for a wide range of public health services, including those for substance misuse, sexual health, smoking cessation, obesity, and school nursing. The BMJ found that many local authorities have deployed public health funds to support wider council services that are vulnerable to cuts, such as trading standards, citizens’ advice bureaux, domestic abuse services, housing, parks and green spaces, and sport and leisure centres.

Only 45% of respondents to a recent BMA survey of public health professionals working in local authorities and at Public Health England believed that the public health grant was being used appropriately in their area, while almost half (49.6%) believed that the grant was seen “as a resource to be raided” by local government.

The BMA’s survey also highlighted fear about future staffing levels in public health, with just 12% of respondents believing that there would be enough substantive consultant posts available to serve the needs of the population in 10 years’ time.

The Association of Directors of Public Health told the BMJ that it was particularly concerned about a vacuum in public health leadership at the top of local government, with a quarter of director posts currently unfilled or filled by temporary appointments.

I am even more concerned about Public Health England’s (PHE) apparent failure to adequately ensure that the public health money is spent in line with the ring fence.

The national authority, Public Health England, has said that it supported local authorities making tough decisions and that it was right for public health grants—totalling £2.8bn across England for 2014-15 – to be used to leverage wider public health benefits across the far larger spend of local government.

Duncan Selbie the head of PHE said “The duty is to improve the public’s health, not to provide a public health service.”

At Blenheim our translation is it is about improving the health of the overall population not treating people who are ill. This is particularly unfortunate for those whose treatment is the responsibility of local authorities and PHE. PHE seems to be giving the green light to local authorities to loot and plunder the ring fenced public health grant at will.

This will then come as little comfort to those who now rely on the specialist health services to support them overcome problems with drugs and alcohol and brings into question whether these services and a relevant proportion of the funding should be transferred back to NHS England which is about providing a public health service.

As part of its investigation the BMJ issued requests under freedom of information legislation to all 152 upper tier local authorities in England (most of which are unitary, county or city councils), asking for details of all services commissioned and decommissioned since April 2013 and for details of commissioning intentions for the coming year.

Of the 143 authorities that provided information, almost a third (45) have decommissioned at least one service since April 2013, while others have cut funding to certain services, the BMJ found. Many councils are decommissioning individual contracts for services such as sexual health and substance misuse and then re-commissioning new integrated services to make efficiency savings. Other authorities have decommissioned services that they said were not having the desired outcome on public health or delivering value for money.

In total, more than half of authorities (78) have commissioned or re-commissioned at least one service since April 2013, and the pace of change is set to escalate this year as councils carry out root and branch reviews of services after the year of consolidation.

Sue’s Story

When I look back now, I realise how naive I was.  Throughout  37 years of marriage to an alcoholic, I really believed that I could change him and make him well. I would hide the alcohol, cut up the credit cards, cry, shout, plead and threaten.  He did try to get help and was in and out of rehab several times, but his heart wasn’t really in it and he kept ‘falling’.

My breakthrough was a friend’s advice: “you can’t help him, you can only help yourself.” She told me about Blenheim’s CASA Families, Partners and Friends service. They impressed me from the start, showing real understanding of and empathy with my situation. I decided against one-to-one counselling as I was afraid that I would be encouraged to leave my husband  (I now know that you have to make your own decisions) and I didn’t want to. Instead I joined a support group. It felt very safe and I learned quickly that I needed to create some distance from my husband. In my doing just that, he started to really look at himself. My CASA group sessions, and the fact that my husband was too ill to get out of the house to get his alcohol, finally broke a pattern of nearly 40 years of dependency.

He is still sober, three years on. He has rebuilt a relationship with his adult children and we go out together, to the cinema and to visit friends. I am now a Blenheim volunteer and I cannot thank them enough for showing me that you cannot change anyone apart from yourself, and for helping  me to make those changes.