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.

Tories – England needs you to show strong, inclusive leadership

England has the best drug treatment system in the world; it exists because of the vision of far sighted people from all political parties and the dedication of amazing staff, organisations, charities and public officials over the last 50 years.

Cuts in drugs and alcohol funding, along with the lack of political leadership and the lack of priority in England may in the coming years have a major negative impact on some of the most vulnerable people in our communities.

The moving of drugs funding into Public Health England, where illicit drug use is not a strategic priority, has given a green light to some local authorities to make heart breaking cuts in services, Birmingham being one example.

There has never been a more urgent need to have clear English government leadership matching that of Scotland. Spelling out the responsibilities of local authorities along with the levers to ensure they deliver. I would like the next government to take clear action to protect the best drug and alcohol treatment system in the world. Provide better opportunities for those in recovery and significantly reduce the death toll by committing to harm reduction, responding more robustly to rapidly increasing numbers of drug and alcohol related death and serious illness. I also would like to see a greater emphasis on responding to other health needs of those with drug and alcohol problems.

Any government with an ounce of decency would follow the Portuguese example and move rapidly to bring hepatitis C treatment up to the standards of HIV treatment. If hepatitis C treatment was running trains only 3 in every 100 would get to work and many would die on the platform.

I would like to see the incoming government do the following things with drug and alcohol treatment policy and funding;

  • Identify and appoint a single Senior Government Minister to be responsible for drug and alcohol policy, accountable to Parliament
  • Commit to evidenced-based practice
  • Ensure everyone in recovery from drug and alcohol problems has opportunities to rebuild their lives
  • Develop a national harm-reduction strategy to reduce drug and alcohol related deaths and ill health
  • Widen of the access to residential treatment focusing on need rather than the failure of everything else
  • A minimum unit price for alcoholic drinks is introduced along with health warnings on labels and prominent display of calorie’s
  • Create a national commissioning Ombudsman, to ensure transparency and accountability for local commissioning decisions
  • Widen the remit of the Care Quality Commission (CQC) to include all local authority-commissioned drug and alcohol services
  • Ensure the competence and appropriate accreditation of the drugs and alcohol sector workforce, in line with other areas of health and social welfare, by investing in an independent association
  • Follow the guidance provided by the Advisory Council on the Misuse of Drugs (ACMD)
  • Reinvigorate independent research on drugs and alcohol to fill the gap left by the UK Drug Policy Commission (UKDPC)
  • Ensure comprehensive access to the life-saving drug Naloxone, across the whole of the United Kingdom, in line with World Health Organization (WHO), ACMD and public health guidelines and advice.
  • Ensure the availability of services and National Institute for Health and Care Excellence (NICE) -approved treatments for all patients diagnosed with hepatitis C, in line with international guidelines
  • Everyone in recovery from drug and alcohol problems has opportunities to rebuild their lives,
  • Ensure access to safe and secure housing, employment and meaningful activity and support for health and mental health
  • Investment is provided for a national programme to tackle the stigma and discrimination experienced by people in recovery from drug and alcohol problems
  • ensures expenditure on drugs and alcohol treatment is maintained at a time of severe budgetary pressure on local authorities

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.

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.

Concerns with procurement, tendering and commissioning in the drug and alcohol sector

Quietly in meetings over coffee I and other CEO’s and senior managers in the sector have been sharing concerns for years about poor procurement and tendering in the drug and alcohol sector. When I spoke to Martin Barnes, CEO at Drugscope the umbrella organisation for the drug and alcohol sector, recently shared the long standing and growing concern with the state of commissioning and procurement in many areas.

However to address the issue we need evidence of the impact on staff, organisations, and examples of poor practice and waste. (How much does it cost service providers to tender, how much money do commissioners spend on consultants?) We cannot just complain about the process we have to demonstrate its impact, unfairness, and consequences for service users and on service provision and quality. It is perfectly legitimate for local authorities to retender work provided to them by contractors, however in the context of Big Society there needs to be a level playing field for the third sector and local third sector providers.

Poor and frequent commissioning has a number of serious consequences not least of which is the cost. An exercise 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 commissioner per tender.

Low Morale

At a recent provider meeting with Public Health England (PHE) in London concern was raised by PHE about the low morale of staff across the treatment system.

Feedback by those there was that this was due to;

  • Constant rounds of retendering of services.
  • Changing goal posts (and the lack of thanks for a job well done).
  • A TUPE cycle of 1 year job insecurity – 1 year changing an often great service to something different unclear and underperforming (if you keep your job and even if it’s still with the same provider) – 1 year performing in a new role (often excellently) – 1      year job insecurity.  Often this cycle is truncated and eventually inevitably leads to worker burn out for many people.
  • Many services have been retendered several times over a three year period inevitably causing insecurity and disruption to service delivery.
  • Worries about costs cutting by Local Authorities in the coming years and further redundancies.
  • The current lack of direction and leadership in the sector.
  • Most people not having had a pay rise for 4 years.

Procurement, tendering and contracts

We have to accept that tendering of services is here to stay and that providers will all win and lose contracts, however I 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.

The contracts are often very one sided and allow cancelation with three or six months notice.  Often providers are asked to agree to the contract as a condition of being allowed to tender which is clearly unfair. Contracts need to be far less easy for Local Authorities to wriggle out of with an expectation that any but the most major changes required are done via contract variation rather than retendering except where there are clear performance issues.

At Blenheim we are concerned about the minimum turnover requirements that are beginning to affect the ability of small providers to tender for contracts they currently hold. This is where to bid for work you have to have a minimum turnover of say £5 or £10 million.  I am aware of many smallish and medium sized charities that have not been able to bid for their own contracts back in their own right forcing them into shot gun marriages with other providers as junior partners. This has on occasions included Blenheim despite us being in the top 750 charities in the UK by income out of 66,000 charities.

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.

Blenheim is concerned that we are starting to see the demise of local third sector organisations operating and attuned to local communities and their replacement by profit motivated or organisational survival motivated or growth driven organisations. This I already hear and see impacting detrimentally on service provision.

Blenheim is concerned about minimum standards in the drug and alcohol sector with the move to Local Authority commissioning and the demise of the National Treatment Agency. Providers are all being forced to compete on price rather than quality and this has a direct impact on who is employed or made redundant. The people service providers employ and their skills and ability is what makes the difference to the mothers, fathers, children, sisters, uncles, neighbours, friends and grandparents with a drug or alcohol problem we are here to help. These people deserve a quality service delivered against exacting standards of performance and staff competence not the cheapest available.

Blenheim is 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. This is now a regular occurrence and issues have included;

  • Unfair decisions which when challenged are changed or not.
  • 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.
  • Complete lack of understanding by many commissioners of TUPE rules.
  • Attempts to dump significant pension liabilities on incoming organisations where NHS or Local Authority is the outgoing organisation.
  • Sometimes completely ludicrous and 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.

At Blenheim we think its time we should stop talking and start acting as a provider and a sector to raise these concerns via Drugscope and other forums.

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

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

These changes include;

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

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

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

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

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

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

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

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

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

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

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