Colin Drummond: Cuts to addiction services are a false economy

“Savings” in specialist services are increasing pressure elsewhere in the NHS, says Colin Drummond.

Shocking images of drug users sprawled unconscious or standing statue-like in an intoxicated state have begun to surface in the media recently. [1]

Meanwhile deaths involving heroin and/or morphine have more than doubled since addiction services were transferred from NHS control to local authorities in 2012, and are now at the highest level on record. [2] Last year there were more than 15 000 drug related, and over 1 million alcohol related, hospital admissions. [3]

The need for better access to addiction services is clear.

The Royal College of Psychiatrists has three solutions: Sustainability and Transformation Plans must ensure a return to joint addiction service commissioning between the NHS and local authorities; there must be at least 60 addictions psychiatrist training posts in England; and there can be no further cuts to local authorities’ budgets for these services.

Before 2012, drug and alcohol services in England were jointly commissioned by the NHS and local authorities. Substantial government investment meant a long track record of success since the 2000s. The Health and Social Care Act made local authorities solely responsible for commissioning these services—and unlike the NHS, council spending on drug and alcohol services is no longer ring fenced. With reduced central government funding, councils have been forced to cut services to make savings.

People with drug or alcohol dependence are stigmatised and so their services are often the first to be axed. Typically, addiction services in England have seen cuts of 30% but some areas are planning cuts of up to 50%. [4] In Birmingham, for example, the addiction treatment budget was cut from £26m to £19m in 2015-16. [5]

The main opportunity to make cuts is in the workforce, meaning fewer specialist addictions psychiatrists, clinical psychologists, and nurses, and a greater reliance on doctors without specialist training and volunteers with limited training. The number of training posts in addictions psychiatry has decreased by 60% since 2006. [6] While 10 years ago there were 52 trainees, a Royal College of Psychiatrists survey found that in 2016 just 21 senior trainee posts were filled. [7] Addictions services increasingly struggle to find qualified specialists, leading to lower standards which impact on the effectiveness and safety of patient care. To meet the needs of people with drug and alcohol problems, we must return the number of addictions psychiatry training posts in England to 60.

In addition, NICE approved, evidence based harm reduction treatments are under attack by the government. [8] This has resulted in some local authorities limiting how long patients can remain on methadone treatment, and “payment by results” contracts have removed the incentive for addiction treatment services to take on patients with complex needs who are likely to need longer and more intensive treatment. [8,9] As a consequence this group is either unable to access addiction services, or they fall out of treatment during transitions between service providers through tendering processes every three years. This continual and unnecessary churn of service providers is inefficient, ineffective, and costly.

Cutting community based addictions services has transferred the burden of patients with drug and alcohol dependence on to already pressurised emergency departments and general psychiatry. The 15 074 hospital admissions in England for illicit drug poisoning is an increase of 6% on the previous year—and is a staggering 51% higher than in 2005/06. [10,11]

Cuts at a local level make savings—but what is the real cost? Our previously well functioning treatment system has been downgraded by a short term strategy to save money. This is a false economy. If we want to tackle the rise in drugs related deaths, there must be at least 60 addiction psychiatry training posts in England and there must be no further cuts to addiction services by local authorities.

Colin Drummond is professor of addictions psychiatry at the Institute of Psychiatry, Psychology, and Neuroscience, King’s College London and a consultant psychiatrist at South London and Maudsley NHS Foundation Trust. He is the chair of the Addictions Faculty at the Royal College of Psychiatrists and a National Institute of Health Research senior investigator.

References:

[1] http://www.bbc.co.uk/news/uk-wales-north-east-wales-39178982

[2] ONS, September 2016

[3] NHS Digital, February 2017

[4] The Sentinel 2017; 30% cuts already: Lancet, 2014; Liverpool Echo, 2016

[5] Lancet, 2014

[6] Drummond, Workforce Strategy for Addiction Psychiatry Training. RCPsych, 2017

[7] RCPsych evidence to HEE Workforce Planning, July 2015, p5

[8] Middleton, J, McGrail, S, Stringer, K, Drug related deaths in England and Wales, The BMJ.

[9] Anonymous, Guardian 2017

[10] NHS Digital, February 2017

[11] NHS Digital, February 2017

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  • T McCarthy

    Timely commentary indeed.
    The commissioning cycle is in danger of becoming a downward spiral regressing to the meanest, worst paid, least evidenced provision – with the welcome addition of more service receiver engagement being used as a fig-leaf to cover cuts.
    The bundling together of contracts (a sign of failed commissioning processes: competent engaged commissioners ought to be able to procure a constellation of services to work in partnership – shifting to big all-encompassing contract shifts the responsibility for partnership wholly to providers) excludes all but the biggest agencies in most areas.
    The UK evidence base for effective alcohol and other drug treatment was developed in an environment where services were delivered by multi-disciplinary specialist treatment services. There is no evidence that charities employing doctors deliver equivalent services. Sidelining NHS providers in the unseemly rush to slash funding is inevitably increasing pressure on universal front line services: Emergency Departments and the Police. These services are already dealing with the effects of cuts in health and social care funding. Cuts that have led to increased homelessness de-stabilise the most vulnerable and those with the most complex constellations of need resulting in more presentations with mental ill health and addictions issues.

  • Woody Caan

    Prof. Drummond’s call is timely, and truly urgent. Addiction services are already a source of geographical inequalities (e.g. very poor services in many rural or coastal areas) and the failure of workforce planning means that skills in treating addictive behaviour built up since the DDUs appeared in 1968 will be lost. If addicts are only to be assessed and managed by non-specialist professionals, all the past evidence is that those well-meaning non-specialists will neither recognise nor respond to the significant proportion of patients who have multiple problems (Caan W. Misfortunes never
    come singly. Perspectives in Public
    Health 2009; 129(5):210-211). Those patients who have experienced unresponsive, ineffectice services go on to be pessimistic about healthcare…. and avoid it.

  • Dr Tony Rao

    Professor Drummond’s opinion piece only echoes my own experience as a community old age psychiatrist working in an area high deprivation and associated substance misuse. Over the past 5 years, I have seen the piecemeal dismantling of NHS addiction services within my NHS Trust. Over the coming decades, we are likely to see a rise in older people of the “Baby Boomer” generation who are at risk of drug and alcohol misuse. This has already begun, with older people forming 1 in 5 admissions for alcohol specific mental and physical disorders (compared with 1 in 10 just 5 years ago), the 55-64 age group constituting the highest number of alcohol related deaths and lifetime rates of amphetamine, cocaine and cannabis misuse having risen by 2, 5 and 7-fold respectively in the 65-74 age group since 2000. Similarly, past year cannabis misuse in the 55-64 age group have doubled in the past 15 years. These rises have taken place on a background of a generation who are less likely than previous ones to reduce their substance misuse as they age.

    Not only is the burden of substance misuse seeping into older age groups, but those services commissioned as part of the “any qualified provider” process of tendering are creaking at the seams. These services often lack the skills to manage chronicity, complexity and co-morbidity-skills that doctors have taken years to develop through training and continuing professional development.

    With the demise of addiction services and consequent loss of training posts, those with complex, long-term problems associated with substance misuse will continue to fall by the wayside of clinically effective service provision. This is already being evidenced by public health data and through the experiences of frontline clinicians delivering interventions to people with substance misuse.

    It is not too late to turn around what is already a leaking boat of addictions service provision, but we are close to sinking if we do not.

  • Will Haydock

    This article makes interesting reading, but for me it fails to emphasise the fact that (at the moment at least) the reductions in funding for substance misuse services aren’t (necessarily) the result of competing local priorities; they’re simply the result of reductions in the public health grant (which is still ringfenced overall, though not for substance misuse specifically). The arguments about (for example) addiction vs social care shouldn’t really be happening locally yet – though the article is right that those are probably on the horizon. At the moment, the only things substance misuse should really be competing with for funding are sexual health, prevention, health visitors, school nurses, health checks etc – the things Public Health departments commission.

    Having said that, this may be clearer/easier in some areas than others. Where there are separate Public Health departments to manage the public health grant, this may make things a bit clearer, with there being less chance of that seepage into other missions/departments. All the same, it’s the Director of Public Health who has to sign off that the grant has been used for bona fide public health work, so perhaps that’s an area where more pressure could be applied.

    Fundamentally, I worry about the concluding sentence of this article, which suggests that it’s local authorities that are making these decisions, when it’s really central government outsourcing the decision to local organisations. (The same thing happens with Police and Crime Commissioners.) I’m afraid that this kind of rhetoric can lead to public services fighting against each other, when we should be trying to change the terms of the debate – but it’s really difficult to do that *and* have to work with the budget we’re given. That makes people a complicit part of the system they’re challenging.

  • Will Haydock

    I’d agree in lots of ways, Trevor, but as you know I think we can work better within the current commissioning framework to maintain the diversity and quality you’re concerned about. What we can’t do at the moment is avoid the budget reductions. And I think those are more fundamental than the commissioning structures/context/skills – but those cuts do apply to commissioners as well as services, meaning that it’s more difficult for commissioners to be ‘competent’ and ‘engaged’ in the current environment where they have less time and fewer staff in their team. I think there are reasons why that ‘bundling’ of elements of service happens, but I think collaboration and consortium work is something that can genuinely happen.

  • T McCarthy

    You’re right Will and from my work researching high performing commissioning partnerships a decade or so ago (before your resources were depleted).
    The findings from those high performing areas were consistent: that those excellent commissioners partnerships were thoroughly engaged with the services they convened for the benefit of their local communities. There was senior support in those areas backing up the work of specialist alcohol & other drug commissioning. There was leadership; there was a shared understanding of the inter-connected nature of local public health and social care services. Fundamentally the local leaders in public services understood that alcohol and drug problems are often indicative of other social problems and highlight deficits in local services and resources.
    It is tougher now, of course and I agree with you: collaborative consortium work can happen. My genuine belief is that it should and would be safer, more effective and preferable to the current position: a developing over-reliance on larger provider corporations that inevitably dilutes local partnership capital.