We must draw attention to the evisceration of a previously well-functioning addiction treatment system

The Care Quality Commission (CQC) report on inspections of residential drug and alcohol detoxification services in England makes for sobering reading. [1] During 2016/17, the CQC took action against 72% (49 out of 68) of providers because of breaches in the Health and Social Care Act, and failing to meet fundamental standards of care. Enforcement action was taken with 12%, and notices to cancel the registration of two providers were issued. The report details a catalogue of clinical governance failures, including not addressing clinical risk, not following best practice guidance, poor medicines management (including controlled drugs used in addiction treatment), having insufficiently trained staff, and a lack of essential employment checks on staff. Only eight years ago 77% of inpatient detoxification services were rated as “good” or “excellent”. [2]

The Royal College of Psychiatrists and others have drawn attention to the evisceration of a previously well-functioning addiction treatment system in England. [3,4] The 2012 Health and Social Care Act transferred commissioning to local authorities and presaged cuts of up to 30-50% of the addiction treatment budget. [3] This has happened against a background of rising drug and alcohol related acute hospital admissions and the highest level of opiate related deaths on record, having doubled in the past three years. [5] We have seen a reduction of 60% of training posts in addiction psychiatry since 2006 and a greater reliance within the treatment system on doctors without specialist training in addictions. [3] The psychiatry training pathway is currently the only route to General Medical Council endorsement as a medical specialist in addictions in the UK.

Inpatient detoxification services have experienced the greatest impact. These services treat the most vulnerable patients, who mostly have complex physical and mental health comorbidities, and carry the highest level of clinical risk. [6] In 2008 London had eight NHS inpatient drug and alcohol treatment units providing specialist care; all have closed. The picture is similarly bleak across the rest of England. This loss of an entire tier of specialist NHS services has undermined clinical safety, lost essential national training, and eroded clinical research capacity.

These NHS specialist units have been largely replaced by independent sector residential treatment units, with places “spot purchased” by a myriad of local authorities, often located far from, and with little connection to, the communities they serve, and with much reduced funding. The units are often clinically supported by local GPs and community pharmacies with little specialist background in addiction treatment, and a sometimes token role in supporting clinical governance or treatment policy. Because these units are funded and provided outside of the NHS they are not connected with CCG monitoring, and in particular, NHS England controlled drug accountable officers and local intelligence networks.

The government views commissioning of addiction services as a matter for local decision making and market forces. NHS inpatient units with their statutory governance structures and remit for training and research disappeared because they could not compete in this unregulated market. But this has been a false economy. The most vulnerable people are being poorly served, and the burden of managing addiction is falling increasingly on already overstretched NHS emergency departments and mental health services. In addition, a clustering of deaths associated with the period of instability around transfer of opiate patients from one provider to another has been identified. [7]

It is worth remembering why we had NHS addiction treatment units in the first place. In the 1960s a hands-off approach to the treatment of drug dependence led to an iatrogenic epidemic of heroin addiction fuelled primarily by the prescribing practices of medical practitioners. This led to the establishment of the very same NHS units that have been dismantled over the last 7 years. [8]

The Shipman Inquiry 39 years later also identified ongoing risks with opiate prescribing and led to a raft of new regulations. [9,10] That many residential detoxification services now seem to be operating outside of these rules should be a cause for concern.

The policy experiment with addiction services has failed. An urgent review of commissioning is needed. The Sustainability and Transformation Partnerships are an opportunity to return the NHS and local authorities to commission addiction services jointly. Local authorities and the government need to stop any further cuts to services, and the NHS needs to ensure there are at least 60 training places for addiction psychiatrists in England. The third sector has an important part to play. But the CQC report is a warning that inpatient detoxification provision cannot be safely delivered without the NHS playing a significant role. Ironically, the US health system is moving in the opposite direction to England, in response to the epidemic of drug related deaths, bringing addiction treatment into mainstream healthcare. [11]

Colin Drummond, Chair, Addictions Faculty, Royal College of Psychiatrists and Professor of Addiction Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London.

Ed Day, Vice Chair, Addictions Faculty, Royal College of Psychiatrists and Senior Clinical Lecturer in Addiction Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London.

John Strang, Chair in the Psychiatry of Addictions, Institute of Psychiatry, Psychology and Neuroscience, King’s College London.

Competing interests: CD and JS are partly funded by the NIHR specialist Mental Health Biomedical Research Centre at the South London and Maudsley NHS Foundation Trust and are NIHR Senior Investigators. CD is partly funded by the NIHR CLAHRC South London at King’s College Hospital NHS Foundation Trust, and is partly funded by the Care Quality Commission as a National Professional Adviser in Substance Misuse. The views expressed are those of the authors and do not necessarily reflect the views of the Department of Health, the National Institute for Health Research or the Care Quality Commission. ED is a co-investigator on an HTA grant from the NIHR. He has been a co-applicant on a grant from the Alcohol Research Council investigating frequent attender for alcohol problems in the A&E department. He has received an honorarium from PCM Scientific, a medical education company for speaking at the Improving Outcomes in the Treatment of Opioid Dependence meeting in 2016 and 2017. He has been an unpaid trustee of three charities in the past 3 years (Action on Addiction, the Society for the Study of Addiction and Changes UK).

References

1. Care Quality Commission. Briefing. Substance Misuse Services: The Quality and Safety of Residential Detoxification. November 2017. Care Quality Commission.
2. Healthcare Commission. Improving Services for Substance Misuse: Diversity, and Inpatient and Residential Services. Healthcare Commission, National Treatment Agency for Substance Misuse. January 2009. http://www.nta.nhs.uk/uploads/2007_8_substance_misuse_national_report_diversity_tier_4.pdf
3. Drummond C. Cuts to addiction services are a false economy. British Medical Journal, 2017, 357, j2704 doi: 10.1136/bmj.j2704
4. Advisory Council on the Misuse of Drugs. Commissioning Impact on Drug Treatment: The Extent to Which Commissioning Structures, the Financial Environment and Wider Changes to Health and Social Welfare Impact on Drug Misuse Treatment and Recovery. 2017. ACMD, London. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/642811/Final_Commissioning_report_5.15_6th_Sept.pdf
5. Office for National Statistics. Deaths involving substances that are commonly abused. September 2016. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2015registrations#deaths-involvingsubstances-that-are-commonly-abused.
6. Day E, Ison J, Keaney F, Buntwal N, Strang J. National Survey of Inpatient Drug Services in England. 2005. National Treatment Agency for Substance Misuse, London.
7. Bogdanowicz KM, Stewart R, Chang C-K, Shetty H, Khondoker M, Day E, Hayes RD, Strang J. Excess overdose mortality immediately following transfer of patients and their care as well as after cessation of opioid substitution therapy. Addiction, 2017, http://onlinelibrary.wiley.com/doi/10.1111/add.14114/full
8. Interdepartmental Committee on Drug Addiction. The Second Report of the Interdepartmental Committee on Drug Addiction. 1965. Ministry of Health, HMSO, London. http://www.dldocs.stir.ac.uk/documents/2nd-brain-report.pdf
9. The Shipman Inquiry. Fourth Report: The Regulation of Controlled Drugs in the Community. Command Paper Cm 6249. 2004. The Shipman Inquiry. http://webarchive.nationalarchives.gov.uk/20090808160142/http://www.the-shipman-inquiry.org.uk/fourthreport.asp
10. Care Quality Commission. The Safer Management of Controlled Drugs. Annual Update 2016. 2017. Care Quality Commission.  http://www.cqc.org.uk/sites/default/files/20170718_controlleddrugs2016_report.pdf
11. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. 2016. HHS, Washington, DC. https://addiction.surgeongeneral.gov/surgeon-generals-report.pdf