Sharon Cox: How are we assisting our most disadvantaged during Covid-19?

New collaborations between drug and alcohol services and homeless charities provide some hope, says Sharon Cox

Drug and alcohol services have had a hard decade. They have experienced some of the largest cuts across the health services. The tendering of services out to the wider third sector, away from the NHS, had a significant and devastating impact on those who work within the services. Though arguably it is the constant tendering which is most devastating. We have witnessed a professional clear out; a percentage of those at the height of their profession with decades of experience moved on, some taking early retirement and some going back into nursing, psychology or psychiatry within other health departments. I myself worked within NHS addiction services and when my senior colleagues started to leave the profession following retendering, I too left, there was little or no senior experience or influence to learn from. The opportunity to develop and grow diminished. 

The changes over the last decade are probably most felt by those within or seeking treatment. For example, contract tendering brings uncertainty of service provision and there has been a systematic expansion of cheaper group-based treatments and less opportunity for one-to-one, structured psychological therapies. The wide range of therapies has also narrowed. Most concerning has been the limited number of treatments available to service users. While treatment cannot go on forever, you cannot easily put a timeline on recovery either. If you tried it certainly wouldn’t be 6-8 sessions. Drug related deaths continue to rise, there has been a year on year increase since 2012, and 2018 saw the largest percentage rise. 

And so it is then, that drug and alcohol services were already on their knees when covid-19 arrived. Many working in the sector were afraid of what was to come and how they would be able to cope with such a fragile and precarious service to offer.  From the perspective of those working within the substance use services, the lack of clinical support, which was stripped out of the services to make them run cheaper is particularly worrying. This is one of the many holes in the system the cuts created and is now being exposed. 

However, now over a month on from official lockdown there are now stories coming out from the field which provide some inspiration and perhaps some hope for new ways of future working. 

As those who are sleeping rough are being offered accommodation to ensure people can adhere to the Government’s physical distancing guidance, so too have many local authorities, homeless charities and substance use services worked together with researchers to plan how best to support substance use needs, including the safe use of alcohol and assist with tobacco cessation. We are hearing stories of individuals being placed into accommodation with daily access to opioid substitution therapy, plans being made for immediate alcohol withdrawal—which if not managed can be fatal—and an offer to use an e-cigarette for either immediate tobacco harm reduction or for longer term cessation plans. It is especially welcoming that tobacco cessation has been so centrally aligned to drug harm reduction plans at this time, as tobacco related death rates are disproportionally higher amongst adults experiencing homelessness and substance dependence, and yet so very often an overlooked health need. More still, mobile phones are being offered as a way of keeping in touch with keyworkers, as a means to report daily symptoms, report health changes, but also to aid social connection. 

What is surprising is that there has been a long-held assumption that those with difficult lives, presenting with severe and multiple substance use and mental health comorbidities cannot or should not change more than one behaviour at a time, certainly not without inpatient treatment. Current circumstances are directly challenging this practice. While the longer term outcomes will not be known for some time, there is a sense that those who are often deemed hardest to reach are somewhat more “reachable” and in a position of relative stability, so now is the time to seize the moment for future changes. 

The speed at which some of these interventions have been organised is particularly impressive, the third sector is used to innovative responsive challenges, but the wider coordination with allied services is particularly impressive. With both the homeless sector and the drug and alcohol services being so heavily cut over the years, this joining of forces is vital, as a means of increasing the critical mass of expertise that can be delivered and mutual support for workers. 

Looking ahead, where people go and what they are offered post lockdown is no small undertaking. As has been written before, tough decisions are being made, and with the existing treatment provision rationing of care is sadly inevitable. Therefore, we should anticipate and prepare for the fact that for many of those who work within the sector and those accessing services will be emotionally affected by the events that have unfolded. There will be an emotional fallout. 

What lies in store for those currently sheltered in hotels is not known. Many things will be lost during the pandemic—let’s make sure that the new collaborations between drug and alcohol services and homeless charities are not among them. 

Sharon Cox, Senior Research Fellow, London South Bank University

Twitter: @Sharon_ACox

Competing interests: None declared