A new report confirms how devastating funding cuts for addiction services have been, say Ian Hamilton and Alex Stevens
The eagerly awaited second report on drugs from Dame Carol Black has been published. Originally commissioned by the now health secretary Sajid Javid when he was at the Home Office, the brief was to make recommendations to prevent and treat problem drug use. One of the aspects that Dame Carol was advised not to explore was legislation, which, given its importance on this issue, seems a significant limitation to impose.
Dame Carol’s report shows the need to restore investment in treatment, reform leadership and commissioning, and build integrated services and support, including housing and employment. She also calls for a renewed focus on prevention and early intervention, as well as diversion away from the criminal justice system.
This new Black report underlines the lack of ownership by the government on this issue. She found that six government departments have a role in drugs, making any potential policy progress messy and complex and at risk of unravelling when ministers fail to work together. In announcing the 2017 drug strategy, the then home secretary Amber Rudd promised to solve this problem by personally chairing a Drug Strategy Board. This has since been quietly disbanded. The report recommends a new cross-party Joint Combating Drugs Unit. This will be set up, although it is not yet clear which minister will be accountable for its progress.
For those involved in the treatment of people who develop problems with drugs, Dame Carol confirms what they will already know. Cuts to funding have been brutal. They have been accompanied by a fragmented commissioning process. Here Dame Carol pulls no punches: “In many local areas,” she writes, “psychosocial interventions are limited and their delivery is substandard, frequently amounting to little more than a chat with a drug worker.” She now recommends increased accountability for achieving higher standards in the commissioning of services, as well as new money.
She makes clear how investing in treatment can produce larger savings in costs by reducing crime and, at the same time, improving health and social outcomes. She calls for investment in treatment and recovery services in England to rise by £119 million in year one, rising to £552 million in year five. This would increase the size and quality of the workforce across the sector, enabling more people to access drug and alcohol treatment. She estimates that this would create savings five times as large by year five. Dame Carol also provides some practical advice to the government. Any investment should be ringfenced for drug treatment rather than placed into a general budget, which risks funds for treatment being diverted to subsidise other services.
One of the professional casualties of a decade of budget cuts in this sector has been the near extinction of addiction psychiatry. When commissioners are looking for savings, specialist medical input has been viewed as expensive and dispensable. The reduction in the number of addiction psychiatry training posts, along with the retirement of older addiction psychiatrists, means this skilled input has been missing from multidisciplinary treatment. It is unimaginable that this expertise would be removed from other areas of health, such as oncology or coronary care. Even with funding restored in the sector, it will still take years to rebuild the specialty of addiction psychiatry as training posts are developed and supervisors found that can provide the experience and skills needed to support these roles.
The exclusion of legislation from Dame Carol’s remit has hampered her ability to recommend fundamental reform. For example, there have been calls from both the Royal Colleges of Physicians of London and Edinburgh, and both the Faculty and Royal Society of Public Health, for drug possession to be decriminalised in order to reduce barriers to treatment entry. This call has been supported by the House of Commons Health and Social Care Committee, and Scottish Affairs Committee. They see it as vital to tackle the ongoing public health crisis of drug related deaths. The Home Office has, however, set its face against legal reform, so Dame Carol was limited to recommending changes within the current legal approach.
The government set a remit for the report that also ignored one of the key pillars of the international response to drugs, in which the UK was a pioneer in the 1980s and 90s. Harm reduction, an approach which recognises that risk can be reduced even when people use drugs, was not mentioned in the government’s brief for Dame Carol, probably because it conflicts with ministers’ preference for abstinence. Nevertheless, her report recognises that drug related deaths have risen to new record levels in every year since 2012. She supports expanding opioid replacement treatment, naloxone provision, and needle and syringe programmes. In her support for overdose prevention, the report also implies that ministers should reconsider their opposition to the piloting of safer injecting facilities, where people can consume drugs under supervision and access other support.
In its immediate response to the report, the government points to £80 million of additional funding for drug treatment this year. We will have to wait for the upcoming spending review to see if the Treasury will implement Dame Carol’s more ambitious five year investment model. Unless serious political weight can be put behind her report, the risk is that it will be neutered by shortsighted penny pinching, as well as by politicians’ fears of genuine reform.
Ian Hamilton is an academic at the University of York with an interest in addiction and mental health. He previously worked as a mental health nurse with people who had combined mental health and substance use problems. Twitter: @ian_hamilton_
Competing interests: None declared.
Alex Stevens is a professor in criminal justice at the University of Kent. He researches the overlap between drugs, crime, and public health. He has previously been a member of the Advisory Council on the Misuse of Drugs and a special adviser to the House of Commons Health and Social Care Committee. Twitter @AlexStevensKent
Competing interests: I am a trustee and board member of Harm Reduction International and chair of Drug Science’s working group on supervised injecting facilities. Nothing further to declare.