Czar GazinG
FINDING THE
RIGHT BALANCE
I
As deputy drug czar for the Blair
government, Mike Trace oversaw the
expansion of today’s drug and alcohol
treatment system. In the fifth of his series
of articles he gives his personal view of the
successes and failures of the past 20 years,
and the challenges the sector now faces.
n last month’s article, I looked at what the
sector needs to do to achieve better results
with fewer resources – focusing on reducing
bureaucracy and redirecting activity towards
the most effective interventions. I also said
that we need to do less of some things and,
controversial as it may be, one of the things we need
to reduce expenditure on is the clinical component of
drug treatment – the cost of prescribing, purchasing
and dispensing medicines.
This is not a simplistic call to prioritise abstinence
and recovery. Amazingly, after 40 years of debating it,
too many people in the sector still see the
abstinence/harm reduction issue in binary terms –
choose your side and criticise the other side. An
effective system has to have a full menu of services.
Good healthcare provision for drug users is
important, and the delivery of harm reduction
interventions to people at risk should be at the core of
any local treatment service. Substitution treatment in
particular is proven effective in attracting opiate users
to services, helping them to stabilise their lifestyles
and reducing overdose and infection risk.
But, looked at from the perspective of changing
needs and tightening finances, our focus of resources
on the healthcare aspect of treatment presents two
problems. The first is a mismatch between presenting
needs and allocation of resources. Our treatment
system has been built around the needs of daily heroin
and/or cocaine users. As this cohort has aged, there are
new generations presenting to services with similar
patterns of use, but many more whose problems are
with cannabis, novel psychoactive substances (NPS) like
spice, prescription drugs, or alcohol.
In recent years, only a small proportion of people
presenting to treatment are primary heroin/opiate
users (in 2017/18, around 30 per cent), but substitute
prescribing is the service most commonly provided (to
around 50 per cent of all clients recorded on the
National Drug Treatment Monitoring System that
8 | drinkanddrugsnews | May 2019
year). Of course, substitution treatment is also
relevant to those using opiates as a secondary drug,
but there will also be hundreds of thousands of people
struggling with the use of non-opiate drugs who do
not present to treatment services because they do not
find what is on offer attractive.
The second problem is that of spiralling costs. The
days when substitute prescribing was seen as the cheap
option seem long gone. The rise in supervised
consumption, the costs of the drugs themselves, the
shortage of suitably qualified doctors and nurses (allied
with exorbitant agency fees), and the raising of
standards on governance and dispensing by the Care
Quality Commission (CQC) and the National Institute
for Health and Care Excellence (NICE) have led to a
multi-headed inflation of costs that stretches provider
resources and commissioner budgets. In some of the
Forward Trust contracts (prison and community based),
the cost of delivering medicines safely to clients takes
up over 40 per cent of the entire service budget. I am
prepared to consider that other providers are more
efficient than us but, looking at the financial profiles of
contracts run by others, the general picture is the same.
So, while it is important to maintain good clinical
components of any local treatment system, we do have
the problem that too high a proportion of the available
budget is spent on them, and we have to remember
that these services are not relevant to an increasing
proportion of potential clients. Meanwhile, this
concentration of resources pushes out any possibility of
investment in other areas of provision – including other
harm reduction measures – or quality improvement.
It’s not clear what we do about this, as any
reduction in coverage or quality of clinical services is
quickly met with challenges from CQC or
commissioners, which can lead to loss of contracts.
However, the sector needs to find a way out of this
dilemma. We know that good quality healthcare
provision attracts people into services, and can provide
a good foundation for behaviour and lifestyle change,
Amazingly, after 40 years
of debating it, too many
people in the sector still
see the abstinence/
harm reduction issue in
binary terms – choose
your side and criticise the
other side. An effective
system has to have a
full menu of services.
but it is not enough on its own.
All the research on substitution treatment
emphasises the need for it to be allied with
psychosocial/therapeutic work to be effective, and the
recovery programmes and pathways that move people
towards independence and reduce the burden on
clinical services are still not sufficiently widespread or
well funded in our system. We need to have a mutually
reinforcing balance between healthcare provision and
recovery pathways, but the sector does not have that
balance at the moment. This inhibits our impact.
There are indeed many challenges facing the
sector, but not without possible solutions. In my next
piece I will try to lay out my vision of how we can
create a new period of positive achievement.
Mike Trace is CEO of Forward Trust
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