One of the key figures in the story of drug treatment in England, ex-NTA head Paul Hayes talks to David Gilliver for DDN’s tenth anniversary issue.
Paul Hayes was chief executive of the NTA from its inception in 2001 until the agency’s functions were taken over by Public Health England last year. He now works with a range of voluntary sector organisations including DISC, the Cyrenians and Family Action and is an honorary professor at the London School of Hygiene and Tropical Medicine.
Prior to the NTA he’d worked in the probation sector for almost 30 years, and was chief executive of the South East London Probation Service when he was asked to put himself forward to be chief executive of the new organisation.
What attracted you to the NTA job?
‘There are two aspects. I’d led on drug and alcohol policy for the Association of Chief Officers of Probation for a number of years and I was working in Southwark when the first heroin epidemic hit, so I was acutely aware of the change in the environment – it was an issue that I was confronted with on a daily basis.
I was given a job developing drug policy for the probation service in London, and then when I became a chief I was given the national brief, so I’d worked in drug policy for many years before the NTA was created, and it was put to me that this might be a good thing for me to do. On a less positive note, the probation service was being restructured at the time and my job was being abolished, so in personal terms it wasn’t much of an ask – it was either the NTA or the dole.’
The NTA improved access, cut waiting times, oversaw reductions in drug-related deaths. How big was the difference it made to treatment in this country?
‘Immense, absolutely immense – I firmly believe that. If you go back to the Audit Commission’s 2002 report, Changing habits, it describes the treatment system before the NTA was created. People waiting months, very early drop out, and what you got was what that particular service believed in – one of the things that report talks about is inconsistency in treatment and how it’s belief-driven rather than evidence-driven. But the most important thing really wasn’t the NTA, it was the money.
The Blair government chose to invest an awful lot of money in drug treatment. Central government spend went up from £50m a year to about £400m – that was the direct spend, the criminal justice money was on top of that – and the real reason for the creation of the NTA was that Jack Straw, who was home secretary, basically didn’t trust Alan Milburn, who was health secretary, to spend the money on drugs if it was just given to DH. They wanted a new outfit to ride shotgun on it, so they created a quango jointly owned by DH and the Home Office primarily to oversee the money.
We then decided to take on a best practice, performance management, commissioning oversight role to achieve that, but that wasn’t set in stone and it was actually very difficult to achieve, because we cut across a lot of the pre-existing assumptions about how things should operate, within both health and the criminal justice system. We had to fight quite a lot of Whitehall battles, battles with the health bureaucracy and the criminal justice system and local authorities, in order to create that space. But a lot of that comes back to the money. If you’re dangling cash around you’re given an awful lot more licence than if you’re not – “we want you to do all this new stuff, by the way here’s 400m quid to do it”. That makes life a lot easier.
So the performance management stuff was important, the leadership stuff was important, identifying best practice was important. But without the money, and the government’s commitment to spend the money – Gordon Brown’s money, Tony Blair’s leadership – we wouldn’t have got anywhere.’
Do you think Tony Blair’s contribution is something that’s acknowledged?
‘Everybody hates Blair, but I think there may be different views in a different generation. From my point of view, leaving foreign policy aside and just focusing on drugs, the drug treatment sector does owe Blair a great debt – the central direction we got, particularly as a cross-cutting issue. Drugs wasn’t important enough to any one of the government silos to actually deliver it. It wasn’t important to DH, which is why Norman Baker’s call for drug policy to go to health would be a mistake, in my view – it doesn’t kill enough people and it doesn’t make enough people sick. As far as they’re concerned, drugs is very small beer, and it’s smaller now because it’s largely been capped off. It’s nowhere near as significant as tobacco, obesity, alcohol, cancer, dementia – if you’re running the NHS, how much attention are you going to pay to drugs?
If you’re running the Home Office you’re rather more interested because of the drugs/crime link, but it’s still not top of your list of priorities – it’s one thing among many. If you’re interested in welfare dependency then it plays a role, but unless you’re Iain Duncan Smith it isn’t going to be near the top of your list of priorities either. So it matters at about the 5 per cent level to about half a dozen different departments, but not enough to any of them to really give it some oomph. The only point in our system where cross-cutting issues really come to matter is at the centre of government – at No.10 – because that’s the only place where they have to own all these different 5 and 10 per cents that stack up to being a real issue.
So you needed not only the money, but a government that was structured to drive things from No.10, and that was how Blair did stuff. Obviously all of that – targets, performance management – became deeply unfashionable, and I think it’s very interesting that Nick Clegg is now saying he’s taking mental health seriously because he’s imposing targets on the system. The Lib Dems and the Tories spent years castigating the previous Labour government for too much focus on targets and bureaucracy, so I think it’s very interesting that they’re now learning – as most governments do – that localism and absence of central direction is a great theoretical prospect in opposition but it’s no way to run a government.’
Overall, what do you think the NTA’s main legacy will be? You’ve mentioned before that it might well be the National Drug Treatment Monitoring System (NDTMS).
‘I think it is, and I think it’s important that that’s been retained in Public Health England, because you need to know what you’re doing, to account for what you’re spending your money on, how many people you’re treating – heroin users or ketamine users. The world changes and you need to keep abreast of that – are you doing as well with men as with women, are black people getting a fair shake, is the North East performing as well as London? If you’re not asking yourself those questions then you’re not really able to address what’s going on and improve it, and you’re letting service users down. And unfortunately, in order to do that, you’ve got to do boring stuff like keying in information, and it has to be collected in a consistent way.
James Brokenshire, when he was on the front bench in opposition, read out the NDTMS definition for waiting times, I think it was, basically to take the piss out of it, and all the Tory backbenchers were laughing their heads off. Well, five years in they’re still using it.’
On that note, how much of a change did you see when the coalition government came in?
‘Much less than anyone expected. There was a change in attitude – the NTA immediately became the enemy within, because we weren’t ‘their’ NTA. The important thing from our point of view was to hold on until PHE came in, because it was ‘their’ Public Health England. So PHE, even though it continued the same policy, was a good thing, whereas the NTA was a bad thing.
But this happens to all governments – all of sudden you’re in charge of stuff. You’ve got a set of ideas you picked up from think tanks, you come into government and instead of being able to make broad statements about you’ll do this and do that, all of a sudden what you think and what you say actually matters and you’ve got civil servants saying, “here’s the reasons why the other lot did these things that you spent the last five years saying were stupid.” You start looking at them and you go, “maybe it wasn’t so stupid after all – maybe there’s a reason for that. We still think bits of it are bonkers or ideological, but other bits of it maybe make more sense.”
So what you can do is say to them, “you want more people to recover – here’s the sensible way to do that. You want that to happen at the same time as drug-related deaths not going up, as keeping a lid on crime, here’s the bits of what the other lot were doing that it makes sense to keep, and here’s the bits you could sensibly change.”
We were able, with an awful lot of help from some very, very smart civil servants in the Home Office and DH to get the key ministers to see that it was actually in their departmental interest, and in the interest of the country as a whole and of service users, to keep much more of the existing package than anyone would have dreamt they were going to keep from the simplistic IDS/Centre for Social Justice pre-election line. The other thing that helped was that IDS didn’t play his cards very well within government and wasn’t able to persuade Andrew Lansley and Theresa May to go down his route.’
How many of those achievements of the NTA under threat now, do you think?
‘To an extent, everything’s under threat. NDTMS isn’t under threat instantly –the solidity of it was exemplified I think when Oliver Letwin agreed that it would be used as the basis for the payment by results pilot, so instead of being vilified it was co-opted. How long PHE continue to invest in it, and exactly where it goes, is another matter.
But there are significant signs of disinvestment from local authorities. Some of that might be legitimate – seeking better value – because investment in the sector went up so rapidly that it’s impossible to say that it’s all been as well spent as it should, but there are limits to how far you can actually cut back. People will want to readjust between drugs and alcohol, people will want to spend on what I’ve previously called “narrow public health” – most of the benefits around drugs accrue in terms of crime, welfare dependency etcetera, which historically have never been very important to public health. Locating public health in local authorities should make it easier to make that argument, but there is a sense in which that success that you’ve acknowledged is largely invisible in the media and political circles.’
I was just about to come on to that.
‘So you’ve got Nick Clegg and his “failure in drug policy on an industrial scale” stuff, and while that’s the default position – while the left think we’ve got a failed war on drugs that will be solved by decriminalisation or legalisation, and the right think we’ve got a wrong-headed harm reduction-led policy when we ought to have abstinence – the only thing they can agree on is that we’re going to hell in a handcart. Which is the opposite of the reality.
I gave a lecture to a group of criminology students recently and the only thing they were interested in were the numbers I started off with, about the improvements in the system, the decline in use and the crime reduction. They were gobsmacked, they had no idea. They were saying, “What are your references for this?” and I said, “It’s the ONS – this is what the official figures say.” People just don’t know. It’s so locked into the media assumptions that it’s failed, and in a sense it becomes a sort of proxy space for left and right to have an argument. I think it’s even the case that because it’s working, because we’re not at the state of crisis we were at in the ’80s with HIV or the ’90s with escalating crime, to an extent that enables people to go back to their ideological corners and throw hand grenades at each other. If there was a real problem they’d roll their sleeves up and get it sorted.’
Do you think all that polarisation is starting to ease off at all?
‘I think the polarisation in the sector – the harm reduction/abstinence wars – has calmed down. There’s still an appetite in bits of government to re-ask the question about time-limited methadone, for example, which in my time they asked four times and always got the same answer. They keep hoping they’ll finally find someone to tell them what they want to hear, but the evidence remains the evidence.
What hasn’t calmed down is the ideological stuff about the legal status. But what I think will change things dramatically is what’s happening in Colorado, funnily enough. I think that will actually harden opinion against changing the law, because now we’re starting to ask detailed questions about how does a market work and how regulated can a market be. So rather than being theoretical these issues become real. I think people are very dubious about where Colorado’s going to lead.’
With the involvement of big business and so on?
‘Absolutely. I don’t think there’s a space in between prohibition and marketisation – that’s my gut instinct. You might be able to get there in Uruguay, when you’ve got government control of supply – a political impossibility here – but not in a European-wide free market. What is the space that enables you to have something that’s marketed but exerts real pressure on the producers not to maximise their market? We try to do it with tobacco, with alcohol but, particularly now with social media, I don’t know how you’d prevent viral marketing and so on. How do you stop bigger and bigger entities operating in the market and trying to get the number of people using their product up, when at the moment it’s falling?
To come back to Clegg and his “failure on an industrial scale”, you only need to adopt a radical policy like decriminalisation if you think the thing’s not working. If you think it is working then you need to look at the harms that come from prohibition and address them directly, rather than running the risk of doing more dramatic things.
We lock up only small numbers of people for cannabis possession – 500 a year, according to official figures – and they only go for two or three weeks, but it does seem crazy that we’re locking people up at all for simple possession. But if the consequence of getting rid of that is cannabis being marketed, then when use goes up, harmful use goes up, as night follows day. The debate is really about what are the negative consequences of prohibition, and how we can minimise them. You can keep things illegal and not lock people up. You can keep things illegal and stop the police using it as an excuse to give a hard time to young black men. You can stop a conviction for cannabis blighting someone’s employment opportunities by changing the Rehabilitation of Offenders Act. You can actually address the harms that flow from prohibition without legalising.
But as you soon as you begin to legalise I think you’re running a real risk of slipping away from something that’s a very inefficient market – that doesn’t maximise its clientele – towards a market that’s seeking fresh users all the time. And it won’t be the Richard Bransons and the Russell Brands who’ll be using, it will be people who are in and out of our prisons and our psychiatric hospitals, it will the most vulnerable people who are most likely to succumb. I also fear the market may escalate very quickly, like we’re seeing with gambling.’
As it’s the tenth anniversary issue of DDN, what do you think have been the most significant changes in the sector over the last ten years?
‘In 2004 the treatment system’s expansion was well in train, but I think the biggest thing has been the re-focus away from expansion and getting people in, to trying to improve the offer for people when they are in, and trying to strike that delicate balance between holding on to people for as long as you need to and working with them in order to maximise their opportunities to recover. Improving practice to do that is a really big ask.
Eventually we were successful in getting the clinicians to recognise that they weren’t being ambitious enough on behalf of many of their patients. That’s now accepted, and the stuff that John Strang led on was very helpful in that – finding a clinically appropriate space where we can actually protect people and give them a platform for them to recover. The big question for me, and this is something the ACMD have been looking at, is that we need some benchmark for what good looks like. How many people can you actually expect to recover? There are no really solid international comparators.
If you talk to the Americans, for example, they say, “well, no one’s really got to the stage you’re at in England” – a system where the vast majority of people who need to be in treatment are in treatment, a system that can get people in quickly and hold on to them – so nobody else knows. Without some sense of what good looks like, we’ll always be vulnerable to being told that it’s not working.
As a slight corrective to that, what I’m not sure of is the extent to which we focus too much on the drug and not enough on the person. There’s a group of people in society who’ve been dealt a not very good hand – they’ve been born into families with difficulties, born into cities and regions with very poor employment prospects, they’ve been let down by the education system, they’ve got mental health problems. If they’re the majority – which the evidence suggests they are – of the population addicted to heroin and crack, then maybe the issue we should be looking at isn’t how many people we can cure, as such, but how do we actually manage a population that will continue to struggle with life, only one of whose problems is actually focused on their drug and alcohol use?
So it might actually be that the number of people you can expect to recover isn’t a product of the drug they’re using, but of the society they’re living in and the economic and social disadvantages that they suffer within that society.’
Which is a much bigger issue to try to tackle.
‘And for the current government, particularly, a much more challenging prospect than to say drug use is a cause of poverty. If you think drug use is a cause of poverty then you don’t have to think in terms of redistributing wealth, and for a party of the right that’s a nice comfortable place to be. But if you believe that poverty causes drug use, then that does suggest that you need to do something about redistributing wealth and maintaining investment in public services.’
So finally, what do you think the sector might look like ten years from now?
‘This might sound peculiar, but I think the optimistic scenario would be that the sector is still dominated by a diminishing cohort of heroin users who haven’t yet recovered, and they haven’t been topped up by new cohorts either of heroin users or users of some substance as yet unknown that’s arriving from some lab in India or China that wreaks new havoc. If we’ve got a diminishing number of heroin users left over from the epidemic of the ’80s and ’90s and a system that’s flexible enough to continue to provide services to that cohort and respond to the probably smaller numbers of people succumbing to dependency on other drugs as they emerge, and that frees up money to provide better services for alcohol users, that would be the golden scenario.
I see not reason at all, structurally, why we shouldn’t be able to do that. But the big proviso, of course, is money. If there’s not enough money retained in the system to do that then we come back to competing priorities in the NHS and local government. Which, at the risk of sounding like a stuck record, is why you need the broader perspective. If you’re not thinking crime, worklessness, child protection – if you’re just thinking narrow health – then you’re not going to want to make the investment.
But I was very disappointed and shocked to see the recent big increase in drug-related deaths, and we need to watch that like a hawk. It might be a blip, it might be something about the recording, it might be a consequence of the end of the heroin drought, but we need to be looking at that. And if that’s followed by an increase in use, when those numbers come out, then I think all bets are off.’ DDN