CZAR GAZING – Finding the right balance

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... Read it in DDN Magazine.

Mike Trace is CEO of Forward Trust

In 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 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, 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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