A new drug strategy was released by the Home Office on 14 July – here are some responses and we will add more as they come in. To add yours, please email the editor.
Concerned at lack of focus on harm reduction
The English Harm Reduction Group are a coalition of organisations including the National AIDS Trust, Release, Blenheim, DrugScience, International Drug Policy Consortium, SMMGP, Harm Reduction International and IDHDP.
We express great concern at the lack of focus on harm reduction in the new drug strategy. Harm reduction is an evidence-based response that protects people and ultimately saves lives – at a time when drug-related deaths are the highest on record.
- Heroin and morphine deaths rose by 109 per cent in England and Wales between 2012 and 2016, when the evidence is overwhelming that harm reduction initiatives can reduce them. Initiatives such as opioid substitution treatment (OST) and needle and syringe programmes are only mentioned fleetingly within the strategy, and others such as drug consumption rooms and heroin assisted therapy (HAT) are completely absent.
- It is appalling that the government acknowledges in the strategy that the rise in drug-related deaths is ‘dramatic and tragic’, but proposes no concrete action plan to reduce them. For example, the strategy comments on the importance of naloxone to prevent overdose deaths but proposes no national systematic approach to naloxone provision, nor any new funding for this vital intervention. It is shocking that while drug-related deaths have outstripped both road traffic fatalities and deaths from blood borne viruses, there is no coordinated response from central government.
- This erosion of services continues against a backdrop of funding for all drug services being continuously reduced. Public health spending has been reduced by more than 5 per cent since 2013 and, according to analysis, a further £22 million in cuts are to be made to drug treatment by the end of 2017/18. Without funding, drug services will not be able to function effectively.
- The government has dismissed decriminalisation of drug possession offences as being simplistic. Yet the World Health Organisation and a multitude of United Nations agencies have called for the end of criminal sanctions for possession and use of drugs in recognition that criminalisation creates barriers to those needing treatment and increases health harms.
People who use drugs are often vulnerable and marginalised. This new drug strategy simply does not begin to support them and reduce drug-related deaths. We call on the government to implement the recommendations of the Advisory Council on the Misuse of Drugs to tackle opiate related deaths. These include: optimal OST prescribing; easier access to naloxone; a national HAT programme; and that drug consumption rooms are implemented where there is need.
The government must also ensure a minimum level of care by requiring local authorities to provide drug treatment and harm reduction services by law.
An excellent way forward
The NHS Substance Misuse Provider Alliance welcomes the publication of the drug strategy. From our perspective this provides a balanced roadmap for the future, which can either be embraced in spirit of co-production or alternatively critiqued to the extent where a desire for the perfect gets in the way of the good.
Our approach will be to make a success of the strategy, embrace the elements we deem positive and constructively work to address the areas where further development is required.
We welcome the strong focus on the importance of partnership working that is present throughout the document. This is particularly the case where the strategy stresses the importance of working with colleagues in mental health, employment, the criminal justice system and housing. These are not necessarily new ambitions and relationships do already exist in many areas, but from our perspective they often do not function operationally or have become ineffective. As NHS providers we are used to working in partnership and look forward to reinforcing these relationships.
The emphasis and focus on a number of vulnerable groups is important. However we particularly welcome the emphasis on the increasing relevance of physical and mental health issues and how these factors can compound an already complex picture with regard to the vulnerabilities of the ageing, traditional service user population.
As service users get older, drug and alcohol treatment services need to ensure they have an appropriate, knowledgeable workforce that is able to intervene appropriately and navigate the range of services someone encountering long term conditions will encounter. Drug and alcohol treatment should not be seen as a ‘niche’. Increasingly it is important that the sector steps up as a full and engaged partner in health and social care that understands its responsibility – not only to the individual, but in positively influencing the population’s health.
We are pleased to see the strategy acknowledging the changing profile of substance use in the country and the broad spread of issues now encountered, for example addiction to medicines, CSE, Chem sex, IPEds, the place of the internet and the global nature of both the issues and solutions associated with substance use. Of particularly note is the focus on substances such as synthetic cannabinoids and the renewed commitment to address these issues. The Alliance will continue to make its contribution to this and many of the debates included in the strategy.
We are aware that this is a drug strategy, but also note the inclusion of alcohol in many places and would welcome the merging of the two in future years, particularly as that is the expectation at a commissioning, prevention and treatment level.
We note that the strategy emphasises successfully addressing substances with the goal of complete abstinence. While an ambition of supporting individuals to become free from dependence must unify all treatment providers, it is important to guard against a simplistic or narrow interpretation of this – the most fatal interpretation being a lack of acknowledgment and value placed on the reduction of substance related harm. This is particularly pertinent when considering the very troubling rise in drug-related deaths. We wholeheartedly support a sophisticated, ongoing and energetic effort to reverse this trend.
We note that the strategy talks about extended and diversified information collection and analysis. While we value the availability of high quality information and deem this essential – particularly in measuring joint outcomes with partners in employment, mental health, housing and the criminal justice system – we would caution against any increased administrative and reporting burdens.
This is particularly important when we see drug and alcohol treatment budgets consistently reducing across the country. Providers are doing their utmost to innovate, target their resources and mitigate the impact on the person who receives treatment. The success of this varies and is heavily influenced by how budget cuts are applied. It is important that we are mindful of this scenario with regards to any development or initiative, and the potential impact on frontline resources.
The strategy does not particularly discuss the role of commissioners in local areas and the central function and accountability they should have for ensuring the successful commissioning and management of treatment systems. We would welcome a stronger overview of commissioning functions, processes and decisions along with more support and resources to support them in this function.
A move towards stronger governance, as described in the strategy, with the establishment of the Drug Strategy Board and the appointment of a national recovery champion is broadly welcomed by the Alliance. Senior ministerial control is a powerful statement that will aid the provision of stability and direction for the sector.
As a representative forum of service providers, we would assert that this board needs to include the voice of providers from both the NHS and voluntary sector to support its effectiveness and relevance. This will ultimately benefit our service users but we also would hope provide stronger assurance into local decision-making. We note that this function remains within the Home Office, but are encouraged at the commitment to a cross- cutting strategic view recognising the multi-faceted nature of these issues. We are particularly encouraged by the emphasis on moving mental health and substance misuse closer together.
Broadly, we feel the new strategy, along with the newly published updated clinical guidelines, provides an excellent road map for the development of the sector over the coming years. As with any roadmap there are some paths that will need to be trodden more, and ones that have not even been mapped yet.
The test of the success of this strategy is not now though, but when we reflect on it and ask ourselves: did we as government departments, local commissioners, elected members and service providers step up for those we ultimately serve, and for the reason that this sector exists – the individuals, families and communities blighted by drugs? I hope the honest answer will be ‘yes’.
Aspirational… but leadership and detail are missing
It has been a week since the new drug strategy has been published. Rather than rush to respond we have taken the time to read, consult and agree our views before outlining our considered response to the strategy.
The emphasis placed on prevention is also to be welcomed. It is far better that we aim to prevent drug use rather than wait for it to develop and then attempt to tackle it. What is worrying is the lack of detail on how this will be achieved and what extra resources will be available to undertake this. The same could be said for the emphasis on dealing with young people, unfortunately as budgets are cut young people’s services are increasingly being commissioned as part of the wider adult services. A clear statement from the government that young people’s service should be separate and distinct and incorporate a high degree of prevention work would have been reassuring.
Where the strategy is strong is that it attempts to raise the profile of other drugs and also other marginalised groups affected by drug use. The sections on families, domestic abuse, sex workers, homeless, veterans, old users, the spread of NPS, chemsex, image and performance enhancing drugs and prescribed medication shows that the strategy is attempting to cover a wider remit and scope.
While the sections on dealing with drug users in the criminal justice system do outline a range of interventions from diversion through to sentence the greatest concern would be how much of this is achievable. Given the current state of the prison service and the problems with the CRCs is it realistic to expect any meaningful treatment to take place for those that involved in the criminal justice system and perhaps the ideas outlined are more aspirational than achievable.
It is good that the ring fence for funding for treatment services will remain till 2019 but disappointing that this isn’t for longer. It is good that the strategy highlights the risks associated with the tendering culture and reminds commissioners that there are other ways to enhance performance, quality and outcome that are more collaborative and do not require a re-tender.
I am pleased that the focus on recovery remains as I do believe that we should be encouraging, motivating, challenging and supporting people to change. A broader definition of recovery would have been useful so that stable clients on maintenance scripts aren’t excluded and measures to show reductions in medication were included. Both would have given a more nuanced overview of how treatment is working.
However the rise in drug related deaths is a major problem and the lack of detail or focus on harm reduction measures within the strategy is a worry. Harm reduction is the core of a quality drug treatment system and I would have welcomed a dedicated section outlining clear expectations on what harm reduction measures should be in place, rather than these being lost in other sections within the document.
I welcome the use of outcome data to show success and I welcome the focus on ensuring quality, it is good that the importance of high quality staff is recognised and that concerns about the residential sector have been highlighted. More detail in all these areas would have been good but it is helpful they form part of the strategy.
Overall the strategy attempts to cover a lot of ground. In doing so it doesn’t provide detail and some of the aims can be seen as unrealistic in a time of shrinking budgets and wider issues within the criminal justice system. However the establishment of a new Drug Strategy Board is welcomed in that we hope this brings a positive influence to bear on local government in protecting drug and alcohol budgets. Providers need to play a significant role on this with service users to ensure that the reality of the pressures on local authorities and providers in not diluted. Hopefully the new recovery champion appointed to the Drug Strategy Board will help with this process.
As a provider I don’t think it comprehensively addresses the core challenges of increasing treatment outcomes and reducing drug related deaths. It attempts to widen the focus of the drug policy but fails to provide the detail and leadership on how this can be achieved and therefore feels like a good, well intentioned effort but slightly disappointing.
Where’s harm reduction?
SMMGP welcomes many of the strategy’s ambitions including:
- The emphasis on the importance of an evidence-based approach
- The recognition of the importance of providing holistic services for those with complex needs
- The importance of partnership working across a range of services, including housing, employment and mental health
- Support for work with families
- The importance of strong commissioning
However, it is difficult to remain positive about achieving many of the strategy’s good intentions working within the reality of the sustained and ongoing cuts to the drug and alcohol sector and the public and voluntary services in general.
One of the most concerning issues for those who work in the field in recent years is the rise in drug-related deaths in the UK. While this matter is raised in the new drug strategy, there appears to be an absence of support for evidence-based approaches to address this (for example drug consumption rooms, or consideration of decriminalisation of possession or use of drugs, or how to reach people who are not in treatment through for example harm reduction initiatives).
There is also an ongoing focus on the pursuit of abstinence without mention of the essential role that harm reduction fulfils in reducing drug-related deaths. So SMMGP believes that while the Drug Strategy’s ambitions are good, it frustratingly does not provide a realistic direction for how they will be delivered.
Resources are a must
We welcome the long-awaited drug strategy, for which we have been pressing this last year. We trust that the required resources will also be forthcoming, to make the objectives outlined in the strategy a reality.
A welcome emphasis on complex needs
Turning Point welcomes the release of the new drug strategy, especially as we face changing trends in people’s drug and alcohol use. People continue to use new psychoactive substances despite criminalisation last year; there is an increasing number of people using image- and performance-enhancing drugs; and an ageing population of heroin and crack users has resulted in a dramatic increase in the number of deaths as a result of drug misuse since 2012.
We welcome the emphasis on equity of access for a range of people with differing needs and recognition of those with the most complex needs, people with a dual diagnosis – defined as someone with two or more co-existing needs – as well as wider population based interventions. We also welcome the emphasis on supporting people through peer support or recognising the centrality of housing and employment to a sustained recovery.
Mental health is a key theme throughout the strategy, recognising that mental health and substance misuse are strongly interlinked. Partnership working with other agencies is important in order to develop resilience among young people, families, homeless people, serving military personnel and veterans.
The establishment of a drug strategy board overseen by the home secretary should bring a much needed focus on drug treatment and help support local areas to ensure they are delivering safe and effective services. The focus on transparency of commissioning is also welcome and recognises the vulnerability of drugs treatment to local funding arrangements. It is essential that if basic standards of good treatment are to be maintained that there is monitoring of local spending on drug treatment.
We hope the emphasis on data collection and evidence-based support will highlight that investment in drugs services helps not only to save lives, but also to reduce the financial impact on the NHS, local authorities and the criminal justice system.
Clear call for decent housing
In the new drug strategy the government have announced their intention to appoint a national recovery champion who will report into a new drug strategy board, chaired by the home secretary and including representatives from the wider government departments. One of the important roles of the recovery champion will be to ‘seek to address stigma faced by people with drug or alcohol dependency issues’.
At Phoenix we are committed to giving people in treatment and recovery a voice. One area where people face significant stigma is in accessing decent appropriate housing that will support their recovery process. At Phoenix we know the difference housing can make to helping people keep well during and after treatment.
We are very pleased to see a clear recognition from the government in this strategy of the need for decent housing for people in recovery. The strategy says: ‘We will work with treatment providers, the homelessness sector and housing support services to identify and share best practice to support local authorities in identifying routes into appropriate accommodation for those recovering from a drug dependency.’
The new strategy sets out some important priorities for all concerned with the impact of drugs on our society. The government has made it clear that the ambitions of the strategy can only be achieved through effective partnership working. At Phoenix we are in no doubt our work helps people and their families recover from the devastating impact of substance misuse. We are glad to see the government committing to a number of critical measures that we hope will ensure everyone can get the vital help they need, when they need it, wherever they are in the country.
No mention of LGBT people
LGBT Foundation are glad to see chemsex recognised within the strategy.
For several years, we have been providing advice and support for people involved in chemsex and we have seen the importance of targeted harm reduction advice and a holistic approach to addressing drug use, sexual health and other underlying issues, such as mental ill health and internalised homophobia.
We welcome PHE taking a lead in building consensus and awareness of good practice and ensuring needs are met in all areas.
Even within MSM in Greater Manchester, we have found there to be huge diversity in drug use, including higher rates of using opiates and crack (www.lgbt.foundation/news).
Therefore, it is disappointing for there to be no mentions of LGBT people in the strategy as it is vital drugs and alcohol services are proactively engaging LGBT people, and staff are equipped to provide effective and appropriate support for LGBT people.
Continued investment is vital
We welcome the new drug strategy. Since the 1990s the investment into, and delivery of treatment has increased significantly and we hope this will continue. This investment has contributed to many thousands of people receiving high quality treatment and recovering from their addictions. We have also seen huge reductions in drug related crimes and other harms.
We welcome the fact that the home secretary is to have direct involvement in overseeing the roll-out of the new strategy and will directly chair an inter-ministerial group ensuring that the aims and benefits of treatment are understood and owned across government.
We have a treatment system in the UK that is often considered to be world leading and we welcome the consistency in approach that the new strategy brings, its focus upon a system that balances the reduction in harm with long term abstinence, that focuses investment on those most at risk, that is rooted in clinical evidence of effectiveness and which also promotes those measures that we know have transformative impacts upon our service users: employment, skills and housing.
If substance misuse is going to be tackled, there needs to be cooperation between a number of government ministries and local government departments including health, justice, employment and children’s services. Drug treatment is a complex issue that requires the correct level of attention and emphasis on both recovery and harm reduction.
The renewed focus on drug-related deaths is encouraging. We have been working on a number of prevention techniques to reduce the number of drug related deaths, including identifying and predicting those people who are most at risk of overdose, and it is vital this continues.
A renewed focus upon tackling the specific problems facing our prison system and the prisoner population as a result of new patterns of drug use and supply is also to be welcomed.
Drug use affects families and communities across the country and we will be working tirelessly to promote the benefits of treatment, to reduce the unfair stigma often faced by our service users and are committed to ensuring that all agencies pool their resources and expertise to generate long term benefits.
Whilst we welcome the focus on alcohol abuse, it is disappointing to see it treated as a subset of this long-awaited drug strategy. There is a lack of concrete strategy on mental health, dual diagnosis or joining up systems to treat those who need it, as the responsibility instead falls to local authorities to agree this approach. These are all factors which can play a part in substance misuse, and how it is treated, and we would look for clear national direction to effectively tackle these issues as a whole.
Although this strategy is encouraging, it is essential that all of these proposals are supported with relevant funding and investment. Everyone should have the best chance in life, but we are only able to continue our work to support these people with adequate support and investment.
A welcome commitment to evidence
We commend the government’s commitment to evidence-based drug treatment, as well as the introduction of a national recovery champion to drive improvements in rates of recovery from drug and alcohol dependence. Our experience at the frontline of drug services in both prison and the community shows that for successful recovery to truly happen, we need more evidence-based drug treatment programmes – such as our accredited prison substance misuse programmes.
The Forward Trust (formerly RAPt) have been supporting people to build and maintain a life without drugs and alcohol for more than ten years through our Recovery Support Service. This continued care can help build the resilience and strength needed to maintain recovery from addiction and live a positive and productive life with a job, family and community. Our dedicated employment services help people to break the cycle of reoffending and addiction through training and employment activities that are grounded in the real world of work. We believe that anyone is capable of transformational change, no matter how entrenched their addiction or prolific their crimes, and we hope that this new strategy will give more people the support they need to move forward with their lives.
Focus on families
Adfam welcomes the strategy and draws attention to the following points.
Commitment to evidence: Adfam is driven by what works and therefore endorses the strategy’s commitment to evidence-based interventions, in terms of both treatment options and support for families.
Inter-relatedness of problems: For most of the families we work with the substance use of their loved one is not the only issue they face. The challenges of mental ill health, domestic abuse, offending and bereavement sadly often go hand-in-hand with problematic relationships with drugs or alcohol. We therefore welcome the strategy’s acknowledgement that ‘there are families where substance misuse is just one of a number of other complex problems’ and the driving force social inequalities play in the development of all these issues.
Support for and work with families: We welcome the strategy’s recognition of the key role families and parents can play in prevention, the inclusion of the need to support families in their own right, with the suggestion that ‘evidence-based psychological interventions which involve family members should be available locally and local areas should ensure that the support needs of families and carers affected by drug misuse are appropriately met’. The strategy’s highlighting of the efficacy of peer support in the recovery journey of both drug and alcohol users and their families resonates with the experiences of the families and practitioners we work with, and is therefore welcome.
From our experience, much of the support families value can include broader work encompassing one-to-one practitioner support based on listening, signposting and the provision of information – the structured therapeutic approaches mentioned can be expensive or impractical for voluntary and community groups to deliver.
Harms experienced by adult family members: The main focus of the strategy’s coverage of families is driven by the desire to protect the children of those parents who use drugs or alcohol problematically. This desire is laudable. However the realities of the harms experienced by the families of substance users are significantly wider: many of the people Adfam supports are adults profoundly harmed by the substance use of partners, friends and children, both under and over 18. The focus on children within policy discourse means that sometimes the needs of adult family members are overlooked; we would therefore have liked to see a wider focus in the strategy.
Resourcing: The acknowledgement in the strategy of the important role played by the voluntary sector is good to see, as are the commitments to supporting those with substance use issues and their families. Adfam joins others in the sector in noting that the long-term challenge will be ensuring there is sufficient resourcing and political will to meet those commitments.
To add your response, please email the editor.