It’s now been three and a half years since the second part of Professor Dame Carol Black’s Independent review of drugs was published, and while a lot of money has gone into the system since, it’s the certainty of future investment that concerns people the most.
Professor Black has always been adamant, however, that investment wouldn’t be enough on its own – it would have to go hand-in-hand with system change. So is that something we’re starting to see? ‘I think we’re bringing it about much more slowly than I would’ve wished,’ she tells DDN. ‘But one of the reasons is because we probably underestimated the level to which the system had been destroyed by previous lack of resources to local authorities.’
She pointed out in 2021 that even the £552m the review wanted to see invested in treatment over the next five years would only take things back to 2012 levels. Among the serious long-term issues have been the ‘changeover to local authorities without sufficient support, and the diminution of the workforce who were disillusioned and left,’ she says. ‘I think I thought that once we got the money and the right structures, people would respond enthusiastically and want to go back into addiction work. I thought the culture would change to that of realising you needed a holistic system, but it’s taken far longer to bring that about – or to start to bring that about.’
Significant steps
There have been some significant steps forward, including the establishment of the cross-government Joint Combating Drugs Unit, but to help create a truly holistic system she’d wanted to see ‘proper recovery units’ in every local authority. ‘We are getting there,’ she states. ‘We’ve got the LEROs – they’re not as well developed as we want them to be, and not as well supported, but we have commissioning standards for them and we have a framework. So we are setting up a proper recovery community system.’
Some local authorities have ‘without doubt’ responded better to the challenges than others, just as some providers have been more supportive than others, she says. ‘But that’s the nature of the beast. When it comes to employment, I wanted IPS [Individual Placement and Support] available in every local authority. We’ve now managed to achieve that, and we are getting results – we’re getting people back into work, or into work for the first time. In terms of housing we’ve got good collaboration with the department, but it’s slow because there are so many other needs in the housing sector. So that needs a lot more attention.’
And it’s that ‘combination of things’ that’s clearly vital, she states. ‘People used to say to me, “What if we just didn’t do housing?” or “Let’s forget about getting them into work.” But you’ve got to do all of it, you can’t pick and choose.’
Significant challenge
Another significant challenge has of course been mental health. ‘That’s been a struggle because of the traditional fighting between the NHS and the drug treatment system over whose job is it to look after it, so we’re having to work through that. There are some – but not many – very good examples where NHS mental health trusts and the commissioner have worked together to make it work, so it’s often dependent on people in leadership wanting this to happen.’
The review made it clear that mental ill-health and physical, sexual or psychological trauma were issues that needed to be fully recognised as ‘the drivers and accompaniment’ of drug dependency issues, not separate problems for dual diagnosis. There’s more and more talk of having a trauma-informed approach these days – how much of that is still just a buzzword, and how much is a reality?
‘I hate “trauma informed”,’ she says. ‘We can all say it, and it sounds very nice, very modern and trendy. But what you need are proper interventions and treatment for trauma, not just “trauma-informed care”. There are proper psychologists with proper validated programmes for how you help someone come to terms with that trauma. We don’t have that.’
While there are some good examples of appropriate treatment being available – HMP Grendon’s therapeutic community model, for instance – they’re ‘very sparse’, she says. ‘It’s something that we’ve got to get in there.’
In the meantime, however, it might be more a question of getting the mental health basics right. ‘So if you’re a drug-dependent person who’s distressed, anxious, a bit depressed, my dream is to get that treated in the treatment system – not have to wait for a referral, because these are not difficult things to treat. Of course if you’re schizophrenic you’ll need access to a proper mental health service, but I’m talking about simple things.’
Key themes
One of the review’s key themes was that drug dependency issues need to be recognised as a chronic health condition, like diabetes or hypertension, with all the necessary long-term follow-up that goes with that. Has there been good progress there?
‘Not in the way I would like it to be,’ she says. ‘I think that’s down to a change of culture, and that doesn’t require money. It requires people from the very top down to see that addiction is a health condition, with a lot of social implications.’ This also means not treating people as second-class citizens when they go to hospitals, she says. ‘It means treating them as people who need help.’
The review pointed out that the NHS had also been poor at engaging with the wider health needs of people who use drugs, and the range of conditions they can develop – ‘heart disease, lung disease, cancer. But because of the way they’re stigmatised they often just don’t use the services’, she says.
Stigma is clearly something that’s discussed a great deal within the sector, but is there a sense that things are starting to improve more widely in terms of how people are treated when they go to the GP, or the pharmacy to get their medication? ‘I think there’s a long way to go,’ she states. ‘But I think what the public probably don’t appreciate, and maybe politicians need to appreciate more, is that your best way to get safe streets and to stop drug dependent people committing petty – and more serious – crime is to offer them high-quality treatment and a good recovery system. We know that internationally, from the best research.’
Far too many drug-dependent people are sent to prison, she says. ‘I’m not against the law coming in there if people have committed crimes, I’m against disproportionate treatment.’ The secure estate and wider society can’t simply be regarded as separate issues, she points out, and she’s recently completed an independent internal review for the government – which is yet to be published – on the care of drug-dependent people in prison.
‘What we also haven’t achieved yet is enough diversion from prison, but I’m hoping David Gauke’s forthcoming sentencing review will help that,’ she says. One problem is that diverting people means having somewhere to divert them to – ‘high-quality treatment in the community where you can hold people carefully and appropriately, and that has not been easy to achieve,’ she says. ‘The workforce is simply not there. So it’s complex, and it’s difficult. But I’m a glass half-full person and I think we’re certainly better than where I started.’
Wider issues
Is she hopeful that the new government will continue the general direction of travel? ‘Yes, I think so,’ she says, ‘and it aligns with four of their five missions.’
‘I think, rightly, they’ll want more that supports prevention and supports young people, but one of the reasons we weren’t able to do that is because there isn’t the evidence telling us what to do, there isn’t the science-based research. We’ve now put much more money into research – and there is research going on – but it doesn’t just happen overnight.’
And all of these issues are inextricably linked with wider – and more intractable – problems, of course. ‘How do you prevent the poverty and deprivation that means young people are living in really awful circumstances – getting expelled from school, going into care, getting drawn into crime, into gangs, into the criminal justice system,’ she says.
‘These are the big generic social issues, and you have to be in this for the long haul. As far as I can see, things can always change. But our change of government hasn’t led to a desire for change of direction.
Sustainable funding
‘Overall, is the quality good enough? No, it’s not,’ she continues. ‘Has there been enough innovation with the money, rather than just going back to “let’s employ more drug workers?” No. But I would say, overall, we’re going in the right direction.
‘Can we get sustainable funding at the next Spending Review? We said it was a ten-year strategy, not “we’ve had three years of money and all will be well”. All is not well. You can’t do it that quickly.’
In the end, her view is ‘thank goodness we did it’, she says. ‘Because I dread to think of where we were. I think on the whole we’ve done the right things, and I think most people around the world think we’ve done the right things. They’re just very difficult to do.’