What's wrong with o ur national Drug Strategy ?

1. What's wrong with our national Drug Strategy ? Dominic Harrison @BWDDPH And how do we improve it?

2. Issues • Smoking, Drinking and Drug Use 11-15 year olds in England • Political Culture and Drug Culture • Drugs Strategy: Doesn’t say enough • Drugs Strategy: Could say more • Managing Incidence • Managing Prevalence • Drugs & Alcohol Assets /Recovery Capital Concepts: • Assets & Needs • Assets and Risks • Outcomes Frameworks • Next Steps: NHS & Public Health Reform • Health & Wellbeing Strategy

3. Reducing Demand, Restricting Supply, Building Recovery (2010) Key Issues to be addressed: - Social Harm Crime & re-offending Family Breakdown Poverty ‘It is acknowledged that all of the above cause misery to individuals, destroy families and undermine communities’. Ambition – To stop people taking drugs 3 main themes Reducing demand Reducing supply Achieving recovery. Overarching aims Reduce illicit drug use Increase the numbers in recovery ‘Integrated services for drugs and alcohol users should be a priority (in the community and in prisons)’

4. Smoking, Drinking & Drug Use 11-15 year Olds: England 2006-8 Source: ONS/NHS Information Centre (2010)

5. Political Culture DH Routemap for Sustainable Health (2011) Better Value Healthcare (BVHC) Political Quarterly

6. Drug Culture Futures? ‘War On Drugs’: R. Regan 14th Oct 1982 Drugs Futures: Economist October 1 2011 • “Britons are especially fond of psychoactive substances. Ten adults in every 1,000 has a drug problem, the highest ratio in Europe” • …In contrast new recreational drugs are proliferating. Some 24 novel compounds were detected in 2009 by the Monitoring Centre for Drugs and Drug Addiction, a Lisbon-based outfit funded by the European Union. The figure rose to 41 in 2010; a further 20 appeared in the first four months of 2011. • Economist: How recreational drug use—and the problems it causes—are changing :Oct 1st 2011

7. doesn’t say clearly enough? • There is a significant cohort of very vulnerable and ‘service institutionalised’ heroin/ crack- cocaine users for whom competing with other unemployed stable, well educated & ‘cheaper to employ’ citizens means an ‘economically and socially independent’ drug free future is unlikely. • There is a larger group of drug using citizens who can attain drug free recovery if supported with housing, employment, relationship building and ‘extraction’ from negative local social influences/networks or more effectively - placement within new local recovery communities. • There are now rapidly evolving: ‘legal highs’, designer drug capacities, smart/recreational drugs, life/personality/performance enhancing drugs – that legislation will never be fast enough to manage & control. • Poverty is a key driver – substance misuse will increase during economic crises. • Reduce Incidence as well as manage prevalence.

8. could say more clearly? That we need to : • Acknowledge (with Alabama) ‘we cannot treat or arrest our way out of this problem’ • Have steady disinvestment from a treatment to public health / recovery approach • Develop a more differentiated targeting of prevention and treatment on integrated substance misuse /addictions including increased use of e-health solutions at population level • Liberalise (not legalise) our approach to drug harm / control (e.g. with penalties/awareness courses etc) • Develop earlier more integrated intervention in ‘whole household’ approaches aimed at reducing inter-generational transmission • Gradually Shift future NHS intervention investment from where it is now to (ACE) alcohol/ cocaine/ecstacy/designer drugs. • Alcohol is the number 1 population drug use risk and should be prioritisd. • Engage more public services in Level Zero/level 1 intervention (e.g leisure services)

9. What's Killing Us? : Causes of the HI Gap in Spearhead LA Areas

12. Recession Impacts Cabinet Office Social Exclusion Task Force (2009). Learning from the past : Working together to tackle the social consequences of recession. Evidence Pack December 2009.

13. Managing Incidence: BwD: Shifting Population Alcohol Consumption and Risk 24- 25,000 (24% population) Alcohol treatment Safe/moderate 21 Units men 14 units women Hazardous Over 50 units Alcohol free (14%?) Harmful Up to 50 Units

14. Managing Incidence: BwD: Shifting Population Alcohol Consumption and Risk 10,000 (14.5% population?) Safe/moderate 21Units men 14 units women Hazardous Over 50 units Alcohol Free Harmful Up to 50 Units

15. The conundrum of alcohol-related harm (1) • Between 1995 and 2008, the major components of the increased gap between spearhead and non spearhead mortality, appear to have been alcohol-related. Alcohol-related gaps appear, however, to have narrowed slightly since. • If it were not for alcohol-related deaths, the objective to narrow overall spearhead life expectancy gaps would almost certainly have been achieved for males; and would be well on the way to being achieved for females. • But – from population surveys between 1998 and 2008, spearhead and non-spearhead populations have experienced very similar rates of increase in average alcohol consumption and in binge drinking (on revised quantifications of wine consumption). Surveys of drinking tend to show similar (and dramatic) consumption increases in all income groups except the very poorest.

16. The conundrum of alcohol-related harm (2) • On-going clinical studies appear to find that the experience of alcohol harm in the two ‘worst’ deprivation quintiles has been radically different from that in the three ‘better’ deprivation quintiles; there has been relatively less increase in alcohol-related mortality over the past 15 years in more affluent populations, in spite of their experiencing a big increase in hazardous drinking.There has been substantial increase in mortality in the two most deprived quintiles. • The major components of the mortality increases are in alcoholic liver disease in early middle age (45-64); and also in digestive cancers and alcohol-related dementia in late middle age (60-74): • Killing yourself from alcoholic liver disease in middle age is hard; it takes a lot of drink over a prolonged period, long after the experience of drinking becomes overwhelmingly unpleasant, for the drinker and for anyone who knows them. • Recovery from alcoholic liver disease can be easy and quick; stop drinking dangerously, and if you survive the following months, your risk of liver mortality will drop towards the population average in less than two years. • So what is stopping people from stopping; and why has success in stopping become relatively more difficult in more deprived populations in recent years?

17. Managing Prevalence: ‘getting ill less’ versus ‘getting ill better’ • The context for these achievements, since 2007, is that of open and shared commitments by Local Strategic Partnerships to adopt locality-wide and cross-sectoral actions aimed at reducing incidence, through tackling differential exposure to avoidable health risks. • This is the conventional Prevention agenda for ‘getting ill less’. • There has been less success in responding to increased health inequalities in alcohol-related harm; relatively insignificant in the baseline period, but now in many localities, the major component of their mortality gap. • We find that areas with increased alcohol-related mortality do tend to also to have experienced increased patterns of harmful drinking; nevertheless alcohol-related mortality in other areas with equally increased exposure to harmful drinking has increased much less, if at all. This suggests: • That differential alcohol-related local mortality is not so much about differential incidence, as about differential recovery, • That to tackle inequalities in alcohol-related mortality, localities need to tackle differential access to recovery assets • This corresponds to the Asset agenda for ‘getting ill better’

18. Managing Prevalence: Getting Ill better: the Asset approach • Differential access to personal, social and reciprocal assets is significantly associated with: • The under-construction of illness; persons with poor access to assets for wellbeing tend to be recognised as ill later, to access services less appropriately, to have higher levels of unmet health needs and to die sooner, • The under-construction of recovery; persons with poor access to assets for wellbeing – once recognised as ill – tend to stay ill longer, to recover less completely, and to consume higher levels of health resources • Clinical Approach to ‘Getting Ill’ • Become ill when you are diagnosed as having a pathological condition by a doctor or health professional, • When the doctor or specialist has finished with you, your are ‘discharged’, long-term illnesses do not have a limited duration, so long as the underlying pathological condition (e.g. diabetes, cancer) persists, • Clinician seeks to discharge patient, so far as possible, the way they were, • ‘Recovery’ is only recognised in relation to addicts and alcoholics. • Asset Approach to ‘Getting Ill’ • Become ill when you are recognised, and can recognise yourself, as ill within your social context; you are then ‘constructed as ill’ allowing you access to illness resources and assets, • Recover from illness when you are able to function within your social environment of choice; long term illnesses can have a duration; indicated as experiencing condition as non-limiting, • Full recovery is associated with control; having access to a state in which the condition will not recur, • Recovery is normal and real; and is a contagious condition (as is non-recovery)

19. Assets & Needs Assets High Blackburn with Darwen Needs High Low Low NW City

20. ASSETS reducded increased increased reduced RISKS Assets and Risks Body mass normal weight Adult social drinking at moderate levels Teenagers abstaining from alcohol Non-smoking – adults & teenagers High recreational participation Joining local groups (esp. sports & religious) Social contact and trust with neighbours Adult satisfaction with work/life balance Continuing participation in education Satisfaction with long-term relationships Body mass overweight Adult social drinking at hazardous levels Teenagers making their own way to school Teenagers cycling and walking Teenage recreation away from home Light adult recreational participation Adults attempting to quit smoking High adult time commitment to home life Going out at night Body mass obese or underweight Adult drinking at harmful levels Any under-age alcohol consumption Cigarette smoke, active and passive Sedentary lifestyle Not joining local organisations & groups Low recreational participation Sub-standard housing or neighbourhood Worklessness in adults of working age Living alone Adults abstaining from alcohol Teenagers taken to school by parents Teenage use of parents’ car transport Teenage recreation at home Adult mistrust of teenagers ‘hanging around’ Parents’ mistrust of non-household adults High adult time commitment to work Staying in at night

21. Health and Wellbeing Strategy Framework Delivery Plan: Short, Medium and Long Term Focus

22. Health Outcomes Frameworks Alignment: Public Health, NHS and Adult Social Care Public Health Adult Social Care and Public Health: Maintaining good health and wellbeing. Preventing avoidable ill health or injury, including through reablement or intermediate care services and early intervention. NHS and Public Health: Preventing ill health and lifestyle diseases and tackling their determinants. Awareness and early detection of major conditions Adult Social Care and NHS: Supported discharge from NHS to social care. Impact of reablement or intermediate care services on reducing repeat emergency admissions. Supporting carers and involving in care planning. Adult Social Care NHS ASC, NHS and Public Health: The focus of Joint Strategic Needs Assessment: shared local health and wellbeing issues for joint approaches.

23. OutcomesFrameworks : Target Domains Health Services Lifestyle & Behaviour change Public Health & Social Care Wider Social determinants

24. NHS Public Health/Prevention Spend Transfer to LAs • tobacco control; • alcohol and drug misuse services; • obesity and community nutrition initiatives • increasing levels of physical activity in the local population • assessment and lifestyle interventions as part of the NHS Health Check Programme; • public mental health services; • dental public health services; • accidental injury prevention; • population level interventions to reduce and prevent birth defects; • behavioural and lifestyle campaigns to prevent cancer and long term conditions; • local initiatives on workplace health; • supporting, reviewing and challenging delivery of key public health funded and NHS delivered services such as immunisation programmes; • comprehensive sexual health services (this includes testing and treatment for sexually transmitted infections, contraception outside of the GP contract, termination of pregnancy, and sexual health promotion and prevention • local initiatives to reduce excess deaths as a result of seasonal mortality; • role in dealing with health protection incidents and emergencies (Annex B) • promotion of community safety, violence prevention and response; and • local initiatives to tackle social exclusion.

25. Next Steps The Director of Public Health will carry out as core functions: - • The overseeing of commissioning of drug and alcohol treatment services • Work with local partners including the Police and Crime Commissioner, DWP, Housing, Prisons & Probation • Accountably to the Health and Wellbeing Board Outcomes • Abstinence • Prevention of drug related deaths and BBVs • Reduced Crime and re-offending • Sustained employment • Ability to access suitable accommodation • Improve mental and physical well being • Improved relationships • Capacity to be an effective parent

26. New Health and Well - Being Strategy Health and Well- Being Priorities Health and well-being services NHS Local Authority & Partners Social care (children and adults,Third sector Housing, transport, Big Society Leisure, Education, Partnerships, Economy, Social enterprises Primary & Community care Secondary & Tertiary care Specialist & National care Support at home Institutional care Acute care General population Low level advice & support People choosing less dependent more cost-effective options £20Bn gap in funding Increasing demand on services NHS “flat cash” funding