CPSDU UPDATE 23/03/11 The 2010 Drug Strategy : Harm reduction or abstinence or both?

1. CPSDU UPDATE 23/03/11The 2010 Drug Strategy:Harm reduction or abstinence or both? Dr Jenny Keen Clinical Director, PCASS Royal College of GPs Regional Lead for Substance Misuse Honorary Senior Lecturer, Academic Unit of Primary Care, University of Sheffield

2. DRUG STRATEGY 2010 • ‘Reducing demand, restricting supply, building recovery: supporting people to live a drug free life’ Paul Hayes, Chief Executive of the National Treatment Agency: • ‘The new drug strategy is unashamedly recovery-focused, but that does not mean it is abstinence-obsessed’. (Network newsletter, Feb 2011)

3. DRUG STRATEGY 2010 • Short (25 pages) • Document about social policy not treatment (17 out of 25 pages are about supply and demand and social factors) • Drugs and alcohol misuse as a social phenomenon not a medical condition • Emphasis on social policy solutions • No discussion of treatment specifics • Doctors and pharmacists not mentioned • NB to be followed by BRIC document (National Service Framework)

4. Drug strategy 2010: themes • Reducing demand- focus on early years support, drugs education in schools, pupil premium to reduce disadvantage, Early Intervention Grant, work in criminal justice system • Restricting supply- border agencies, Community Safety Partnerships, disruption of organised crime networks, international co-operation • Building recovery in communities (the recovery agenda)

5. The 2010 DRUG STRATEGY:SPECIFICS • National Crime Agency (NCA) (against organised crime) to be created to work with UK border agency • Public Health England to be created, with commissioning from within local authorities for drugs and alcohol • NOT liberalisation and legalisation • Cracking down on ‘legal highs’ • Includes prescription and OTC medicines • Alcohol and drug treatment ? to be integrated • Voluntary, community, charity, social enterprise to be encouraged • Payment by Results to be developed

6. HOW THE SYSTEM WILL WORK • “Locally led and locally aimed” • Public Health England (local Directors of Public Health and a nationally led Public Health Service) including the NTA • Directors of Public Health will be in local authorities (jointly appointed by PHE and local authorities) • Directors of Public Health will commission and oversee drug and alcohol treatment services • Local partnerships including Police and Probation, employment and housing • Emphasis on treatment for severe alcohol dependence alongside illicit drugs • Locally led – competitively tendered and rewarded • Local accountability re performance

7. THE RECOVERY AGENDA …going beyond harm reduction “offering support for people to choose recovery as an achievable way out of dependency” BUT “drug treatment can be very effective in preventing wider damage to the community such as high volume acquisitive crime, and together with initiatives like needle exchange schemes, can reduce the harms caused by dependence” How will this be put into action?

8. 1. Recovery • ‘Recovery is an indivdual, person-centred journey’ • 3 factors: wellbeing, citizenship, freedom from dependence • ‘Medically- assisted recovery’ is recognised (ie maintenance) including possible diamorphine prescribing BUT • The ultimate goal for everyone is to be drug free

9. 2. Recovery Capital available to individuals • Social capital (support from family, peers, etc) • Physical capital (money, housing, etc) • Human capital (education, skills, health, work) • Cultural capital (values and beliefs) All these are to be supported to contribute to recovery ? How this fits with overall reductions in public services

10. 3. Locally led and locally-aimed system • Public Health England from 2013 • NTA will become part of Public Health England • Local Directors of Public Health (within local authority) • Directors of Public health will commission and oversee drug and alcohol treatment (not GP consortia) • No mention of Drug and Alcohol Action Teams ? Follow Director of Public Health into local authority? • Emphasis on partnership with other services eg police, housing, employment, criminal justice • Local leadership, competitive tendering, local accountability • Payment by Results

11. 4. Outcome focused services • Freedom from dependence on drugs or alcohol • Prevention of drug related deaths and BBV infections • Reductions in crime • Sustained employment • Sustainable housing • Improved mental and physical health • Improved family relationships and better parenting BUT no prescription for how these should be achieved NB many very similar to old harm reduction outcomes

12. 5. Whole systems approach • Working with pathways into education, employment, housing, etc • Single integrated care plan • Seamless transitions and joint working • Joint commissioning across services where possible • Drugs and Alcohol to be integrated into one National service Framework

13. 6. Inspirational recovery-orientated workforce! • ‘culture of ambition’, ‘belief in recovery’ • National Skills consortium to build skills framework eg training for Jobcentre Plus advisers • Replacement of Models of Care with BRIC

14. 7. Recovery Networks • Recovery champions- 3 types Strategic (commissioners, Directors of Public Health etc) Therapeutic (early adopters of recovery model in the treatment system) Community (mentoring by recovered drug users locally)

15. 8. Reintegration • Housing • Employment opportunities • Effective child safeguarding systems • Benefits system to ‘support engagement with recovery services’ ie claimants in treatment will get tailored benefits but those refusing treatment will have rigorous enforcement • Incentives to be built into the universal credit system to reward treatment uptake

16. 9. Medically assisted recovery • Recognition of success and importance of maintenance treatments in harm reduction, crime prevention etc • Recognition of good evidence base for maintenance treatments BUT Going beyond existing evidence base so that everyone works towards eventual abstinence All must ‘engage in recovery activities’

17. 10. ALCOHOL • Emphasis on interventions with highly dependent drinkers and specialist treatments but no detail • Drug misuse/alcohol dependence in one National Service Framework • Implication that alcohol treatments to be delivered by same providers as illicit drug treatments • Social policy aspects of alcohol not mentioned (eg price per unit etc) • No mention of GP treatment, shared care for alcohol, etc • No mention of increased funding to support developments

18. FOCUS ON OUTCOMES! • Freedom from drug or alcohol dependence • Prevention of deaths and BBVs • Reduction in crime • Social reintegration/mental health improvement • Better parenting How to define and measure these? Much debate... NDTMS? TOPS?

19. PAYMENT BY RESULTS • 6 pilots: drugs recovery for adults, 2011-2013 • Development is ‘work in progress’ • Little detail yet known • Probably some sort of ‘tariff’ system • Aim to incentivise the system to deliver recovery outcomes • Debate as to how to measure and reward recovery outcomes • Debate as to role of harm reduction outcomes • Concern re creation of ‘perverse incentives’ by crude outcome measures

20. NATIONAL SERVICE FRAMEWORK CONSULTATION: BRIC (BUILDING RECOVERY IN COMMUNITIES) • Models of Care to be replaced (MoC) • Probable integration of drugs and alcohol into a single MoC document • NTA to produce a new ‘safeguarding protocol’ • Consultation on BRIC 13 weeks currently happening • Individuals or organisations can respond • Specifics of treatments and pathways will be in the new NSF

21. SO WHAT ABOUT PHARMACY? • Nowhere mentioned in the strategy – NB neither is general practice! • Recognition of importance of harm reduction outcomes • No detail about delivery or funding • No real definition of recovery – NB where recovery is required, ‘engagement’ seems to be measured where outcomes are required, process is still being measured BUT competitive tendering and commissioning by local authorities will presumably affect all parts of the system

22. SO HOW WILL THIS AFFECT PRACTICE? • More power in local commissioning groups but NOT GP commissioners – probably unfortunate for alcohol services • Providers will be expected to deliver ‘recovery’, however this is defined • No more money for alcohol but greater expectation for its treatment in treatment services • Long term maintenance will be frowned on • More local variation- possible postcode lottery • Eventually, some form of ‘payment by results’ • A lot will depend on the outcome measures selected to measure ‘recovery’ BUT NB no government wants to see crime rates rise so some softening of approach may be expected over time!

23. Risks inherent in new strategy • If ‘recovery’ means becoming totally drug free, risk that it may lead to ‘revolving door’ and increased heroin deaths (maintenance reduces heroin deaths by a factor of 6 out of 7. Loss of tolerance is the greatest risk factor for heroin deaths). • Payment by results can lead to inaccurate reporting, playing the system and perverse incentives rather than to improved outcomes • Commissioning of clinical services from outside the NHS commissioning structures is always risky especially with competitive tendering

24. SUMMARY: THREATS AND OPPORTUNITIES • ‘Recovery’ agenda may lead to loss of harm reduction and increased deaths • Expansion of voluntary/social enterprise sector can lead to poor clinical governance where clinical services are involved • Is there the expertise in public health nationally to commission effective local drug and alcohol services? • Will harm reduction interventions e.g. needle exchanges suffer, especially in more recovery-driven services? BUT • Local flexibility may lead to increased influence by local service providers and better local decision-making • Alcohol services may develop better alongside drugs services • Benefits system may lose its perverse incentives and support recovery • Same people may ‘recover’ who were otherwise on lifelong maintenance!!

25. To answer the question... • Harm reduction and abstinence are not polar opposites • The pendulum of drugs policy tends to swing between the two and has swung back towards the abstinence agenda • Abstinence can be seen as the pinnacle of harm reduction- but there are lots of important steps on the way • No-one can oppose ‘recovery’- it’s all about interpretation and how it applies to individuals

26. BRIC consultation • NTA website • Building Recovery in Communities • ‘ a consultation for developing a recovery-oriented framework to replace Models of Care’ • Have your say!