Opportunity to change

Sara Kulay, author of a new Audit Commission
report on services for drug misusers, outlines how the pieces are
in place to improve co-ordination between services and raise the
quality of treatment.

As drug misuse and drug-related crime continue
to dominate the headlines, pressure is growing to find ways of
tackling it. One aim of the government’s national anti-drugs
strategy is to double the number of drug misusers in treatment by
2008. Part of this strategy – the establishment of the National
Treatment Agency (NTA) – also reflects a new determination to drive
up standards and improve the quality of care that drug misusers
receive.

Specialist support provided by community drug
teams (CDTs), GPs, social services departments and street agencies
are key to the success of the anti-drugs strategy, but many drug
misusers are still struggling to get the help they need, when they
need it. Many of the staff working in drug treatment services are
highly motivated but services are still thin on the ground. The
result can be limited treatment options and long waiting lists. And
some local GPs can be reluctant to get involved. In about half of
the drug action team areas surveyed in the Audit Commission’s
Changing Habits survey,¹ fewer than 10 per cent
of GPs worked with specialist services to support drug
misusers.

When drug misusers manage to obtain a service,
under-developed care management arrangements and poor co-ordination
between different agencies often reduce the scope and quality of
care. The complex nature of drug misuse means that many misusers
need varying combinations of services and must be supported along a
treatment “pathway”.

Yet some CDTs give care planning a low
priority. Few try to follow up people who have dropped out of
programmes or missed appointments, sometimes taking this to reflect
a lack of motivation to change. Working with clients who will often
relapse can also dampen workers’ own expectations. One worker
interviewed for the study argued that “we can’t set long-term goals
for this group – they are too chaotic”.

A large number of clients receiving treatment
for drug misuse will also have other needs – for example, a mental
health or an alcohol problem, or difficulties with housing, jobs
and relationships. Yet poor links to other agencies, such as
housing and mental health services, can mean that drug misusers’
wider problems are neglected. Different service priorities and
philosophies of care, high workloads and the absence of joint
training can also undermine partnership working.

Weaknesses in local treatment systems
inevitably mean that some drug misusers fall through the net. Long
waiting lists can drive potential clients away. In one area where
clients routinely waited five months for an appointment with the
CDT, only one in every three clients offered an appointment ever
attended. As one heroin misuser pointed out in the study: “When you
want to come off drugs, it is then, not four or five months down
the line.”

Where those with complex problems fail to get
support, the likelihood increases of repeat episodes of
imprisonment or hospitalisation – the “revolving door” syndrome.
Many staff in drug treatment services reported that they still have
little contact with prison services and are rarely contacted to
provide follow-up support to prisoners who received treatment
during their sentence. Research suggests that without adequate
support, many will simply resume their habit on release and some
will return to prison time and again.

So what is to be done? New funding provides a
fresh opportunity to reshape local provision, improve the quality
of support and give staff the tools they need to do the job. With
national investment in treatment set to increase from £234
million to £401 million between 2000-1 and 2003-4, local
commissioners and providers face the challenge of ensuring that
both new and existing resources are used to best effect.

Successful approaches will depend on closer
working between those commissioning drug treatment services and
those providing them. With purchasing split between health
services, social services departments and criminal justice
agencies, joint commissioning groups are needed to promote a more
co-ordinated approach and to ensure that each agency gives
treatment sufficient priority. Fundamental service reviews will
require better information about the performance of existing
services and the type of support that drug misusers require. At
present, the absence of separate contracts and service
specifications or meaningful reporting requirements for treatment
services can make it hard to assess the quality of what is on
offer.

In many areas the first task will be to
address long waiting times and gaps in the range of treatment.
Better partnerships between GPs and specialist services and
improved training are needed. Many GPs still feel that they lack
the expertise to prescribe substitute drugs and receive inadequate
support. Of 1,574 GPs who responded to Changing Habits,
about two-thirds said they feel they lack sufficient training to
support people with drug dependency problems and do not have easy
access to specialist services.

Attracting more drug misusers into treatment
is also a priority. This could mean changing the way services are
organised. Many crack cocaine misusers want informal services that
provide open access and offer a broader range of psychosocial
support. Also, services that view their core business as
prescribing substitute drugs to heroin misusers, operating rigid
appointment systems and offering little access to counselling, are
unlikely to meet the needs of this particular group.

More imaginative recruitment strategies will
also be needed to reach target groups. One service attracted more
black misusers of crack cocaine by setting up a 24-hour crack
telephone helpline and advertising in minicab firms and
launderettes. Others have provided outreach support to sex workers
using drugs, contacting them via their cards left in telephone
kiosks or through local saunas and massage parlours.

Better care co-ordination will be the
cornerstone for helping people through the maze of local services
and ensuring that they obtain appropriate support from a range of
agencies. Good pathway management will require more systematic
screening and assessment, care planning and review. Approaches in
related fields provide models. The care programme approach in
mental health, for example, is used to achieve better
co-ordination, with specialist mental health teams taking the
lead.

A team that brings together social and health
care professionals may prove to be the best option for
co-ordinating care for drug misusers, allowing both medical and
social care needs to be addressed together in multidisciplinary
assessment and care planning. Existing CDTs could provide the
focus, especially where they include a broad mix of professional
groups.

Where CDTs are unwilling to take on a broader
role, preferring to focus on clinical treatment, other options
could be considered. These could include setting up a separate care
management project or locating care co-ordination with a
well-established street agency or social services department.

New initiatives to support those with more
complex needs must also be explored. Some agencies already offer
support to ex-prisoners using link workers based in voluntary
agencies, while others have increased investment in resettlement
services that offer more long-term housing and practical support.
The development of Supporting People, the new policy framework for
supported housing, provides opportunities to extend these types of
schemes and review policies in relation to drugs and homeless drug
misusers.

Local efforts to improve support must be
supported by improvements in the national policy framework. Some of
the weaknesses in current arrangements stem from uncertainty about
what sort of treatment interventions and staffing mixes work best
or a failure to deliver services in line with evidence-based best
practice. Lack of relevant training among some of the existing
workforce, difficulties recruiting and retaining staff and the
absence of any national comparative performance data can also
hamper service development. There is a clear role for the NTA in
addressing these issues.

Building up the capacity of the treatment
sector to improve the quality of support will take time. But more
funds, a greater sense of urgency and new initiatives such as the
NTA all point to a better future for drug treatment services. If
the opportunity is missed, the losers will be some of the most
vulnerable people – and communities – in the country.

Drug teams

– Community drug teams (CDTs) are statutory
bodies, often NHS-based, that view drug misuse in a social context
and seek work with other services, such as housing, social services
and GPs.

– Drug action teams (DATs) in England, and
drug and alcohol action teams (DAATs) in Wales, are multi-agency
bodies that aim to ensure co-ordination between agencies and assess
whether local spending plans and initiatives are aligned to
government targets on drugs.

Sara Kulay is project manager at the
Audit Commission and author of the Changing Habits report,
published this week.

References

¹ Sara Kulay, Changing
Habits, Audit Commission, February 2002. The report is
at www.audit-commission.gov.uk/home/