Drugs bust?

    There can be no doubt that the government wants to tackle the drugs
    problem. Although its drugs tsar’s star quickly burnt out, the
    government swiftly replaced Keith Hellawell with an updated drugs
    strategy two years ago. This strategy created the context for the
    National Treatment Agency for Substance Misuse (NTA), a special
    health authority created in 2001, to oversee drug treatment
    services at a national level in England. Parallel structures were
    set up in Scotland, Wales and Northern Ireland.

    Like most government bodies, the NTA has targets to meet: to double
    the number of people in effective, well-managed treatment to
    200,000 in 2008 (from 100,000 in 1998); to increase the proportion
    of people who successfully complete or continue treatment; and to
    reduce average waiting times for treatment services and
    counselling.

    The NTA says that it is on track to meet the 2008 deadline: in
    2002-3, there were 149,000 people in effective treatment. It is
    also confident about the numbers completing treatment.

    Reducing waiting times has proved trickier. On average, waiting
    times are down by about one-third, but the multiple targets (each
    service has a different one) typically aim for a two-thirds
    reduction.

    Targets aside, how is the NTA performing three years on? Leaving
    out the whole controversy around whether the agency should include
    alcohol within its remit, opinion is still divided.

    Richard Tamlyn, head of consultancy at drugs information charity
    DrugScope, says: “The NTA cops a fair amount of criticism, some of
    it inappropriate.” He thinks professionals need to remind
    themselves of the context into which the NTA was born. “It came
    along at a time of great expansion in the treatment field, when the
    government was trying to put a central focus on all issues of
    drugs. It had an enormous job to do and it’s moving forward.”

    Tamlyn believes that the NTA initiative on models of care has been
    its most significant achievement. Models of care is equivalent to a
    national service framework for drug treatment services, aiming at a
    co-ordinated approach to treatment.

    For the first time this established an over-arching principle as to
    how the different aspects of drug treatment fitted together, giving
    commissioners a clear picture of what they needed to commission in
    their area. “It pushed on inter-agency co-ordination,” says Tamlyn.
    “It encouraged service providers to talk to each other and think
    about the whole picture and how users move through the
    system.”

    Tamlyn’s team helps agencies implement models of care. He concedes
    that the degree of co-ordination varies across the country. “In
    some areas agencies are working well together, but you don’t see
    widespread care co-ordination yet. Many are functioning well in
    terms of interagency referrals.”

    In other areas, though, he sees a silo mentality.

    “Someone presents to a service and it grabs hold of them rather
    than assessing whether they are appropriate for that service,” he
    says. “The thinking is that we must offer them something.”

    This leads to concern that people have been trundled through to
    specialist services whether they need them or not, blocking them
    for those in greater need. One way for the NTA to meet its waiting
    times target is to make sure users are signposted to the right
    service.

    Others are less sure about the success of models of care. Indeed,
    some critics go so far as to say that it is the NTA’s weakest area.

    Richard Kramer, head of policy at social care charity Turning
    Point, has his feet firmly in this camp. “I think it has found it
    difficult to implement in practice, which means people aren’t
    getting sufficiently co-ordinated care. And because information is
    not being shared across agencies, they still get repeat assessments
    and referrals.”

    Kramer argues there is a big difference between setting a national
    framework and implementing it on the ground so that the individual
    gets better co-ordinated services. “There’s a long way to go,” he
    says.

    Turning Point wants the NTA to set up a national steering group to
    identify all the different agencies – from housing to education,
    employment to GPs – involved in users’ lives. It also wants to link
    government programmes, such as Supporting People, to treatment
    plans.

    Tamlyn agrees. “People don’t just need support from specialist
    services,” he says. “Tackling substance misuse needs to be part of
    all government agendas.”

    This is a widely held view. The whole philosophy behind models of
    care is about drug treatment but the solution can’t be made up of
    just one part. People need to have hope in other aspects of their
    lives – hope, for example, that they can get a job or live
    somewhere decent.

    Peter Martin, chief executive of national drug and alcohol
    treatment charity Addaction, says: “We need to help people reinvent
    their lives and I don’t see how models of care will do that unless
    we include other agencies. The drugs bit that we work with isn’t as
    important as what they are doing with the rest of their lives. It’s
    left to the providers to make that leap. Addaction experiences
    massive difficulties with homeless clients. We can get everything
    else in place, but we can’t produce housing.”

    Martin is also concerned that the NTA is too bureaucratic. “We
    wanted a raging, charging bull and what we have got is becoming a
    white elephant,” he says. “We needed it to be small and
    authoritative to break away from the we/they dichotomy of the
    people who deliver services and the people responsible for
    commissioning them. But it hasn’t brought the field together to get
    behind the national drugs strategy.”

    And there is another, more philosophical concern for Martin. He
    fears there is an over-reliance on putting people on substitute
    prescriptions.

    “Addaction works to help create independence,” he says. “There is a
    range of treatment options, but the NTA seems to think the answer
    is getting people on prescriptions of methadone. It’s short-term
    expediency to get people into treatment. What happens to them next?
    Where are the additional rehab places we need? It focuses on the
    medical model and that’s pretty dated. There are more productive
    ways of working with people.”

    This is a misconceived view, according to NTA’s chief executive
    Paul Hayes. “We see abstinence from illegal drugs as the eventual
    goal for the vast majority. But for large numbers of people with
    dependency problems, maintenance prescribing will be the most
    appropriate effective treatment.”

    Hayes agrees, however, with the criticisms levelled at models of
    care. “It needs to be broader and include the social integration
    agenda. It’s difficult to get it right and some places are doing it
    better than others.”

    As for the bureaucracy accusation, he holds his hands up: “We are a
    bureaucracy, we can’t hide from that. We exist to try to make sure
    that money spent on treatment is spent wisely.”

    He cites an Audit Commission study into the NTA’s work in the North
    East that found it had made a significant contribution to improving
    the effectiveness of drug treatment. “The conclusion I draw is that
    although we do place an additional burden on the system, we are
    excellent value for money.”

    Hayes is the first to admit that people think the NTA lacks teeth,
    but says: “Theoretically, we don’t have a lot of power; neither do
    the Audit Commission and other bodies across government. But we can
    work with all the key players to persuade them to do the right
    thing – they know our connections and that we have political
    support. We have more than enough levers to pull to correct bad
    practice when we find it.”

    But with a review of all arm’s-length bodies in the Department of
    Health about to report, can he be so confident of government
    support?

    “Our understanding is that the review acknowledges the significant
    contribution from the NTA and that it will continue at least until
    the end of the current drug strategy in 2008,” he says. “Whether it
    goes beyond that is another matter.” CC The publication of the
    alcohol harm reduction strategy for England last March came more as
    a relief than a celebration. After six years of waiting we finally
    knew what we were dealing with. Or so we thought. The reality of
    the strategy is that it has promise but no promises. Nothing is
    ruled out, but nothing much is ruled in either.

    Affectionately known as AHRSE, the strategy is enigmatic in the
    area of social care. While there is a welcome emphasis on the need
    for health service staff to be trained to identify and deal
    appropriately with problematic drinkers, there is no parallel
    reference to the wide range of social care staff whose caseloads
    are complicated by alcohol.

    The lack of social care involvement makes the proposed audit of
    service needs even more crucial. The disappointment felt by local
    specialist services at having to wait another 12 months could be
    offset if the audit results in the dovetailing of alcohol treatment
    with other forms of care in a way that reflects drinking’s role in
    daily problems.

    Although work has not yet begun on the audit of services and needs,
    the government has taken its first steps towards alcohol-specific
    models of care. This should go a long way towards giving social
    workers and others the knowledge and responsibility they might be
    expected to have, and puts into context some of the recommendations
    made by last year’s commission on the future of alcohol
    services.

    So there is plenty of scope for action, but little impetus in
    taking the strategy forward. By contrast, the pillar of the
    strategy highlighting the role and responsibilities of the alcohol
    industry is getting a great deal of attention. There is a growing
    realisation that the government’s confident assertions that the new
    regime due to be introduced by the Licensing Act will, at a stroke,
    eliminate the scourge of binge drinking and its after-effects are
    over-optimistic.

    This is matched by an understanding that the alcohol industry’s
    actions do not always match its rhetoric when it comes to cleaning
    up its act. By far the most vigorous activity in moving the
    strategy on occurs in the discussions between government and
    industry in pursuit of the “progress” that is to be reviewed early
    in the next parliament.

    Whatever the private conversations, alcohol is a very public
    problem. The current emphasis on binge drinking provides a useful
    focus for the debate but it is by no means the whole story. The
    hidden harm often seen only by the family and their supporters
    needs to be brought into the conversation and those who know most
    about it given a leading role.

    A few weeks ago Tony Blair asked the alcohol industry to set up an
    event at which he could remind it of its responsibilities. That’s
    good news, but the industry can only ever be part of the problem
    rather than the solution. Tackling the problem has to involve
    something more than just a private debate between industry leaders
    and ministers. When will the discussions with leaders in health,
    social care, probation and local planning happen?

    A great deal can be done at a local level. This week Alcohol
    Concern launched a toolkit for developing local alcohol strategies.
    Part of this process involves building trust, confidence and energy
    to tackle problems across local communities and services.

    A national strategy surely needs to instil a similar energy and
    confidence, as well as direction, into the key players at national
    level. After six years that is something we are still waiting for.

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