The government is shifting the drug treatment emphasis. Gordon Carson hears concerns that, as a result, agencies may lose some flexibility in their approach to users
(pictured: Noreen Oliver, founder and chief executive of BAC O’Connor, a progressive drug treatment service in Staffordshire)
The coming to power of a new government has brought a change in emphasis of the community drug treatment system, from harm reduction to a more explicit focus on abstinence and recovery. This move was outlined in the latest drugs strategy, on which consultation has just closed. Questions remain over the measures that could and should be employed, particularly placing time limits on methadone prescriptions and introducing payments by results for drug treatment services.
It falls to the National Treatment Agency for Substance Misuse (NTA) to work out many of the practicalities of these policies. Its chief executive, Paul Hayes, says drug treatment has improved dramatically in the past decade, from a situation where it was under-resourced: “People had to wait months for treatment, and the quality wasn’t very good.”
By 2008-9, though, 12% of adult drug users in treatment completed their treatment free of dependency, almost double the proportion in 2005-6, according to the National Drug Treatment Monitoring System. And about half of the estimated 330,000 heroin and crack addicts in England were in effective treatment, up 4% on the previous year.
Nonetheless, Hayes says the time is right for a further strengthening of ambition, to a situation where open-ended methadone maintenance for opiate users should not be the default position.
The NTA’s business plan for 2010-11 states that most heroin users entering treatment should be told from the outset that “substitute prescribing is planned to be a time-limited intervention that stabilises them as part of a process of recovery, not as an end in itself”. This principle has already been introduced in the prisons system, in updated guidance published in April that says prisoners on sentences of more than six months “should be expected to work towards becoming drug-free”, with prescription reviews every three months.
The very mention of such specific time limits, even with the caveat of prescription regimes being reviewed rather than ended, has prompted concerns in the drug treatment sector. John Mallalieu, director of substance misuse services at charity Turning Point, says: “While three months may be an adequate time frame for some recovering heroin users to stabilise on a methadone prescription, one size does not fit all and this is particularly true when treating people with complex needs… the best solution may be a personalised intervention beyond a ‘standard’ time period.”
The experiences of Peter Simonson show just how important it is for treatment to be tailored to individual needs. He has been using opiates on and off for 25 years and been on methadone maintenance over the past 17, and says he has often chosen to go back on methadone to regain some stability. This has enabled him to work or attend college for most of his adult life.
“I’ve had long periods of stability on methadone then have come off it and screwed up my stability,” he says. “I’m trying to look at it pragmatically and thinking there’s no way they can pull that safety net from people with opiate problems.”
However, Hayes says there is no intention to set “arbitrary time limits” on substitute prescribing and the decision will be “down to the individual”. The NTA is putting together an expert group of clinicians, academics, service users and providers, under the leadership of Professor John Strang of the National Addiction Centre, to plot how this approach will work in practice.
While many details of the NTA’s plans and the government’s drugs strategy have still to be worked out, Martin Barnes, chief executive of drug information charity DrugScope, says treatment should recognise that recovery is “also about health, housing, employment, training and social networks”.
Payment by results
One way to incentivise service providers to focus on these issues could be through a payment by results (PBR) model that make more explicit connections between drug treatment and outcomes such as improved access to housing and jobs, and better health.
Cabinet Office minister Oliver Letwin is leading a working group to draw PBR proposals together, including those being developed by the Department for Work and Pensions and the Ministry of Justice.
Applying PBR to drug treatment could be controversial because it requires definition of what constitutes a successful result. As Barnes points out, it is possible that someone who appears to have successfully recovered could relapse. He is also concerned about how the payments system would be structured, particularly the amount of funding that would be granted upfront. “There’s an issue about cashflow and how it might impact on community providers,” he says.
Hayes is aware of the concerns about PBR, particularly that it could lead to services “cherry-picking” clients who are easiest to treat, which is why he pledges that a “series of workable pilots” will be developed to test the policy in practice. He says there are several outcomes, including reducing crime, reducing deaths through overdoses and improved employability, that could be used as measurements of treatment.
The pilot projects are likely to be launched next year, but it will probably be at least two years before it can be seen if they improve outcomes for drug users, he says. Hayes also warns it would be “the opposite of what the government wants” if small, local providers were hurt by a PBR system.
Whatever form the pilots take, there is agreement that community drug treatment has improved significantly in the past decade. The challenge now is to ensure that the ambitions of the government build on this and do not set it back.
Case study – ‘Recovery starts the day the client walks in’
Noreen Oliver, founder and chief executive of drug treatment charity BAC O’Connor, supports greater ambition in the drug system to move clients towards recovery. But, she says, this should be part of a balanced approach that gives service users more choice. Packages of care should include psychosocial interventions, whole family support, housing and further education, she says.
Although clients who want to use BAC O’Connor’s residential centres in Burton upon Trent and Newcastle-under-Lyme, Staffordshire, must abstain from drugs and alcohol, Oliver is keen not to push this as the only route to recovery, and instead promotes greater choice for all needing drug treatment.
“We define recovery as starting the day someone walks into any treatment agency, no matter what it is,” she says. “It’s a given that it’s an individualised journey.”
When Oliver set up BAC O’Connor nearly 13 years ago, she wanted to reverse a system where clients were historically sent out of the county for rehab.
Today, 90% of referrals to BAC’s services come from within Staffordshire. It has a block contract with Staffordshire Council and GPs can also book detox beds through practice-based commissioning.
Links to local services, such as a needle exchange, social care, probation, and further education providers, are key to the organisation’s success, says Oliver, who will be a member of Professor Strang’s expert group for the NTA.
Almost three-quarters of BAC’s clients are drug-free two years after they complete treatment. It measures a range of outcomes, also finding out how often former clients have attended accident and emergency, if they have been arrested, and if they are in housing and employment.
Oliver is keen to see more details of how payment-by-results might work in practice, but says it will be “too simplistic to have measurements based on someone becoming abstinent, getting a house and getting a job”. Instead, she would like to see more emphasis on public health outcomes, such as the presence of blood-borne viruses.
She also says clinicians should ultimately be responsible for making decisions on time-limited prescribing. “We should be regularly reviewing care plans and motivating people to move on anyway,” she adds.
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