The NHS APA supports the much-anticipated second part of the independent report focusing on drug treatment, prevention, and recovery but stipulates that fitting funding must become a priority to deliver the recommendations effectively alongside a reformation of partnership working to ensure accountability.
Drug dependency is a chronic relapsing health condition often with comorbid factors. It is much more than just an isolated health issue and to support recovery, effective routes into mental health, housing, and employment must be considered.
The Dame Carol Black part two report, which was commissioned by the Home Office, focuses on drug treatment, prevention, and recovery and outlines 32 individual policy recommendations to the government across four core themes. These four themes centre around three objectives: increasing access to treatment and recovery support for those who misuse drugs, ensuring a high-quality package for treatment and recovery, and reducing drug demand and problematic drug use.
As an alliance of NHS Trusts we welcome the recommendations set out in this landmark second phase report, which includes the recommended and required levels of service provision, as well as the commissioning and accountability mechanisms that should be put in place to ensure that these services are effective and succeed in preventing, treating, and supporting recovery from substance misuse.
In our joint statement with Collective Voice, Adfam and the English Substance Use Commissioners Group we have acknowledged the shared mission for transformational change in the sector. The question now becomes about how these policies can be implemented to over-turn the last 10 years of decline in our treatment and recovery systems. As an alliance of NHS trusts we have now addressed some of these key policies and outlined our position on the recommendations, providing critique and essential considerations for ministers.
Radical reform of funding, commissioning, and leadership
Phase 2 of the report outlines a strategy to ensure that treatment and recovery services are at the same standard as other NHS services. Achieving this will require increases in funding, training, and accountability. Additionally, addiction must be viewed through a multifaceted lens, ensuring that both physical and mental illnesses are viewed as comorbidities of addiction rather than separate conditions.
Commissioning has been fragmented and defunded since the Health and Social Care Act, leaving little accountability within the system. Funding pressures have left some local treatment systems ‘on their knees’, and we applaud the recommended increases for funding to services over 5 years. It is vital that this funding is ring fenced specifically for treatment and recovery spend and distributed based on need. It is also important that medically managed inpatient detox and broader tier 4 commissioning and funding is ring fenced to offer a long-term funding solution for these vital services.
We also support the proposed £150 million of funding over a 5 year period, allocated to providing housing support for those who are experiencing homelessness. We would add to this that there is a need for more Housing First in order to facilitate housing in vulnerable groups. Not only will this lead to better treatment outcomes for service users in terms of their mental and physical health, but there will likely be a link to less crime and a safer society.
Addressing this issue is welcome and necessary, as is the fact that national leadership at the centre of government will be strengthened for a sustained period alongside the creation of a new structure, in the form of a new central Drugs Unit and a Commissioning Quality Standard. It is key to ensure that there is a determined, sustained effort in both neighbourhood and place-based settings, with key actors holding joint responsibility and accountability for the drug strategy in that area. It is critical that the Central Drugs Unit has the ability to hold localities to account and override local politics, utilising strong leadership that is able to deliver on the unit’s main objectives in order for it to be effective.
We support the move to develop a framework through a process of stakeholder engagement to form robust national, regional, and local connections. It is vital that the newly formed Office of Health Promotion (OHP) plays a key role in this with its regional team a vital link in the chain, and the involvement of NHS Integrated Care System must also be central with drug and alcohol addiction becoming significant in its plans.
It is also important to note that local commissioning arrangements include accountability for spend, quality, and outcomes across Local Authorities, NHS Integrated Care System, Primary Care Networks, and Justice Commissioners. Ensuring funding through robust and collaborative tenders that outline expected outcomes will ensure that this development is optimised, and we would also endorse using the new health bill so that tendering can be avoided if deemed unnecessary. Clinical Commissioning Groups (CCGs) and local authorities must be held to account when benchmarking what good looks like in terms of treatment outcomes, which should be considered as a wider picture of multiple services coming together.
Rebuilding services, integrating systems of care and support
The phase 2 report outlines how critical it is that people with drug dependencies have equal access to services including housing, employment, mental health, physical health support, and high-quality personalised care.
Efforts to address ‘addiction’ without work with partners in criminal justice, health, homelessness and mental health fields are futile. We believe a ‘whole system’ approach based on accountability, collaboration and partnership is essential. The review’s recommendation for a local government-led joint approach with health, housing and employment support, and criminal justice is welcome, as is the suggestion for closer working between the Ministry of Justice and NHS England over prison-based treatment.
We, like many of our colleagues working in the addictions recovery sector, also champion that the voice of lived experience needs to be a key focus in any proposed reform to service delivery and we support the recommendation to commission evidence based harm reduction services. It is increasingly important that basic harm reduction services are in place locally, having been demised over the last 10 years. There should also be a focus on early interventions, psychosocial interventions with very vulnerable groups, championed by the voice of lived experience in order to establish support networks and communities.
As outlined in the report, we strongly advocate for the reformation of pathways to strengthen partnership working and standards, and ensure accountability to reverse the steady decline of these standards that have become tolerated over recent years.
System standards must be established to benchmark the effectiveness of using the resources localities have across all partners to reduce drug-related deaths and improve people’s wellbeing.
The workforce must be urgently expanded in line with a strategy that provides clear standards and training for recovery and drug workers, and we welcome Health Education England (HEE) leading on this. We also support the proposed involvement of the Royal College in developing a Centre of Addictions to enable this workforce development.
Care pathways should be underpinned by effective strong partnerships which will be accountable, funded, and organised on the principle of need and addressing disadvantage; this is particularly relevant for pathways with NHS providers. We support the recommendation to develop a professional body in order to ensure coordination within the substance misuse workforce. Addressing the impact of stigma and health inequalities will also be key to aligning with integrated care services. It is also important to recognise that recovery outcomes are not short term, and more investment is needed in order to adequately support and improve long term recovery outcomes, whilst recognising the needs of different cohorts of drug users and drug types.
However, the criminal justice agenda is a stigmatising place for drug and alcohol commissioning. We must avoid further stigmatisation of service users by placing too heavy an emphasis on the crime initiative, and too little on the healthcare initiative. This can be best mitigated by ensuring that drug and alcohol services sit across the Integrated Care System and are regarded with the parity of esteem that other health care services hold. We support the improvement of community sentences to ensure fair access to treatment and benefits, especially in the period following release from prison, and the proposed improvements to substance misuse services in prisons.
Stigma can also negatively impact the likelihood of those in treatment and recovery finding employment. We support the recommendation of establishing the Individual Placement and Support (IPS) intervention within treatment settings, and also the recommendation to provide those in treatment and recovery with Jobcentre Plus peer mentors. There is a need to address ways in which those in treatment and recovery can overcome barriers to jobs due to criminal records.
These recommendations offer some mitigation to the stigma currently experienced on a daily basis for service users accessing essential health care services. However, an urgent review is also needed in respect of the system’s ability to respond to the needs of alcohol users and this remains a huge concern for the NHS APA.
The NHS Integrated Care System is critical to improving physical and mental healthcare for service users, with links to the Community Mental Health Framework and even emerging evidence in some areas, ensuring that resources are directed correctly. In order to form the Community Mental Health Framework to significantly benefit service users in conjunction with substance misuse services, it must be consistently utilised to its full potential.
The reports focus on co-existing mental health problems and drug dependence echoes the NHS APA’s position in this area. We also echo the call for additional investment from NHSE to high quality physical and mental health services. NHS inpatient detox units currently manage a high level of complexity that relieves burden from other areas of the healthcare system. We believe this provision should be seen at the heart of the developing integrated care systems as outlined in the report which provides a critical opportunity to secure long-term funding of medically managed NHS and community detox services.
We welcome the recognition that inpatient detox needs to be invested in through regional and sub-regional commissioning models which have now been established across the country with a universal 12 months of funding. It also aligns directly with the NHS APA business case for securing NHS medically managed detox units under Tier 4 specialist commissioning models. There is however, a lot of work that needs to be done to train and educate the workforce and establish effective pathways into treatment.
Prevention and early intervention
Primary prevention and early intervention methods greatly benefit society, and to capitalise on this, policy must focus on educational programmes, youth support across multiple areas of risk, and population-wide campaigns to address and deter recreational drug use.
We support the recommendation to monitor implementation of the statutory RSHE guidance focusing on drug prevention, and provide support and training for teachers. The proposed detailed evaluation after 2 years would help to ensure that this prevention opportunity is being maximised to its full potential. Prevention must also focus on addressing non-drug related areas of risk for young people, including stress, damaging environments, online harm, and behavioural risk factors.
We welcome the move to forge better and closer working with the Department for Education (DfE) on prevention of parental substance use agendas, and for local partnerships to carry out equality impact audits to clearly identify within health and social care systems the access to services that can prevent serious ill-health. This should include smoking cessation, blood-borne virus testing and treatment, and primary care such as hypertension treatment.
Improvement to research and science and how that informs policy and practice
There is a general need for more evidence to support the whole system response and greater investment and an emphasis on research in areas that are currently under-served in the UK; for example psychosocial interventions, effective working with co-occurring addiction, factors promoting recovery and mental health, are warmly welcomed.
We need to develop research to ensure we have informed policy, commissioning and practice. Informed policy is critical in order to form a benchmark against which providers can be challenged to demonstrate fidelity, and commissioners must ensure that it is met.
We also support the aim to improve innovation in research through incentivisation and reward initiatives.
What now?
The current situation is intolerable; very significant change is urgently needed and, in summary, we welcome Dame Carol Black's recommendations, which will forge a stepchange in the right direction.
As an alliance of NHS Trusts, we will continue to place a strong emphasis on a quality, appropriately qualified, skilled, and experienced workforce and strive to ensure that specific gaps in the system, especially where the need is even more acute, are closed. In order for the changes to the workforce to be impactful, we would recommend that system changes are put in place at the senior levels, and that the likelihood of increased competition for clinical posts nationally is taken into account.
As an alliance, we are deeply committed to championing and taking action on these recommendations which will improve the delivery of proven life-saving treatments, and tackle the stigma around addictions that has enabled inequalities to grow. Moving forwards, it is critical that we prioritise the needs of service users and the communities we serve. At times this will mean as organisations from all sectors we need to compromise and work in partnership. As NHS APA we are committed to doing this and look forward to working with the sector to champion the recommendations in this vitally important report.
The full report can be accessed on the government website: Review of drugs part two: prevention, treatment, and recovery