Tuesday, 24 October 2017

Are local authority commissioners responsible for rising drug deaths?

I’m not quite as quick on the draw with blog posts as I used to be.  There’s just more things for me to be thinking about at the moment, it seems.  But I wanted to go back to an article from a couple of weeks ago and question some of the assumptions – or maybe more accurately the inferences I think readers were meant to make.

The first thing to note is that I’m sceptical about the validity of claims based on these kinds of FOI responses.  It can be very difficult to compare year on year spending – particularly in the last few years when substance misuse budgets (or at least the representation of them) will have been hugely affected by the movement from NHS to local authorities.

But more substantially, there’s an implication of causality: that these areas are seeing higher drug-related deaths because they’ve made deeper cuts.

I’m not sure that holds, as this wouldn’t just be about the level of cuts, but the way they’ve been implemented.  From my perspective, if a drug treatment service could only do one thing, it would be needle exchange.  If it could do two, I’d add in a simple, low threshold methadone maintenance service.  And that isn’t just my personal preference; that’s because those interventions are the most evidence-based for reducing overdose, crime, and illness or even death from blood borne viruses like HIV and Hepatitis C.

Of course, there’s an argument to be made that you collect evidence about things you’re interested in, and so we have evidence on these things because that‘s what government was interested in the NTA era.  But that’s a side issue.  The main point is that if you were making cuts you could (should?) still maintain the key services that keep people alive.

But that sentence reveals another key assumption: if you were making cuts.  The fact is that all local authorities are making cuts because the funding they receive from central government is being slashed and public health in particular should be worried given the current proposal to fund all their activity (which includes things like sexual health services, health visitors and school nurses*) from local business rates.

And historically it’s the more deprived areas (which are those more likely to have drug deaths because of multiple inequalities) that receive a bigger chunk of their funding from this centrally-allocated pot.  So when these cuts hit, it’s not just that drug treatment is hit; every service is hit harder than in more affluent areas, which are less reliant on central funding to start with, and also more able to top up their funding through business rates and council tax.

What I mean is, the key thing that links areas of high drug related deaths and high levels of budget cuts is simple: deprivation.

To be fair, this is exactly the point that Alex Stevens makes in the article, but I worry that the tone of the article is kicking local councils on one thing where they don’t deserve is, and then letting them off the hook on another.

The tone is that cuts lead to drug related deaths, and maybe they do, but I’m not sure these stats show that and actually I think that in terms of the evidence and the cost of some interventions, it’s easier and cheaper to keep someone alive than it is to get them into ‘recovery’ – partly because we don’t have so much evidence to guide us (if we could agree on what ‘recovery’ is).

That is, the cuts aren’t local government’s fault, and so they shouldn’t be hammered for that; but how they implement the cuts is their decision, and instead Colin Drummond seems to suggest that approaches to treatment were centrally mandated.

Another factor in rising drug mortality, said Colin Drummond, from the Royal College of Psychiatrists, was the coalition government’s decision to treat heroin users with methadone less often and with lower doses, which he described as “political interference in what is essentially a clinical issue”.
He cited examples where “people disengaged from treatment, stopped taking methadone, went back to street drugs and then overdosed”.

I was never convinced by the emphasis the Coalition Government, and Iain Duncan Smith in particular, placed on ‘full’ recovery and the wonders of residential rehab, but my experience was that these statements came from central government at the same time as the NTA lost its teeth and any practical control over local treatment decisions.  That is, central government might have talked about ‘full recovery’, but there was no barrier to local areas maintaining harm reduction services and sticking to Orange Book and NICE guidelines on methadone maintenance and needle exchange so long as there was the will from officers and elected officials within the council.

So kick councils on how they’ve implemented the cuts by all means: have they made methadone maintenance and/or needle exchange less accessible?  Is that evidence-based?  Is it appropriate?  If they’ve maintained it, what has it been at the expense of?

But don’t kick them for making cuts to treatment, or for the perfect storm of the wider cuts and changes to the welfare state that mean overdose and death is more likely.  Think also of housing, benefits, mental health, wider healthcare.  (Not to mention that people are simply ageing, and having to deal with the long-term consequences of a lifetime of smoking.)  Those factors are just as much (or more?) at fault for rising drug-related death rates as the cutting of a group work programme from 5 to 3 days a week.

Of course, you might have read the article with none of those assumptions and reactions.  It just touched a nerve with me as a local authority commissioner.  I’m happy to defend our decisions about how we’ve managed the cuts to our budget, but don’t ask me why we’ve cut the budget, as that’s not my decision.

*Oddly, Izzi Secombe from the Local Government Association seems to have forgotten that the spend on 0-5s healthcare in the Public Health budget dwarfs substance misuse treatment – just look at Figure 2 here: https://www.kingsfund.org.uk/blog/2017/07/local-government-public-health-budgets-2017-18

1 comment:

  1. Very nice Will I agree with every word and sadly I suspect it is going to get worse. LA budgets are likely to get squeezed further unless the electorate can understand the link between having good services and having to pay for them.