Can we build a more trusting, collaborative substance misuse treatment sector?

I spent Friday in Manchester, at EXCO2019 – the annual conference of the Expert Faculty on Commissioning.  There were lots of fascinating discussions throughout the day, and I’d recommend catching up by looking at the hashtag on Twitter: #EXCO2019.

One of the key issues revolved around balancing ‘dusting off the old vinyl’ and doing the basics well on the one hand, with the bright shiny disco ball of ‘innovation’ on the other.  Pete Burkinshaw from PHE kicked us off with this metaphor, but pretty much everyone else used it thereafter – in fact Kate Hall had already independently written it into her presentation!

As Tony Mercer from PHE suggested (echoed by Paul Musgrave later, who hadn’t heard Tony), we might sit down at home and listen to vinyl, but it doesn’t work everywhere: you might play CDs in your car and listen to MP3s on the train.

And this was the other key theme of the conference: tailored, or personalised treatment.  There’s an idea that I’ve written about before that although we hope tailored, segmented, personalised treatment will be efficient as well as effective and fair, but we shouldn’t take this for granted.  Fordism, where every colour is available so long as it’s black, sometimes has its place.  The devil, as ever, is in the detail, and the risk with this conference (as with most others) is that it becomes a sequence of platitudes, soundbites and metaphors without taking us forward in practice.

There was much discussion of ‘optimal’ dosing, defined as 60mls-120mls of methadone per day, or equivalent.  But Kerrie Hudson had earlier noted that, for her, being able to deal with cravings in the morning with a relatively low dose of methadone (say 30mls) and then use at other times, was a stabilising factor, meaning she could carry on working.  It was appropriate for her particular situation at that particular time.

The sensible way through this is to point out that (a) the patterns of prescribing in our system don’t suggest that most people on 30mls are ‘optimised’ even by their own definition, and the actual dosage of medication someone receives shouldn’t be imposed (whether that’s through an increase or reduction); it should be a joint decision between clinician and patient to achieve a jointly agreed aim.

And that kind of approach, along with all sorts of other initiatives that could be badged as ‘innovative’ or involving ‘segmentation’ were discussed on the day.  But they remain that: isolated examples of good practice.  We don’t (yet) have a tool for segmentation that could structure these kinds of conversations that keyworkers need to have.

In the session I participated in, I had been asked to introduce a discussion of depot buprenorphine – a fact possibly not unrelated to the fact the conference was made possible by funding from Camurus, who make these devices.

I don’t object to this, though the Faculty needs to be careful not to become reliant on one source of funding, and I think local authority contributions would be more appropriate.  I saw my role as being to ask some challenging questions and bring the conversation back to those practical considerations, rather than thinking the innovation will be useful in itself.  Who will this form of medication benefit?  Where could it be implemented effectively and efficiently, given we’re living in tough times financially?

I’m not sure I got my point across, but it didn’t matter anyway, because the discussion, thanks to much more eloquent and passionate commissioners than me, took a turn to be about commissioning and the ‘sector’ in general.

This was where the conversation got interesting.  We talked about how certain metrics and processes, previously centrally imposed (like TOPs and ‘successful completions’) don’t have to be at the heart of local authority commissioning, but the point was made that this doesn’t mean agencies and staff can disregard them even if they wanted to.

As a provider, you can’t be sure that if your successful completions are low in one area because you’re being honest and retaining people in treatment, that you won’t be judged unfavourably when you tender for a contract in another area.  Not all commissioners take this view.

And as a member of staff, if you stop recording people (sometimes optimistically) as successfully completed, or don’t note that they have apparently stopped using on top or committing crime on their latest TOP form, then perhaps you’ll lose a sense of a job well done.  And how will the service user themselves be able to identify that they’re making progress?

It’s not as straightforward as a commissioner just telling a provider to relax about metrics.

And what about length of contracts?  There was agreement that long contracts were a good idea, and local authorities seem to be increasingly open to these.  But it’s not the case everywhere, and the sector still feels competitive.

Nurses leave to work elsewhere in the NHS because there just isn’t (felt to be) the same security in substance misuse.  Locally, in each of the three acute hospitals across Dorset there’s at least one nurse in the alcohol liaison/care team that used to work in the Dorset substance misuse service, and we can’t seem to recruit replacements.

Organisations feel they can’t reveal their ‘trade secrets’ (and if anyone has indeed got the ‘solution’ to ‘addiction’ there certainly keeping it secret), and the spectre of tendering can lead to tensions, fear and anger on the ground.  It’s hard to believe that doesn’t then seep into consultations, affecting service user care.

And this isn’t the fault of those frontline staff or the organisations that employ them.  It’s central and local government that have created and maintained these competitive structures.  And while some people in the room could be congratulated on creating different approaches in their area, this doesn’t change the overall picture or culture as being one of competition and sometimes open confrontation.

So I started to think about how, in practice we could make this change.  And all the themes we’d been discussing seemed to coalesce.  We don’t have clear segmentation tools.  Guidance on ‘good practice’ tends to be relatively abstract (NICE, Orange Book) or just a set of examples designed to show that local government is brilliant (the Local Government Association).  Approaches to performance management vary considerably.  Contract lengths vary wildly from 3 years to 10 or more.

This lack of consistency makes life difficult for providers, who can’t tailor their approach to one commissioner, and commissioners, who end up reinventing the wheel.

Last year, I wrote about how I could see a role for the Expert Faculty as a repository for genuine, practical examples of ‘good practice’, but this would need to be distinct from the work of PHE or the LGA.  Some of the work that could improve the situation is being coordinated by PHE through their review of opiate substitution treatment, which I’m hoping will produce some practical guidance on segmentation, enabling frontline workers to put the ‘phasing and layering’ of treatment proposed by the Medications in Recovery report into real-life practice in a straightforward way.

But there’s more that needs to be done to reshape the sector and build trust.  One thing I wondered aloud about in the session of the conference I was directly involved in was something like a charter or a kitemark for commissioning.

Providers want to feel confident they’re entering into an arrangement with someone who’s reasonable, flexible and constructive, and where they don’t have to worry about misleading metrics.

And commissioners, I’m sure, would embrace a set of principles – particularly if they could take these to elected members or senior management and explain that these (for example not re-procuring every 3 years) are considered good (or even standard) practice in the field.

I’m not going to talk much more about this here, as it’s only the most embryonic of ideas (and I wouldn’t claim that it’s original) but I wonder if it’s worth exploring further.  It would surely give both commissioners and providers the confidence to break free from the shackles of successful completion metrics and 3-year tendering cycles that occupied so much time and prompted so many sighs over the course of the day.

I often ask for comments on this blog, and rarely get any, despite hundreds of people reading it, supposedly, so I’m not expecting a great debate in the comments.  What I hope, though, is that by EXCO2020 we’ll have a clearer sense of the practical, tangible contribution of the Faculty, and whether this sort of initiative is what it should be championing.

Consultations on drug policy

A couple of days ago, I was asked by email for some comments on the current health and social care select committee (HSCC) inquiry and Black report consultations on drug policy.  Tonight, on my own time, I drafted some thoughts.  I've copied these below and would welcome comments.

Just to give some context, the questions in the Black report at this point are as follows:

·       What are the demographics and characteristics of drug users and drug suppliers and how have they changed?

·       What causes individuals to become involved in drug use and/or drug supply?

·       What are the evidence-based approaches to preventing and reducing drug use and drug supply?

·       What causes drug related serious violence and how can it be prevented?

·       What are the most important evidence gaps relating to drug use and drug supply and what further work would be needed to address them?

And those for the HSCC inquiry are:

Health and harms:   

• What is the extent of health harms resulting from drug use?  

Prevention and early intervention:   

• What are the reasons for both the initial and the continued, sustained use of drugs? This refers to the wide spectrum of use, from high-risk use to the normalisation of recreational use. 
• How effective and evidence-based are strategies for prevention and early intervention in managing and countering the drivers of use? This includes whether a whole-system approach is taken. 

Treatment and harm reduction:  

• How effective and evidence-based is treatment provision? This refers to both healthcare services and wider agencies, and the extent to which joined-up care pathways operate. 
• Is policy is sufficiently geared towards treatment? This includes the extent to which health is prioritised, in the context of the Government’s criminal justice-led approach.  

Best practice: 

• What would a high-quality, evidence-based response to drugs look like? 
• What responses to drugs internationally stand out as particularly innovative and / or relevant, and what evidence is there of impact in these cases? 

If you want to respond yourself - and I think this is something everyone with an interest should get involved in - the HSCC consultation closes on Monday.

So here goes my response.  I should point out it's not a formal response; just some thoughts that have occurred to me over a glass of my favourite intoxicant.

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Having read through this, I think the fundamental questions are relatively similar, so here’s my stream of consciousness, which reflects the views of an academic rather than a commissioner.

Most drugs in themselves carry relatively low risk to the individual concerned when used in known dosages and purity, under safe conditions without forming patterns of substance use disorders.  Therefore the health harms resulting from drug use per se are relatively low.  Issues are most likely to arise when purity and dosage are unknown and where people have poor information about how to use more safely (or do not act on this information, sometimes due to the stigma or fear associated with the illegality of certain substances).

People come to use drugs initially due to a mixture of factors, with (anticipated) pleasure of some kind linked to availability.  What people find exciting, comfortable or pleasurable varies, and the effects of different drugs varies and is affected by setting, and so the reasons are as varied as people who use drugs themselves.  In understanding why people continue to use drugs, a functional approach is helpful: these substances serve a function for the people who use them, whether that is to have new experiences (‘psychonauts’), distance oneself from previous experiences or thoughts, or simply experience a ‘rush’.

For most people, trauma and poverty / lack of opportunities drive people towards problematic drug use and dealing.  Those involved in dealing are getting younger.  The violence associated with the drug market is the consequence of the substances being illegal, and violence increases when a gap in the market appears – i.e. when existing, stable dealers are arrested and imprisoned.

(But I understand the Black review has been instructed not to consider the legal status of drugs.  And in any case, the police will be more expert than me on this.  I hope Neil Woods from LEAP will be submitting evidence.)

Prevention of pursuit of intoxication and use of psychoactive substances per se is a somewhat futile task.  All societies, to our knowledge, have made some use of intoxicants or intoxicating practices.

Evidence suggests that the most effective approaches to prevent harm from substance use is not to focus on substance use or dispense information and advice, but to educate young people in relation to decision-making and safekeeping strategies, and to discuss these issues with adults in terms of the effects on their wider lives (e.g. improving parenting skills).  Such work should be integrated into broader process/practices, e.g. mainstream education, general healthcare and social work practice.

In terms of treatment, while there is relatively strong evidence that high-quality treatment and harm reduction initiatives can reduce crime and reduce the transmission of blood-borne viruses, there is a lack of evidence regarding ‘what works’ in fostering long-term recovery.  Therefore a priority for government should be to commission and support research that takes a robust, longitudinal approach to evaluate different treatment options and approaches in terms of their effectiveness.

As to whether currently commissioned treatment services are provided in line with this evidence, there are questions to be asked as to whether services engage enough people to make a difference at a population level, and whether, once people are engaged, they receive treatment in line with this evidence, much of which is based on either lab-style settings in terms of talking therapies, or US-style ‘methadone clinics’ in relation to opiate substitution treatment (OST).  What evidence there is suggests that dosages of medication dispensed as part of OST are not generally in line with evidence, supervision regimes are not applied consistently, and talking therapies are not delivered in line with tight guidelines.  In most cases there is certainly not joined up health and social care provision for the client group who have run into issues with substances, with services commissioned and provided by separate organisations, operating to different priorities and policies, and using different IT systems.

This is not to say that services are not appropriate and effective, given the limited nature of the evidence base.

The biggest challenge to delivering quality services is currently capacity.

Treatment services have been more than decimated in recent years, with cuts in most areas of at least 20% to budgets since 2013, and prevention work has become patchy and hard to monitor with the change how schools are overseen.  At the same time, resources expending on addressing the supply of drug use, for example through ‘county lines’, have increased in areas such as Dorset.  This is currently a ‘zero sum game’, and therefore it would appear that resources are being focused at less effective points in people’s lives, given that we know treatment can help reduce the burden problematic drug use and associated acquisitive crime can place on the criminal justice system.

A high-quality, evidence-based response to ‘drugs’ would be regulate all substances and therefore permit use that is in line with good harm reduction advice: i.e. where people can know and control the dosage and purity of the substance, and the manner in which they ingest their preferred intoxicant.  There would be more accessible treatment, better integrated with different elements of the health and social care system, a better evidence base by which to judge the performance of this system, and more resources to support the oversight of the system in relation to quality.

As for international comparisons, no country has this cracked, partly because opportunities for innovation are hampered by international treaties and the position of the UN and particularly the USA.  In general, we know that harm is not simply determined by a country’s regulatory or treatment system, as confirmed by the Home Office report a few years ago.  Each country should take a tailored approach to each substance, based on its history and starting point today.  Social and cultural context play a key role in determining problems and appropriate solutions – just look at trends and approaches to alcohol use in different countries around the world.  An approach that is perfectly reasonable and successful in one context can be destructive in another.  However, to focus on specifics, the approaches adopted by Uruguay and Canada for cannabis seem to me the best models for effective regulation introduced so far, though they will need careful monitoring to evaluate their impact, particularly in comparison with the various alternative regimes in operation across the US.  These initiatives could and should go further, however, and cover all intoxicating substances – though with regimes tailored to the particular risks associated with each drug.

As you’ve probably guessed, I’m writing this on my own time, as it may not be what you were looking for!

Best

Will.

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UPDATE:
This morning I was asked why I hadn't mentioned Portugal, and whether this would be a good idea.

This was my response:

Personally, I think we're not far off the Portugal model in the UK, with treatment offered for most people who commit drug-related acquisitive crime and very few people (in the grand scheme of things) imprisoned for possession. The greatest harms (DRDs, child exploitation, cuckooing) wouldn't be solved by decriminalisation, but only legalisation.

But you're right that it at least reflects an achievable step, and highlighting it could convince people that change is possible.