Has substance misuse treatment been moved out of the NHS?

I’ve been struck recently by the number of articles and comments lamenting the state of substance misuse treatment in the UK (and England specifically), and the fact that some of the problems and solutions identified seem to be missing the point.

Two of the clearest pieces have actually been written by the same person, Julia Sinclair, for two different outlets – the BMJ Online and Mental Health Today.  It’s not exactly a torrent of articles, and although this post is a bit of a rant, I should be clear that it’s not aimed at Julia; I have a lot of time for her critique of the state we’re in.  It’s more that her comments have stirred up some frustrations I have with the wider debate about the commissioning and provision of substance misuse treatment services.  You’ll need to judge whether I’m missing the point myself!

Fundamentally, the argument runs that people who use drugs are getting a poor service from treatment, and this is due not only to budget cuts but also the separation of mental health services from substance misuse, which is the result of local authority commissioning which has taken substance misuse treatment out of the NHS.

First off, I want to acknowledge that I actually agree with a lot of the substance of this critique.  Budgets have been cut substantially, treatment is often not as accessible as it should be, provision of opioid substitution treatment isn’t always delivered in line with guidelines, and links with mental health support can be poor.  And I don’t want to enter into an argument about whether the NHS or third sector organisations are good or bad.  Or whether substance misuse commissioning would be somehow ‘safer’ in the NHS.  That’s been well covered before (see here and here).

My point is simply that if we are going to try to improve services, then we need to be able to diagnose the problem accurately, and that means learning from the past, rather than idealising and misunderstanding the arrangements that were in place.  As I often argue on this blog, I think this is less about structures (where budgets sit, which organisation commissions, which organisation provides) and more about getting the right people doing the right work.  That’s the hard bit.  It’s pretty straightforward (and even neat, logical and rewarding) to run a procurement process or take a position on a grand policy issue, but it’s harder to actually ensure that staff are getting appropriate clinical supervision and engaging in reflective practice, for example.

So what about that history?  What is it and why does it matter?

Well, the narrative from the articles (and plenty of other people I encounter in person, from politicians to frontline practitioners) is that before 2013 and the public health reforms, we lived in a world where there was a budget held by the NHS, which was used to fund NHS organisations to deliver high-quality, well-integrated substance misuse and mental health care.

I don’t want to speak for every person, organisation or area, so I’ll just focus on my own experience.  None of these points is accurate.

Prior to 2013, in Dorset, Bournemouth and Poole we had one PCT (though only recently – there had been several in the recent past, all with different approaches to substance misuse which persisted).  This did indeed fund the local community health trust to deliver various bits of substance misuse treatment – an inpatient detox unit in the east of the county, prescribing teams and shared care nurses, as well as funding shared care arrangements with GPs who wanted to be involved (which was a bit hit and miss).  The provision available, though, wasn’t just about the ‘substance misuse’ commissioning; in the west, where there was no inpatient unit, we had use of mental health beds for detoxes, though of course the input to that wasn’t quite the same.  (We lost the use of those beds while the same trust provided both mental health and substance misuse services.  Cuts to mental health budgets drove that, independent of commissioning responsibilities or budgets in substance misuse.)

But this NHS work wasn’t the only provision locally.  And crucially the funding for that NHS provision had nothing to do with the ‘pooled treatment budget’ (PTB) handed out by the National Treatment Agency.  Neither did the social work input to those teams, provided directly by the local authorities.  Neither did the housing provision or ‘supporting people’ work sometimes provided by organisations that also delivered substance misuse support.

Setting aside data concerns, the NTA was part of the story through the three Drug and Alcohol Action Teams (DAATs) locally that were hosted by the three local authorities.  These commissioned various organisations (incidentally all third sector) to provide things like harm reduction, group work, criminal justice interventions (DIP), and aftercare.

So we were doing local authority commissioning of the third sector well before 2013.  In fact, when people talk about ‘the sector’, they’re generally talking about that era of 2001-2013 when there was increasing funding available – and organisations like CRI (as was), Turning Point and Addaction grew dramatically.  Not the NHS.

(If you’re interested in the history of the third sector in providing substance misuse treatment, it’s worth looking at the work of Alex Mold, particularly this article.  There’s a long history that doesn’t start in 2013 or even 2001.  And the NTA’s successor, PHE, has actually written a good history of drug use and treatment in England – see chapter 1 here.)

This patchwork provision, I’m afraid to say, was not seamless and certainly not flawless.  And the issues weren’t simply with the third sector communicating with the NHS.  Even within the same organisation there were issues with ensuring people received the right care, at the right time, in a coordinated way.  Having had discussions with mental health professionals in the last couple of years about how we can improve links between the two services (now provided by different organisations), I have heard some world-weary complaints about how ‘we’ve been talking about this for 20 years or more, and nothing ever changes’.  So much for this being better when it was ‘all in the NHS’.

It was crap in 1982 and its still crap now. All you hear is people at conferences saying how the two need to work together. More like 40 years than 20, certainly more than 6.

— John Divney (@JohnDivney) August 21, 2019

And in fact it is still, as much as it ever was, in the NHS.  The prescribing services may no longer be provided by GPs or the local community health trust, but they are provided by another NHS trust – in fact, one with a specialism in mental health.

But I’m overplaying the position taken in those particular articles.  Julia calls for a ‘return to joint NHS and local authority commissioning of addiction services’; it’s just the blunt phrase ‘addiction services were moved out of the NHS into local authorities in 2013’ that gets my back up, as this suggests that everything went wrong when things moved out of the NHS – only most things weren’t in the NHS anyway, and those that were are still often delivered by the NHS.

We have some structures for joint commissioning still, but I’d accept those could be more proactive in driving genuinely joined up work.  But equally let’s not kid ourselves that DAATs were some ideal world.  My experience was that they were seen as a decision-making body for the local authority element (and we were generally able to get committee agreement for our proposals), while the NHS (PCT) saw itself as being bound by its own processes, not the DAAT Board.

For me, the issue isn’t that addiction services have been taken out of the NHS.  When Julia worries that ‘addiction services are now often disconnected from wider health and care services’ we’re more in agreement.  That word ‘care’ us crucial here, and highlights that the fundamental issue isn’t about organisational boundaries and responsibilities.  Despite nominally being part of local authorities, my experience is that public health commissioning and social work provision are more separated than they were before 2013.  We’ve lost those embedded social workers (though particularly in Dorset Council some of those staff are doing different, but extremely valuable work related to substance use).

The loss of those embedded social workers, just like the loss of the mental health beds, isn’t down to commissioning responsibilities.  How could it be if hosting commissioning in one organisation is a solution?  It’s all part of the local authority…

In reality, it’s down to all organisations being squeezed and choosing, as a result, to focus on ‘core business’.  And substance use isn’t seen as core business by anyone but public health teams (and even then it’s questionable).  Don’t imagine it was seen as ‘core business’ and the budget didn’t get raided before 2013.

The challenge isn’t where these responsibilities sit; it’s getting the right people to talk to each other, in the right way, at the right time.  As we all know, that can just as hard within a single organisation as across them.  Sometimes it’s actually easier across organisations because people aren’t competing or jockeying for position.  But that, like all of this, depends on circumstances.  Let’s not imagine we can find a solution in structures.