Where Have I Been?

Updated: Jul 22

I have not written about drugs as much lately as I used to. This has been more about my own relationship to the drug and alcohol sector than it has been about my interest in or commitment to drugs policy and those affected by it.

About ten years ago my closest relative was arrested on a series of very serious charges. Over the following years I supported her through the court system, prison and referrals to special hospitals. She had a profound substance misuse problem as well as serious mental health issues.

When this first happened I was shocked and hurt and incredibly worried. But I believed that the system - within and alongside which I had worked for the previous 20 years - would deliver a just and fair resolution which would see my relative receive the care and support she needed. What I witnessed instead was a system that was barely coping. One in which vulnerable people simply became lost, where communication was poor or non existent and where resolutions or any kind - for victims, offenders and their families - were accidental at best and non existent at worse.

I learned a lot. Prison is a parallel universe where custom dominates regardless of the compassion and expertise of staff; systems operate in isolation from the community services which support offenders and their families and every attempt to retain connection is defeated by bureaucracy and lack of resources. I learned that a court disposal was in many cases just that - a way of disposing of the offender without regard to individual circumstance or pathology. I talked to the families of other prisoners in the holding bay at visiting time and learned that what we'd been through wasn't unique. Even critical health records don't follow an individual once they are within the secure estate. I've spoken to women whose daughters were left in labour in their cells alone and scared and seen a little girl throw themselves at the glass in the airlock door screaming for her mum after a visit. It helped me understand that no matter what plans we get down on paper, how many slides our powerpoint presentation contains, or how hard we work to have a joined up system on paper, it will always be tested by the chaos and happenstance of real life. And when the system doesn't work, we rarely critique what we have built - preferring to blame the individual.

Alongside these personal revelations, the drugs sector was continuing on a path towards radical change. A new government brought a new approach. By the mid point of the last decade, the shift to a recovery focus away from harm or demand reduction strategies was almost complete, with most services having gone through the commissioning led transformation and at least one tendering process. Our services no longer prioritised retention and harm reduction was viewed as a wrongheaded and dangerous concept. There were calls from within government for services to no longer support people on maintenance scripts, and for services themselves to only be paid if they discharged people free of any drug dependency. This effectively caused a schism in the departmental government consensus broadly in support of harm reduction and drug treatment, with bodies like PHE and DHSC still pitching for medically oriented recovery systems and others - like DWP which under the leadership of Ian Duncan Smith had become increasingly influential - proposing changes like those envisaged in the document "Putting Full Recovery First"

On top of this were two factors which would come to affect the delivery of interventions to deal with drugs at a community level, within our sector and for individuals. The first was the 2012 Health and Social Care Act which brought about the abolition of the NTA and the shift of its functions into a new body - Public Health England (PHE). At a local level we saw the responsibility for commissioning drug and alcohol treatment move from PCTs (now essentially CCGs) into the new Public Health teams within Local Authorities. The second change was of course the move to austerity, and such widescale public funding cuts that the dimensions and scope of our centrally funding health and social care services would reduce dramatically over the next 8 years.

In this environment I was skeptical of the ability of the system to 'change course' without causing huge harm. I wondered if a treatment system that had effectively become - after over a decade of unprecedented government investment and interest - an industry, could really make these fundamental changes. To deliver meaningful recovery, services would need to reorient themselves away from delivering to the commissioning machine those services which enabled the commissioning machine to report success to government and to begin to deliver a range of individualised interventions measured - in theory at least - by reference to individual recovery and real improvements in peoples quality of life. And they would need to achieve this against a background of real cuts in funding - for drug treatment, and across the public sector. This would be delivered without any real political levers for change at a local or national level and in the absence of of a consensus position across government departments about the purpose. It didn't seem realistic to me - or fair. I believed we would see the impact of this in increased rates of drug related harm and indeed in drug related deaths.

My confidence in the system in which I had worked and my ability to work constructively within it any longer were seriously damaged. Not just by my own familial experience of the system, but also by these changes in how our work was directed, governed, commissioned and experienced. I had to ask myself some serious questions about the purpose and meaning of drugs services and drug policy and how they interacted within the broad systems of mental health and criminal justice. I wanted to understand how we could marry together a belief in the individuals right to effective, evidence based treatment and support, rational and effective public health interventions and our stated (if idealistic) vision of a drug free society.

Like many drug sector 'old hands' I stopped working in drugs in about 2015, though I did still undertake work on tenders for longstanding clients - largely small voluntary sector providers and charities - up until 2017. However the bulk of my work shifted to supporting new developments in primary care and across integrated commissioning. But my interest remained and I watched developments in drug and alcohol services over the fence. Each year as the latest increase in drug related deaths was reported I prayed that I was wrong, and this was just a blip and that the system would start working again soon. I saw piecemeal solutions applied to intractable problems in the design (or non design) of the system. I read explanation after explanation of why and how we had gone from 46.6 deaths per million people in 2012 to 76.3 by 2018. From one of the lowest to one of the highest rates of drug related deaths in Europe. In the end I came to the conclusion that only a perfect storm - a combination of unfavourable circumstances - could have produced such a wreck.

The question now though is not so much "how did this happen?", but "what can we do about it?". The most important first step I think is saying we have never had a perfect drug strategy, nor a perfect treatment system. This has always been a difficult area of work, not least because its hugely political and that politicisation lends itself to quick solutions, slogans, fads and cure-alls. But we can learn from our mistakes and we can be honest about what does and doesn't work.

Earlier this year before lockdown, the first part of a review of drug policy by Dame Carol Black was published. It set down an important benchmark in drug policy - with an overall message of "must do better". It's in the interests of supporting the sector (and myself) to do just that - I want to start writing about drugs again. Please be patient as I get into to the swing of this - and please contact me if theres any stuff you think I should consider or look at. I'm particularly interested in the experiences of people within services over the last few years - whether you're workers, clients, families or commissioners. I'm also really interested in hearing about stuff that works well - that despite or perhaps because of the changes in the sector has driven real change for people or communities. My writing will be different because I've changed. The world of treatment in which I used to be immersed has changed and also I have seen what we do - and don't do - from the other side of the fence.


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