– Julie Bass, Chief Executive, Turning Point
Will lives be put at risk? Could this be one of the unintended consequences of the Government’s decision to abolish Public Health England?
It may well be a little known fact that the third sector delivers the majority (two thirds) of the drug and alcohol services provided across the country. Providers work seamlessly with public health teams within local government and the result of this is the delivery of high quality, safe services that are clinically robust and deliver excellent value for money.
The Government’s proposal gives no indication that the remit of the National Institute of Health Protection will include drug and alcohol treatment. We are therefore concerned that we could be facing protracted uncertainty and a possible retrograde step when a decision is finally made about the future of provision.
Reorganisation of the system overseeing treatment services, at such a critical time for both local government and the NHS – during the biggest public health crisis for 100 years, is, at the very least, not great timing.
Reorganisations affect staff morale, people leave, expertise is lost and important relationships across the system are broken. Time and energy can be wasted. This can be a price worth paying but perhaps not in these challenging times.
Our fear is that substance misuse and wider health improvement activity has been overlooked in the heat of the pandemic and any failure to recognise the impact of such an oversight could have serious consequences. For example, what will happen if there is no national agency with the necessary resources to highlight the essential role substance misuse services play in reducing crime; in reducing anti-social behaviour; in reducing violence? Most importantly, without an effective national champion, will drug and alcohol services be subject to even further disinvestment, resulting in more preventable deaths?
Then there is the vital work undertaken by substance misuse treatment providers in reducing pressure on mainstream health services such as A&E and primary care. And there is the cost effectiveness of these services being provided outside of a traditional healthcare setting as well as the mental health benefits seen when community-based organisations work together. Now is the time to recognise the value of the current support, particularly during the Covid-19 pandemic; it is not the time to cause confusion or worse to further reduce the available resources.
A recent IFS report stated that “a decade of budget pressures meant that public services entered the crisis with ailing performance levels, severe staffing pressures and having underinvested in buildings and equipment.”
This is certainly the case for the substance misuse sector which has been underfunded for many years. Nationally, funding reduced by 24% between 2014 and 2019. Inflation over this period was 13%, which means that the effective real terms cut to drug and alcohol service budgets over this time period has actually been 37%. Now is the time to invest not de-prioritise.
People with complex needs are falling through the cracks as a result of services tightening eligibility criteria in response to limited resources. Drug and alcohol services do not have eligibility criteria and so they often end up ‘holding’ these individuals. A good example is Kieran , a heroin user with a schizophrenia diagnosis. Having previously used the drug and alcohol service, Kieran presented in crisis, having been assaulted and sleeping rough, asking for methadone. His mental health was clearly deteriorating but the local mental health crisis team would not accept a referral because he didn’t have a phone or an address. He was admitted to hospital and subsequently discharged to no fixed abode. He was subsequently sectioned and discharged two more times over a period of 3 weeks. Despite the fact his behaviour included self-harm and praying to Princess Diana in the middle of a main road, the GP was informed by the Adult Mental Health Team that there was nothing wrong with him – ‘he just wanted methadone’. The homeless shelter said Kieran was refusing to engage with them and they needed proof he was homeless. The local multi-agency safeguarding hub advised that as ‘he has capacity and is staying with a friend’ they could not assist further. The sad fact of the matter is that Kieran is likely to end up dead or in prison without a joined-up multi-agency response that addresses his mental health problems, his substance misuse and his housing situation.
Despite a ring fence on public health budgets – 7/10 councils in England cut spending on drug and alcohol services as a result of wider pressures on local government finance, and in that time, there has been an 11% fall in the number of people accessing treatment. Despite these cuts, local government led commissioning is the best model for the provision of safe, effective clinical services integrated alongside support for people to develop the necessary networks, skills and community connections they will need to sustain their recovery from addiction.
Leadership at a national level is clearly important but locating commissioning for drug and alcohol treatment and other public services more locally enables integration of support that is so crucial in someone’s recovery.
We question whether narrowing the remit of public health is the way forward at a time when there is an ever-increasing recognition that the wider social determinants of health, including poverty, employment and housing, all play their part in improving population health. A cross cutting agenda requires a cross cutting response at every level.
Public Health England had its faults and limitations but it was able to champion the vital importance of good quality drug and alcohol services in tackling health inequalities, building community cohesion and preventing crime as well as in enabling individual outcomes that really do save lives. In the end it is all of us, including many like Kieran, and society as a whole that benefit from the right approach in the long run.
 Not his real name