Drug treatment in England ‘not fit for purpose’, landmark review finds

Dame Carol Black calls for services to be ‘rebuilt’, following ‘disturbing, even shocking’ findings

Drug users prepare heroin before injecting, inside of a Safe Consumption van set up by Peter Krykant (Jeff J Mitchell/Getty Images)

The drug treatment system in England is currently “not fit for purpose” and is in urgent need of repair, a landmark review has concluded.

Dame Carol Black described the findings of her government-commissioned review as “disturbing, even shocking”, as she warned: “Funding cuts have left treatment and recovery services on their knees.”

In response to the review, which warns that entrenched drug use is “a major barrier” to Boris Johnson’s plans for “levelling up” all parts of the country, the government has announced the creation of a new cross-departmental unit to combat drug use.

With the first part of Dame Carol’s review, published last February, having found that entrenched drug use and premature deaths occur disproportionately more in deprived areas and the north of the country, in the second part she now warns that the pandemic has very likely “widened inequalities”.

The report paints a bleak picture – likely all-too-familiar to many within the sector – of “deteriorated” partnerships between councils, health, housing, employment and criminal justice agencies, a “fragmented” commissioning system lacking proper accountability, and a “demoralised” and “depleted” workforce, amid the disappearance of many “vital” detox and residential rehabilitation services.

It concludes that “the public provision we currently have for prevention, treatment and recovery is not fit for purpose, and urgently needs repair”, adding: “The current situation is intolerable.”

Among some 32 recommendations within the review, Dame Carol stressed the importance of getting more people into treatment who require it, diverting people away from the criminal justice system, and ensuring service users are given a wider package of support for housing, employment and mental health.

Achieving this, Dame Carol said, will require services to be “rebuilt”, alongside “radical reform” of funding, commissioning and central government’s leadership, with “improvements ... in how science informs policy”.

“The government faces an unavoidable choice: invest in tackling the problem or keep paying for the consequences,” Dame Carol said. “A whole-system approach is needed and this part of my review offers concrete proposals, deliverable within this parliament, to achieve this.”

Drug-related deaths are currently at an all-time high in England and Wales, having risen for eight consecutive years.

This rise corresponds with a move to cash-strapped local authorities being handed responsibility for funding services, a shift to an emphasis on abstinence within treatment, and an exodus of opiate users from the protective fold of treatment.

Echoing years’ of pleas within the sector for specifically ring-fenced central government funding for treatment services, Dame Carol urged the government to invest an additional £552m over the course of five years, on top of its baseline annual expenditure of £680m, and to require councils to use the money for this express purpose.

“The payoff is handsome,” she said, citing Public Health England estimates suggesting that every £1 invested in treatment returns £4 in savings down the line, adding: “Failure to invest will inevitably lead to increased future pressures on the criminal justice system, health services, employment services and the welfare system.”

However, “increased funding is necessary, but not sufficient”, the review warned, calling on Boris Johnson to appoint a minister responsible for holding “all of government to account”, supported by a new cross-departmental government unit.

On Thursday, ministers announced the creation of a new Joint Combating Drugs Unit, which will bring together multiple departments – the Department of Health and Social Care, Home Office, Ministry of Housing, Communities and Local Government, Department for Work and Pensions, Department for Education and Ministry of Justice.

Sajid Javid, the health secretary, said the government “will look closely at these recommendations and publish an initial response shortly on the urgent action we can take to turn the tide on drug-related deaths and get more people access to higher quality services”.

Also thanking Dame Carol for her review, home secretary Priti Patel said the government was “cracking down on criminals, preventing drug misuse in our communities, and supporting people through treatment and recovery” – pointing to funding of £148m announced earlier this year.

Notably, Dame Carol – formerly appointed as Tony Blair’s government’s national director for health and work, a role she held for six years – also urged the government to recognise “that addiction is a chronic health condition, and like diabetes, hypertension or rheumatoid arthritis, it will require long-term follow-up”.

Currently, one key indicator often used to measure treatment services’ performance – and sometimes tied to how much they are paid by councils – is an individual “successfully completing” treatment without returning for help within six months.

Dame Carol said: “Discharge after short-term treatment is currently used as a measure of success, but should be stopped, as it ignores the fundamental relapsing and remitting nature of the condition.

Calling for trauma and mental health issues – “the drivers and accompaniment of much addiction” – to be dealt with as “co-morbidities rather than separate problems for a dual diagnosis”, she warned that “commissioners of drug treatment services and NHS mental health services must ensure that individuals do not fall between the cracks”.

And she took aim at the frequent recommissioning of treatment services, often every three years, which Dame Carol warned “hampers the creation of a stable network”, adding: “Commissioning is often little more than a procurement exercise, placing undue emphasis on price at the expense of quality.”

“The disruption caused by frequent retendering of drug treatment services has made recruitment difficult and has driven many to leave, particularly professionally trained staff such as psychiatrists, psychologists, and nurses,” Dame Carol added.

She called on the Department of Health to review the procurement process and, alongside Health Education England, to “take urgent action” to rebuild the substance misuse workforce.

And, suggesting that “we can no longer, as a society, turn a blind eye to recreational drug use”, she called on ministers to “invest now in an innovation fund to test out which marketing and behavioural interventions could work in the UK”, adding that, “as the Covid pandemic has so clearly shown, behavioural and attitudinal shifts in health behaviour are possible”.

The UK’s largest treatment provider, Change Grow Live, welcomed the review’s calls for change, and urged the government to come forward with a new multi-agency strategy.

This new approach “must make sure effective, evidence-based treatment is available everywhere that it is needed”, said chief executive Mark Moody, adding: “It must have new measures of success. Recovery is much more than total abstinence.

“For some people, success is no longer using illicit drugs, stabilising their lives and keeping their families together. For others, success is about getting a job or going back to education.

“And it must get commissioning right. We want to see an end to fragmentation of services and short-termism. All the organisations involved must come together to put stable local services in place where they are needed.”

“We have the evidence about what gets people into treatment, what keeps them there and what works in the long-term. A new strategy is urgently needed to put this into practice everywhere in the UK. Collectively, we must make a step change in treatment.”

Dame Carol said she was “hopeful that [the review’s] recommendations will be welcomed by this government as they strongly support its crime reduction and ‘levelling up’ agendas”.