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Editorials

What would an evidence based drug policy be like?

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g7493 (Published 09 December 2014) Cite this as: BMJ 2014;349:g7493

Re: What would an evidence based drug policy be like? - First things first.

I realise that this debate has been more about health versus criminal justice as the driver for substance misuse policy - but I would like to look at it in a deeper more fundamental level than the high level policy for a moment.

In practical terms, at the level of service provision in England, the only game in town appears to be whatever the commissioners say it is. "What works" is in effect being ignored. This is my understanding of the current situation, and this is why:

As we know, substance misuse (SM) services are now commissioned by Local Authorities (LAs) - not Clinical Commissioning Groups. We also know that LAs don't have enough money and are cutting funding to SM services - regardless of any evidence of overall benefit to the economy that we know investment in treatment produces.

Public Health England (PHE) - who is responsible for this commissioning, do not appear to have any power to stop this degradation of funding (sometimes by up to a third in mid contract). However, there seems to be a modest sum of money that has recently identified by PHE for a pilot scheme - which appears to be a small step in the right direction. From the PHE web site:

"A further £5 million of funding has also been announced as part of the Health Premium Incentive Scheme (HPIS). The scheme is designed to reward local authorities that make improvements to their localities public health by providing cash incentives. Under the scheme, which will be piloted during 2015 and 2016, local authorities will be rewarded for meeting one mandatory national public health target, related to improving drug and alcohol services, and one local target of their choice."

Detail appears to be lacking at the moment - and we could speculate about how much of that money will actually end up supporting local drug and alcohol services.

In the meantime, the focus that commissioners have, appears to revolve around metrics such as "successful completions" rather that any actual measure of the quality of service received by individuals. This may be being driven by the "recovery" movement - which has seemed to have led to recovery being interpreted by some in such a way as "the only good treatment outcome is stopping any prescribed substitute medication".

The consequence of this seems to be an overt or covert pressure on service users to "get off their script" - possibly regardless of other gains that are being made such as health, housing, no criminal activity etc. This pressure is also present on the workers and prescribers - despite evidence, guidelines and indeed Professor Strang's own recent report suggesting that any attempt at time limited or premature stopping of scripts can be dangerously counterproductive. However, any harm reduction statistics (drug related death rates, Hep C infection etc) do not seem to be of as much interest these days in terms of contracts and funding. Indeed, recent figures seem to show a rise in Heroin related deaths - which had previously been falling.

Unfortunately, big providers in the field appear to be going along with commissioning requirements without engaging in robust and informed debate about what a good service may look like. (If this is not the case then I would be very happy to hear of the ways that commissioners have been helped to change their tender specifications, and I will gladly stand corrected). Small providers just do not seem to have the clout to compete and their flexibility, local knowledge and skilled teams built over years are often lost to treatment services. Of course, some may work for a new provider, but the world of the big organisation - which has often rapidly expanded and is working hard to manage this - is not the same as the smaller local set up. The larger the organisation becomes, the danger is that it becomes more prescriptive and less flexible for individuals. This is often not appropriate in the complex and often difficult world that substance misusers and their workers inhabit.

I am not saying that services in the past could not have been improved - by no means - there have been many things that have needed to change. But the way to do this is not to focus on simple outcome numbers, but to focus on the quality of the treatment and individual receives.

My contention is that what is needed in any professional/service user interaction - and by extension in a whole service, is the concept of competent compassion. If one or the other of these is missing or weak, then treatment (of whatever modality) is likely to be at best ineffective and at worst dangerous.

These are the fundamental things that a service user wants and needs. After all, that is what we would want if we saw a doctor for example - they need to be competent and compassionate. That is also the way we would want our family members to be treated as well. I believe that this has been lost sight of in the current debates on NHS v private v CIC v charity providers, and recovery v harm reduction, crimilisation v decriminalisation etc.

We need to get back to the quality of treatment an individual gets - this used to be the basis of good medical training (for example) - and it still is. However, these other factors (mainly financial and the competition to win and retain tenders) mean that we are in danger of losing sight of what is fundamentally important and should underpin everything that we as professionals do.

Further discussion of this is at www.competentcompassion.org.uk where you can contact me and let me know what you think.

My intention is not to be overly negative and critical of anyone or any organisation in particular, but I believe that now is the time we have to stand up as professionals and get back to the most important principle - that we want to do the best for the person in front of us that we can.

Whatever the "evidence based drug policy" turns out to be - the foundation should be competent compassion, and we should be leading the call to make sure that it happens.

Competing interests: No competing interests

17 December 2014
Joss Bray
Substance Misuse specialist doctor
www.competentcompassion.org.uk
Alnwick, Northumberland.