NTA business plan published

[Ursula]

http://www.nta.nhs.uk/uploads/nta_business_plan_2010_11%5b0%5d.pdf
 
Talk about it here...

[Ursula]

I'm going to have a few things to say about this over the next few days, but the first thing that leapt out at me was a big one.  Terminology is important, and I'd like to know when the decision was made to move from talking about "drug misusers" and "service users" to talking about "addicts" in NTA publications*.  There's been a lot said recently about the power of stigma to keep people from reintegration and encourage ghettoisation, and I can't help but feel that using a word as loaded as "addicts" is a step backwards and risks dehumanising people seeking help for drug problems. 

* the answer appears to be "in March", so it's not as a response to the change in government, but may well have been a pre-emptive move

[Ursula]

Right, first thoughts - this is me writing as me, rather than as a formal Alliance response (that'll come later).

The NTA’s business plan says that “national and local performance will be judged on outcomes
e.g. abstinence rates, employment, and reduced criminality” and emphasises a shift to a payment by results system.  Any such system absolutely has to keep the individual service user’s need at the heart of it.  While the business plan states in several places that there will be people for whom an abstinence-focused approach “would not be appropriate”, and acknowledges that the NTA will need to think about how to avoid situation where services “discharge clients before it is clinically appropriate”, there isn’t any indication that they know how this might be done.

I’m concerned that this could lead to a number of problems for individuals for whom abstinence is not a realistic goal in the immediate future.  Keyworkers will be under pressure to move these individuals through services so that funding streams aren’t affected, and it’s going to be difficult for clients to resist.  And it’s likely that some of the most vulnerable clients will not feel able to speak up about what they feel they actually need in the face of strong pressure towards one outcome for all clients. 

How are services going to identify the individuals who won’t be able to reach a sustainable recovery within an arbitrary time limit?  I’ve heard one NTA staff member estimate recently that this group of people who might require prescribing treatment for longer than the normal time limit (a period I can’t see being set at longer than a couple of years at the most) makes up less than 10% of drug service users. However, their own most recent annual figures say that the number of adults successfully completing drug treatment “free of dependency” was 11% of the number of people in contact with treatment services in that year.  The number of people who completed treatment “free of dependency and with no drug use at all” was 4.3% of the total number in contact with treatment services over that year.  There’s a long way to go from those numbers to the 90% abstinence that this member of staff seemed to be implying was the goal for time-limited opiate substitution treatment. Obviously the figures given above include non-opiate users in treatment, so the exact proportions are probably slightly different for opiate users. It’s worth mentioning at this point that I have no idea whether this 10% or fewer  on long-term maintenance number is an official NTA goal, or simply the opinion of this staff member, so I may be wittering here.

The six month review numbers for people who entered treatment for opiate use in that period were more encouraging, but even that group were a long way off majority abstinence. 37% achieved abstinence and 31% achieved a statistically significant reduction in drug use. Obviously there’s room for improvement and I’m certain that the number of people achieving long-term abstinence would increase if they were offered better keyworking and more access to social and economic capital (through recovery groups, service user groups, housing advice, and better routes to employment, among other things). But I worry that there’s still a sizeable number of people in treatment who are going to be put under pressure to move towards abstinence even if they don't feel that they are ready for it at this point in time. 

The NTA says “service users come into treatment wanting help to beat their addiction and get on with their lives.”  For an organisation which specifically states that there’s no such thing as one size fits all treatment because every user is different, this is a gross generalisation to make about the motivations of service users.  People enter treatment for many reasons: to reduce reliance on street drugs, to move away from committing crime to pay for a habit, to comply with requirements set by the criminal justice system, to please their dear old mum, to try to be be a better parent, to try to make life easier, and yes, to become abstinent. But to say that there’s one defining goal for all service users at the point where they commence treatment is facile and unhelpful. The idea that workers need to be ambitious for service users is an admirable one, but there needs to be realism about the fact that different service users have different ambitions for themselves. There’s a risk of stifling the kind of success that actually listening to an individual’s assessment of their needs can achieve.

The other thing I’m somewhat worried about is this paragraph:
The evidence-base for effective drug treatment is robust, as enshrined in NICE recommendations and the UK Clinical Guidelines. However the NHS has been criticised for being slow to adopt successful ideas and new practices. The coalition government wants to actively encourage innovation and improvement in healthcare, so that if emerging evidence says something new works, then clinicians and managers should feel free to get on and do it.
There’s a lot of dodgy research out there on drug use and treatment and while I’m sure that the above will lead to some splendid examples of good practice making it to the mainstream early, there’s surely a chance that it will also provide an opening for damaging work with a dubious evidence base.

Having said all this, I’m thrilled to see the focus on doing more around housing and employment, along with improving the skills base of the workforce, and there’s a lot in the plan that I’m in agreement with. 

[wastedyouth]

i did find this very heavy reading so forgive me if i get the wrong end of the stick about a few things.  New clinical guidlines has introduced strict time limits to end the practice of open ended substitute presribing in prisons.  This prinsiple will be extended into community settings.  They said that doctors would be directly accountable to their patiants for achieving demonstatability better outcomes, and those clinicians who best respond to the need of the service useres will atchieve the best outcomes for them.  I dout that the doctors will be happy tacking and obviously having to arrange that every patiant is reduced and eventully free from drugs completely.  Totally abstenant for the rest of their lives.

The part that i found hard to understand was:
Those in treatment are less likely to die, less likely to contract or spead blood bourne viruses, and less likely to offend.  Treatment also brings other benifits, such as reduced drug use(thought it was supposed to be abstinence).  As well as helping addicts become free of dependancy, drug workers support them to be active citizans, take responsibility for there children, earn their own money and keep a stable home

All theses things are easily and freely available at the moment, this is nothing new
Methadone reduces drug use, Methadone helps them take responsibility for there children, Methadone, helps them earn their own living Methadone, helps them keep a stable home etc etc

One of the good thing that i thought was heading in the right direction was.  The radical change of emphasis will be underpinned by a programme to develop the skills of practioners, provide the right treatment to the right people at the right time in the right settings.  If there was money put into this then i think that this could make a change.

Throughout the treatment plan there was a lot of talk about money , everything went back to how much everything would cost and etc.  I felt it was more directly talking about the amounts of money rather than lets help these addicts so called"parked on methadone.

[Jimmy]

Right, first thoughts - this is me writing as me, rather than as a formal Alliance response (that'll come later).

Having said all this, I’m thrilled to see the focus on doing more around housing and employment, along with improving the skills base of the workforce, and there’s a lot in the plan that I’m in agreement with. 

I agree, there is a lot of positive change proposed in this business plan. However, all the apparent good is undone by a single suggestion: the introduction of strict time limits for substitue prescribing. This, for me, makes a mockery of the whole plan. I mean, what good is improved access to housing and employment whithout long term access to what, for tens of thousands of people, is literally 'life saving' medication?