PDF version of this article is available here
The National Treatment Agency’s February Parliamentary Briefing points to a recent Institute for Government report (Shaping Up: A Whitehall for the Future, January 2010) that singles out the NTA as an exemplar of interdepartmental government co-operation.
The IfG report critiques the highly compartmentalised nature of government as a structural weakness that impedes action on cross-cutting issues. (A cross-cutting issue is one whose governance extends across multiple governmental departments. Examples of cross-cutting issues include child welfare, social mobility, domestic violence, the environment, and human rights).
Substance abuse treatment is a particularly robust example of a cross-cutting issue, as it has an extensive history of inter-departmental administration between the Department of Health, Home Office and latterly the Ministry of Justice.
Progress has been hampered in the field as the fiscal benefits for spending on drug treatment – traditionally from the Department of Health budget – are accrued in another department – the Home Office, in the form of reduced crime. As the IfG report points out:
…spending on drug-abuse treatment programmes in the NHS can generate large savings, but mostly in the form of reduced crime rates, which means that the Department of Health may not have a strong incentive to spend on this activity.
And:
One specific problem is that drug treatment is a health intervention, so must be delivered within the health service. But the numbers who die or become ill each year from Class A drug addiction are small relative to the numbers whose health is harmed by alcohol, tobacco and diet problems. Thus, the Department of Health has an incentive to deprioritise drug treatment as expenditure.
Although aligned primarily with the Department of Health, the NTA was formed to administer pooled resources from discrete governmental departments and budgets in order to increase the efficacy and availability of drug treatment, fill the vacuum between local and central government provision, and obviate obstructive wrangling between the Department of Health and the Home Office. The NTA has achieved positive outcome in terms of more effective mobilisation of resources. These notable successes in effectuating joined-up government must now be revised and developed as we enter a new era of provision and an uncertain political and economic climate.
In the same parliamentary briefing, the NTA affirms their commitment to creating recovery-orientated treatment systems across England. This shift in focus dramatically illuminates “recovery” as a more extensively cross-cutting issue than “substance abuse treatment”. By displacing the medical and criminological gaze with a more panoramic perspective, the horizon of opportunity expands.
Unlike a substance abuse treatment intervention, a recovery intervention does not necessarily have to be a health intervention, which paves the way for more radical and progressive programs. However, maintaining the binary governmental logic of health and criminal justice precludes involvement of other governmental departments, and arguably inhibit the fullest expression of recovery-orientated treatment and support.
A truly recovery-orientated governmental agency would co-ordinate and pool resources between the Cabinet Office, Treasury, Department for Communities and Local Government, Department for Children, Schools and Families, Department for Innovation, Universities and Skills, Department for Work and Pensions, as well as the triumvirate of the Home Office, Department of Health, and the Ministry of Justice. The problem, as the IfG report demonstrates, is how to persuade these departments to invest in recovery-orientated programs when there is no immediate fiscal benefit to them.
Or is there?
Short answer – we simply don’t know. The key fiscal metrics we use to quantify the value of drug and alcohol treatment are framed in terms of reduced health and criminal justice costs. Until we develop ways of quantifying financial and social benefits of recovery in other areas, a stronger case is unlikely to be made for a far-reaching recovery-orientated agency.
The archetypal recovery equation contains two structural components: top-down governance and bottom-up, grass-roots, community activism. “Recovery” casts a spotlight on the ambiguous and yet to be defined relationship between these components. The NTA has an opportunity demonstrate how a dynamic interface between community and diffused, coordinated government can lead to the best quality provision for those who enter our services. 2
It may be that top-level governance needs a radical root-and-branch reform to bring about a more comprehensive system of recovery delivery suggested above. Until that transpires, grass-roots recovery organisations must take the lead in providing reflexive and responsive recovery that reflects the cross-cutting nature of recovery in our times.
- Stephen Bamber, February 10th, 2010.
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{ 10 comments… read them below or add one }
Another interesting piece, Stephen.
It’s not just demonstrating the fiscal benefits of recovery that’s an issue though. The NTA has spent much of the last ten years building the evidence base for UK drug treatment. Now, it may be that a similar evidence base exists for the recovery movement — after all, it dominates US drug treatment and NIDA spends in excess of a billion a year on drug treatment, so I imagine that there must be something out there — but I’m not familiar with it, and recovery people aren’t doing a good job of telling people what that is.
I get the sense that the things people want to do to as ‘recovery’ services is often just what people in recovery say that they want to do. For example, DAT’s still struggle to get TOPS and NDTMS returns from Tier 4 services, making it almost impossible to judge their effectiveness or their value for money.
It makes it hard to argue that the people responsible for funding and performance managing the sector need root and branch reform before you’ve actually made a convincing argument that what you’re doing is effective and better value than the other forms of treatment on offer.
Hi Peter
Thanks for the comment. Always a pleasure.
As for recovery evidence – well, the Recovery Academy has always been forthright about the need to develop a UK specific evidence base. In fact, that was the starting point for its development.
You want evidence? Well – start with Keith Humphreys’ work on mutual aid:
http://iis-db.stanford.edu/staff/3189/Keith_Humphreys-CV.pdf
But lets be clear – policy is not driven by evidence alone, despite all the rhetoric of evidence-based health care/ EB-social policy. And frankly, I’m not sure it should be… not until we have developed a more mature system for *evaluating* evidence in our field.
That we are still using evidence hierarchies originally designed to evaluate the relative effectiveness of clinical trials of pharmaceuticals to evaluate psycho-social/ behavioural studies is astonishing, for example. But I am in agreement with you Peter – we do need more evidence to support the process of change. Of course. As long as we remember: “Half of what we know will be wrong in 10 years. The problem is we don’t know which half”.
Another point about evidence – it isn’t revealed, it is created. It is created wherever the spotlight of research shines. So we need to shift the spotlight a little – stage left….
- S.
I am puzzled by this statement, Peter:
Now, it may be that a similar evidence base exists for the recovery movement — after all, it dominates US drug treatment and NIDA spends in excess of a billion a year on drug treatment, so I imagine that there must be something out there — but I’m not familiar with it, and recovery people aren’t doing a good job of telling people what that is.
There is in fact an extensive literature out there, which is easy to find. Look at Bill White’s extensive literature, stuff from Connecticut and Philadelphia, writings from Larry Davidson and many others. You can also chase up lots of other scientific literature if you go to relevant databases. Most of this research is high quality. Therefore, they are doing a very good job, contrary to what you say and despite the fact that the field is newer.
Stephen, I hate the term substance abuse. People who use substances do NOT abuse them – they generally like them. Enjoyed the article, thank you!
Hi David.
You’re welcome, and thank you for the comment.
Re: “substance abuse treatment”. In this case, I took my lead from the IfG report, which uses the term (actually they use “drug abuse treatment”/ “drug treatment”) to make my point re. cross-cutting issues as discussed in the report.
I try to be very careful with terminology, and tend to take my cues from the context.
Self-identification and labelling are fascinating subjects. I personally never had problem with the term substance abuse/ substance abuser – but as you imply, this is a personal issue, and not why I used it in this case.
This area is often overlooked by services. For example, I really had issues with being called a service user when using services – I found it a stigmatising term. I much preferred client. No-one ever asked me – although when I mentioned this to one service, they took heed immediately, which I appreciated and valued at the time. The difference, to me, was very empowering to say nothing of the wonderful feeling of being listened to. Others would of course have contrary preferences, or none at all.
The point was driven home to me when I was working in a Tier 3.5 supported housing project. The area manager insisted we referred to our clients as “tenants” rather than “residents”, her argument being that “residents” had subtle connotations of institutionalisation, whereas “tenants” was much more neutral, accurate, and appropriate. They were, after all tenants -having a full tenancy with a Housing Association, not a licence as in a Tier 4 long-term residential re-hab. (When we asked clients, about half had no preference, and half preferred “tenant”.)
These are small details which have a big impact on how we constitute individuals and how they relate to themselves, the service they are engaged with, and the world.
- S.
I thought I was only one working mad hours today – early this morning for me – but you too! Yes, terminology very important, White done good papers on this. Maybe bigger impact on people’s views looking into field, then people suffering with problem. There was a paper I put top of DD a couple of weeks ago on GPs and terminology. We did a lot of prejudice work when I at Uni. Big research project there, I’m sure.
How about ‘substance abuse treatment’ when talking within context rather then substance abuse treatment? Take care and keep up your blogging!
David,
I’m familiar with the material that you’re referring to, and while much of it is very inspiring, it tends to not be much help when it comes to answering many of the hard questions about resource allocation and performance management — which is the context of Stephen’s paper. Possibly because those questions aren’t answerable anyway, or because the answers rely on political rather than scientific or medical decisions.
Some of the questions I’ve got in mind, for example: what is a reasonable balance of resources between aftercare and chronic care? How long should be be providing aftercare services for? What principles do we use to allocate resources in a shrinking system? Does the system focus on those who are at greatest risk, or do we focus on those who appear to show signs of recovery who may very well recover on their own?
Then there are the issues of who gets to make these decisions. Is it the politicians (which is largely the case at the moment)? Is it the patient themselves? (I wish.)
A handful of Conservative politicians appear to have been embracing the recovery agenda of late, and parroting the same sorts of criticisms of the NTA that I often here in recovery circles. (e.g. Drug treatment in the UK is an enormous failure, we’ll be diverting massive sums of money from community based prescribing to in-patient abstinence services, etc. etc.
Now, correct me if I’m wrong but I’m not aware of any evidence that would support this kind of ‘back to the future’ allocation of resources. The best evidence that I’ve seen in respect of this issue (appropriately enough, a study from the 1980′s) suggests that only around 10% of PDU’s are prepared to countenance any kind of abstinence-based treatment programme at any particular time. Put this question to people in recovery circles, and they’re likely to tell you that the only way to improve this figure is by making the system more punitive so that greater numbers of people ‘hit rock bottom’, thereby improving the numbers that are ready to embrace abstinence-based treatment.
There’s no ‘evidence’ to support such a proposition, but many ‘recovering communities’ operate according to a quasi-religious dogma and ideology that is contradicted by the science and the evidence. Where the two issues conflict, people from this tradition will tend to go with the dogma every time. (“Well, it saved *my* life and that’s good enough for me.”)
The important thing about the NTA (to my mind), is that it’s spent the last ten years advocating for evidence-based treatment in a field that has traditionally been haunted by charlatans and scam artists. And so the decisions about what treatments are to be provided are largely determined by those NICE reviews of the evidence on drug treatment.
Now, you may disagree with some of the NICE findings, or with their methodology or whatever. And you’re able to make those challenges because the process by which they reach those decisions is completely open and transparent. Making similar decisions on the basis of ‘Because Bill W. says so!’ strikes me as a totally retrograde step.
Perhaps I’m being unfair here, and wrongly characterising the decision-making processes of the recovering community based on a small number of vocal activists and adherents, but I’m really just really representing the kinds of things that they say to me.
Stephen,
re. terminology, I have to say that I find the obsession with this stuff infuriating. If it was so clear cut, we’d all agree with each other on what we want to be called.
Personally, I’m happy with addict/addiction, but I prefer patient for any relationship that involves treatment by a doctor. Client for a psychotherapeutic relationship that doesn’t involve prescribing, and Service User in a context where you aren’t differentiating because the group involves people from a wide tank.
If you’ve stopped using serices though, I think service user is dishonest.`
Any dishonesty in this respect comes from services who encourage post-discharge involvement on parity with service users, not the individuals themselves.
Actually, dishonesty is the wrong word – it’s just bad practice.
I personally can’t think of one case of someone self-identifying as a service user after discharge.
- S.
PS I like your relational identity matrix:
Patient/ doctor – great.
Psych/ client – great.
Non-differentiated/ service user – great
I agree that professionals collude in it — possibly even initiate it (due to being charged with having to engage with ‘service users’), but I’ve definitely come across numerous cases of people who have been abstinent for many, many years describing themselves as a service user.
That said, there are some services that do keep hold of people for a very long time, so perhaps they aren’t being inaccurate? Also, sometimes they might be engaging with services that aren’t traditional drug treatment — eg. ETE services, Mental Health services, etc. etc.
Mcdermott
I agree with your comment about the recovery agenda being a “quasi-religious dogma and ideology that is contradicted by the science and the evidence”. I went to an event organised by the NTA skills consortium yesterday, apparently Harm Reduction is in tatters and recovery is the only way forward, news to me.