COLLECTIVE VOICE – WRITTEN EVIDENCE (PSR0050)
Collective Voice is the national alliance of drug and alcohol treatment charities. We believe that anyone in England with a drug or alcohol problem should be able to access effective, evidence-based and person-centred support. We know that treatment and wider support has a transformative power for people with drug or alcohol issues, their families and communities. Drawing on the strengths of our members, we:
Introduction
People who access drug or alcohol treatment are, at the best of times, some of the UK’s most vulnerable individuals. But in the current climate of a widespread pandemic their vulnerability is especially heightened, and third sector services that are already struggling to deal with significant disinvestment over the last six or more years are facing an unprecedented challenge to sustain life-saving treatment and recovery support.
We welcome the Committee’s call for evidence on the lessons of Covid-19 for public services. We also appreciated the Committee’s invitation to Collective Voice Director Oliver Standing to give evidence on the issue of people experiencing multiple disadvantage during Covid-19. This response focusses on the successes and challenges faced by charities working in the substance misuse sector, as well as connected fields that support other areas of complex needs, including mental health, homelessness, and contact with the criminal justice system. In this respect, we have only responded to the Committee’s questions that are most pertinent to our expertise.
More than ever, the UK needs a strong and supported charity sector to continue providing aid to the country’s most vulnerable people during the Covid-19 emergency and in the years ahead as the longer-term effects of the pandemic become more apparent.
What have been the main areas of public service success and failure during the Covid-19 outbreak?
Charities across the country are delivering key public services, oftentimes not in isolation or as add-ons to existing statutory services but as core components of state-commissioned care for some our most vulnerable citizens. In this respect, the third sector has long been a trusted partner of the state, with national and local government appreciative of its capacity for innovation, values-driven culture and ability to work closely with sometimes marginalised populations. This relationship has deepened through the wide-scale commissioning of third sector service organisations to deliver core public services around areas including learning disabilities, mental health and drug and alcohol support. This is particularly true in the world of substance misuse treatment, where charities provide the majority of support, made up of both clinical care as well as a broad range of psychosocial and recovery interventions.
People with a history of problematic substance misuse often have underlying health conditions, which range from cardiovascular disease to COPD and other respiratory conditions. These physical health vulnerabilities are often underpinned by trauma and poverty, and accompanied by social and environmental factors, such as homelessness and involvement in the criminal justice system. For these reasons, services supporting people with drug or alcohol problems, or experiencing other areas of multiple disadvantage, were rightfully very concerned about the potential effects of a high prevalence of Covid-19 in these populations.
However, at present the numbers of people in treatment for substance misuse treatment who have contracted Covid-19 appears to be lower than expected. While the reasons for this remain to be clearly evaluated, there is little doubt that the rapid changes to treatment services, effected by a highly motivated and compassionate workforce, were a crucial factor in keeping people safe. The threat of a second wave of the pandemic hangs over us all and there are no signs of complacency in our field in thinking that the job is finished. Provider organisations, whether NHS or voluntary sector, are grappling with the long term challenge of service specification and delivery that builds in social distancing and enhanced infection control measures.
But while it is still far too early to define success during Covid-19 in our sector, it also appears at this stage that people in need of treatment for substance misuse have, in the main, been able to access services that, while partly different in their design, still provide commensurate support to the pre-Covid landscape and are being delivered in line with the established evidence base
The Make Every Adult Matter coalition recently published a Rapid Evidence Gathering report looking at the flexibilities and innovation instigated by Covid-19 in services supporting people experiencing multiple disadvantage across substance misuse, homelessness, poor mental health and contact with the criminal justice system. The report offers an important snapshot of some of the crucial adaptions to substance misuse services, including greater use of virtual contact and changes to the prescribing and management of life-saving Opioid Substitution Therapy medication, which – in the areas surveyed by the MEAM report – have actually resulted in greater engagement by service-users.
Nevertheless, substance misuse treatment providers – particularly those in the charity sector – have faced substantial hurdles created by public service failures in the response to the Covid-19. The failure to equip our public services with sufficient PPE early in the crisis became nationally recognised as a crisis within a crisis, and one that had serious repercussions for many third sector treatment providers which were left scrambling to ensure they could continue to provide the necessary level of face-to-face services while keeping staff and service-users safe. The lack of clarity and efficiency around testing has also hampered our sector’s ability to respond to the pandemic.
Did resource problems or capacity issues limit the ability of public services to respond to the crisis? Are there lessons to be learnt from the pandemic on how resources can be better allocated and public service resilience improved?
The vast majority of spending on drug and alcohol treatment services in England is delivered through the ring-fenced public health grant allocated annually to local authorities as part of the wider local government settlement. The grant also covers areas such as sexual health clinics, smoking cessation programmes and some children’s health services. These core services, including substance misuse services, work to address the social determinants of health that keep people healthy and out of acute health settings.
However, since the Health and Social Care Act 2012 established the move to local government public health, the allocated grant has been gradually eroded – £700m has been taken out of the system since 2014/15 and almost £100m of this was in 2019/20 alone. This means that per head spending on public health has decreased by a quarter during this time. Public health services have been left to deal with a highly fragmented system, driven by localism, where decisions by local actors are paramount. Areas with the greatest need for public health spending, where health inequalities are driving significant disparities in life expectancies between our poorest and richest citizens, have not been protected. In the words of the Health Foundation in their 2018 report ‘Taking our health for granted’, ‘The lack of strategic approach, coupled with real-terms cuts, risks widening health inequalities at a time when the government has pledged to tackle such injustices.’
For drug and alcohol treatment services in particular, spending saw a 14 per cent reduction between 2014/15 and 2017/18 with considerable local variation – some Local Authorities have reduced funding by 40 per cent. Meanwhile, as highlighted by Dame Carol Black’s recent review of drugs, there is a clear case for these services - the cost of illegal drugs to society stands at a £19 billion, but we spend just £600 million on treatment.
We therefore call to ensure that the public health grant is protected and local allocations are increased so that public health services, which are needed more than ever, are properly resourced. Strong national leadership on substance misuse will be crucial to make sure the population in need of treatment (which seems likely to increase because of Covid-19) are given political priority. We understand that the development of a previously announced Addictions Strategy and central monitoring unit have been paused, but the second part of Dame Carol Black’s seminal review of drugs (which will focus on treatment and recovery) will also be an important waymark for our sector to effect lasting, positive change.
On one particular issue during the pandemic, as stated above, the inefficiencies in the provision of PPE and testing were a challenge for many substance misuse treatment providers. Smaller organisations, including those providing residential rehabilitation services, will have been particularly affected by these resource problems as they are less likely to have robust financial reserves to draw on. Anecdotal evidence indicates an additional average cost of around £60,000 per residential rehab on PPE.
While there is a mixed picture across the country in terms of services’ ability to access PPE and testing, with the PPE situation being substantially improved now from the position of six-eight weeks ago, the overall impression is that our field has not been prioritised to the same level as other parts of the health and social care system. In practical terms, this has left some services in a precarious situation with respect to keeping staff and service-users safe, but has also deeply frustrated our field’s ability to maintain the safety and stability of our workforce. Some services have taken on significant costs with respect to purchases of PPE and the employment of agency workers to cover staff absences.
Why have some public services been able to achieve goals within a much shorter timeframe than typically would have been expected before the Covid-19 outbreak – for example, the increase in NHS capacity? What lessons can be learnt?
In our sector, and the wider fields working to support people experiencing multiple disadvantage, it is clear from MEAM’s recent report that the move to radically – and rapidly – alter the delivery of services in the face of Covid-19 has been achieved in some areas by giving service-users and frontline workers greater autonomy in decision-making, while ensuring close collaboration between operational and strategic partners. We believe this model of working – giving services and staff the necessary freedom to keep people safe while also ensuring they adhere to the evidence and work under a system of clear and supportive operational and/or clinical governance – meant that each part of the system was able to focus on deploying its particular strengths. The MEAM report highlights a number of positives from this move for both staff and service-users, including an increased sense of community and shared purpose across agencies and increased trust in individuals and services.
Some public health commissioners have also played crucial roles in keeping services running during the pandemic by maintaining funding while providing flexibility around contractual obligations and postponing procurement, and there have been heroic efforts from local government staff working in partnership with third sector providers. National guidance on procurement from the Cabinet Office and the LGA in the early days of the pandemic was useful in shaping these decisions.
However, we also recognise that the changes to service provision, particularly in substance misuse treatment, did not come without risk or challenge and only in the fullness of time will we be able to understand some of the complexities that will have resulted. At Collective Voice, we’re working with treatment providers – across the third sector and the NHS – and public health commissioners to better understand how services have adapted and the impact of these changes on staff and service-users through the use of surveys and will gladly share our findings with the Committee when this work is completed.
Has the delivery of public services changed as a result of coronavirus? For example, have any services adopted new methods of meeting people’s needs in response to the outbreak? What lessons can be learnt from innovation during coronavirus?
Our field, like many others across the VCSE sector that support vulnerable people, has been forced to dramatically change how services are delivered. This has included – but is not limited to – changes to how people receiving Opioid Substitution Treatment have been supplied with this life-saving medication, rapid formulation and distribution of harm reduction advice and practices, and a significant shift away from face-to-face contact between practitioners and service-users to remote ways of working. These innovations were effected by operational and strategic partners, using their expertise to implement modifications that have kept service-users engaged while mitigating substantial risks and delivering treatment interventions in line with the extensive evidence base.
It is far too early to assess the longer term impacts of changes to these core aspects of treatment and recovery (some of which undoubtedly necessitate an acute managing of risks to service users, their families, and drugs and alcohol workers). But even at this early stage, it’s clear that many in our field are asking themselves the hard questions of ‘what do we keep?’ and ‘what do we lose?’.
The move to greater use of remote working and virtual contact with service-users bears particular scrutiny, not only for our field but many other sectors supporting vulnerable people. While the shift to phone/digital ways of working has meant that many people have continued to receive crucial support from their keyworkers (there is anecdotal evidence of services having greater reach than normal due to a wider use of remote services) there will be many people already in treatment, or in need of treatment but not currently accessing it, for whom online support will be inappropriate, insufficient or practically impossible. Perhaps surprisingly, we have heard that some young people may be less inclined to engage with remote support for substance misuse.
Many people in treatment will lack the ability, financially or skills-wise, to use digital services. For others, even if they are able to access digital support, they will not experience the same type of support they were previously used to. Relationships between people in treatment and their keyworkers are a core component in their journey towards greater well-being, so it is concerning that the immediate impact of Covid-19 may be putting some of these relationships under strain.
Looking ahead to the future, there is little doubt that the successful wider use of remote and digital support tools will be one of the keys to unlocking effective public services in an uncertain future. But this shift must not become a cost-cutting exercise, and should only be established as additional support, not a wholesale replacement which would leave many people in need of treatment to fall through the gaps.
Have public services been effective in identifying and meeting the needs of vulnerable groups during the Covid-19 outbreak? For example, were services able to identify vulnerable children during lockdown to ensure that they were attending school or receiving support from statutory services? How have adults with complex needs been supported?
The rapid response of local areas to provide emergency accommodation for people experiencing rough sleeping at the beginning of the pandemic is testament to services’ ability to identify vulnerable people in society and give them immediate aid in the face of a serious crisis. There have been many positive examples of local authorities, homelessness services and substance misuse treatment providers (many of them third sector organisations), coming together to keep this highly vulnerable group safe during Covid-19. Services have managed to maintain crucial wraparound support and, in some cases, have used the opportunity of the emergency accommodation to engage people with complex needs who may have previously fallen through the gaps in service provision. The London Hotels Drug and Alcohol Service, established to support people with substance misuse problems in the emergency accommodation settings, offers an excellent example of partnership work done rapidly and effectively with a clear sense of purpose.
However, with funding for the emergency accommodation running out and the accommodation providers, many of them hotels, looking to reopen for the general public, the window of opportunity is closing to ensure that the good work that has taken place during Covid-19 for this group will continue in a post-Covid world. The commitment of £262m in the Spring budget for substance misuse services working with people experiencing rough sleeping was very welcome, but the current needs of this group makes it immediate activation essential.
New and pre-existing partnerships across different services, local authorities and commissioners have often been at the bedrock of the innovative support models created during Covid-19 and it is absolutely vital that these structures are maintained as far as possible to continue providing support for people with complex needs. MEAM’s framework for transition planning offers some important recommendations for local areas and central government to provide this continuity. The work of the Fulfilling Lives programme, as well as MEAM, also offers useful knowledge and understanding on how better local collaboration is possible to support people with complex needs.
Coming out of lockdown, the continued identification of new groups of people with complex needs will also be critical, as many services expect the effects of social isolation, loneliness, increased substance misuse and poor mental health will result in increased need for support across the country.
A criticism often levelled at service delivery is that public services operate in silos – collaboration is said to be disincentivised by narrow targets from central Government departments, distinct funding and commissioning systems, and service-specific regulatory intervention. Would you agree, and if so, did such a framework limit the ability of public services to respond to people’s needs during the Covid-19 outbreak?
The early stages of Covid-19 for the substance misuse treatment sector prompted a refocussing of the field on keeping people safe during the pandemic, while maintaining necessary levels of service provision and managing the risks resulting from changes. Covid-19 created a situation where outcome-focussed frameworks for commissioning and contracts had to be suspended as agencies rallied to support the people at the sharp end of the disruption. As things return to a ‘new normal’, it remains to be seen how the commissioning landscape may shift to accommodate the significant changes to service delivery and learn from the experiences of treatment providers and their service-users during the pandemic.
Silo-ed ways of working have often been a bane for substance misuse services, particularly when supporting people with complex needs across other areas of multiple disadvantage, including homelessness, poor mental health and contact with the criminal justice system. Again, MEAM’s recent report highlights how these barriers can be overcome to provide effective person-centred support across a range of issues, even during a pandemic.
The loss of Drug and Alcohol Teams as local focal points for senior-level collaboration around drug and alcohol treatment - following the Health and Social Care Act of 2012 - has had a negative impact, and the realities of austerity unfolding at the same time has worsened systems fragmentation. Health and Wellbeing Board do not offer a comparable function and have not always been effective. Local areas may benefit from local structures to push forward the treatment and recovery agenda by bringing together public health specialists, the police, NHS services and other relevant partners.
Were some local areas, where services were well integrated before the crisis, better able to respond to the outbreak than areas where integration was less developed? Can you provide examples?
Local areas where substance misuse services were well integrated into the wider network of services supporting vulnerable people were better able to move quickly and effectively to keep people safe and maintain support. Strong leadership from commissioners and providers was key to this, as well as pre-existing relationships across different sectors.
The overall experience for substance misuse treatment during the pandemic has been one that highlights the innovative power of localism as local areas moved quickly while waiting for clear direction from central government. For instance, on the issue of ensuring a safe supply of OST medication during the early chaos of the pandemic, many providers and commissioners were forced to take immediate action to keep people safe by creating their own protocols, with national guidance issued some weeks later. However, as highlighted above, one effect of an increase in local decision making is a varied landscape of provision with disparities in access and outcomes for people in need of treatment.
What lessons might be learnt about the role of charities, volunteers and the community sector from the crisis? Can you provide examples of public services collaborating in new ways with the voluntary sector during lockdown? How could the sectors be better integrated into local systems going forward?
An important lesson of Covid-19 is the importance of strong, robust community networks and the crucial role that the third sector plays in supporting healthier communities by providing a broad range of services, protecting our society’s most vulnerable citizens, and engaging community members in this work. By creating and supporting healthier communities, charities therefore provide vital protection for our acute NHS settings by preventing people’s health issues from escalating to the point of hospitalisation; this has been particularly important during Covid-19. Drug and alcohol services are no exception to this broad characterisation of the VCSE sector, particularly in the context of mutual aid groups and recovery communities that support people on their journey to greater wellbeing.
The government announced £750m funding for charities during the pandemic, but many in the sector do not believe it will be sufficient to ensure charities’ beneficiaries get the help they need, and accessing the funding has also been delayed at a time when celerity is key. Charities offer unique social capital and they must continue to be supported to do what they do best. Andy Haldane, Chief Economist at the Bank of England, recently highlighted the importance of social capital in our economies and societies, summing up:
‘We need to invest the rich endowment of social capital created by the crisis, by rethinking and rebuilding the institutional immune system that is our social sector.’
However, our experience of working with charities, NHS providers, commissioners and PHE officials has also shown how important it is to collaborate, not just during a time of emergency but also during ‘normal’ times. Areas that have responded better to the Covid-19 emergency have often been well equipped to do so because of effective relationships between key partners that understand each other’s roles and support each other to use their expertise in the right areas and at the right times.
June 2020