THE NTA: UNZIPPING TREATMENT FACTS

A dozen rehabs in the UK have closed and others made counsellors redundant. Most depend on the state for clients – but it refers only 2% of drug abusers to drug-free treatment, creating a crisis of empty beds and waiting lists of people desperate to fill them. Taxes were spent on a redefinition of “recovery” excluding drug/alcohol-free goals. Deirdre Boyd feels the seven-year itch for change.

You can dowload a pdf version here: Download AT115p-NTAunzipped.pdf

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REHABS CLOSING – LATEST COUNT.

The UK has lost the following life-saving addiction-treatment centres in the past year or so:

• Thurston House, London, is scheduled to close in December (men only, extended care)

• Pierpoint Women’s Unit, Lancashire

• Two Saints, Hampshire

• Phoenix Futures London Residential Service

• Priory Farm Place, Surrey

• Priory Coach House (extended care)

• Barley Wood, Somerset

• Murray Lodge, Coventry

• Hebron House Women & Baby Unit (women’s unit still here)

• Phoenix Bexhill

• Isham House no longer treats addiction patients

• Diana Princess of Wales Hospital, Norfolk, is in administration

• One treatment centre liquidated a company and is selling premises but does not wish to be named.

Addiction Today, and the Addiction Recovery Foundation charity which publishes the journal, supported the National Treatment Agency for Substance Misuse since it came on the scene in 2001. But the long honeymoon is over. There is a seven-year itch for something much better – something on the lines urged at the start.

Of prime importance in the disillusion with the NTA is that over a dozen abstinence-based treatment centres have closed, the inevitable result of the pathetically tiny percentage – 2% according to NTA delivery manager Colin Bradbury – of people with drug problems being referred them, regardless of how clinically necessary rehab is.

The paucity of referrals has occurred under the stewardship of the NTA which is responsible for implementing drug policy in the UK, via 149 Drug Action Teams. Sadly, I have heard stories of Dat commissioners jeering the very idea of drug-free treatment.

Professor David Clarke of Wired has written of “a local commissioner who was telling drugs workers that research showed that residential rehab did not work. Therefore, local commissioners were not going to send people to residential. Very worrying was the fact that the drugs workers believed what he was telling them! No wonder residential centres are struggling to fill their beds, with this disgraceful misinformation”.

The same adjective could be applied to the NTA head-office staff member who unjustifiably told BBC home editor Mark Easton, when researching a programme, that “there is no evidence that rehab works”.

Senior NTA directors have a stated aim of getting people off drugs – but this must surely be mere lip service when millions of pounds in each of its seven years have not been utilised to give its own staff accurate, life-saving information.

Anyone truly interested and impartial can access the research free at the Addiction Today website.

WISE ADVICE WAS IGNORED.

So what has gone wrong? Let’s look at the recommendations we publicised in March 2001. Pursuant to a meeting with treatment providers and Neil Townley, then head of the NTA team in the Department of Health, plus his colleagues, Addiction Today (vol2, no69) publicised the key finding: that delivering funds/infrastructure through Dats was the key barrier to effective implementation of government strategy.

“The NTA is depending on Dats for its plan to work – but the unanimous view was that, while a tiny minority of Dats were good, the vast majority were not trusted. There was agreement that Dats need guidance; there is a high level of unawareness. The NTA needs a carrot-and-stick approach, the stick to include sanctions if performance is not satisfactory.”

Townley wanted an increase in the numbers of clients in treatment, and the effectiveness of their treatment raised. We urged another guiding principle: that the latter be extended to include “starting from accurate, accessible assessment”.

“Assessment is key but it is hugely volatile across the country,” we wrote. “There needs to be a defined continuum of care from assessment onward up to/including resettlement.

“Departments can be driven by individuals prejudiced for or against certain treatments and this can be more powerful than any formal system. Can this be addressed? We also need transparency and perhaps ring-fencing in pooled budgets.”

If these goodwill recommendations had been respected, the issues they addressed would not now be NTA crises. Sadly, ignoring them was an indication of problematic attitudes to come.

CURRENT CRISES: GOOD POINTS FIRST.

These have now reached such a peak that the NTA has been publicly panned by the BBC, Times and Observer among other media, and by the Centre for Policy Studies think tank, which develops policies to limit the role of the state and enable families and voluntary organisations to flourish.

Let’s start with what the NTA did right. It has drawn up some excellent models of care describing how organisations across the treatment and related fields should collaborate for the ultimate benefit of people seeking help. The first problem is in implementing these models of care. The second major problem is lack of transparency surrounding the consequences.

It is to the NTA’s credit that, even though it devoted 3-4 hours of its annual conference last June to the highly-funded UKDPC redefinition of recovery which excludes goals of becoming drug free, and printed a taxpayer-funded booklet on that, four of its senior people confirmed to me in October (two in writing, two verbally) that they will not link the NTA Top outcomes measure form to it. In other words, Top will still indicate whether people have managed to become drug free, rather than blurring the numbers with those who maintain “control over substance use”.

TARGETS WITHOUT AUDIT.

Minutes from a NTA board meeting show that its senior managers’ salaries, including its CEO’s, are directly linked to outcome targets. So there is a keen interest in the figures being presented to show that targets have been met – but this can act against getting both the right figures and the right kinds of figures. The figures rely on the Top ‘validating’ paper which independent researchers describe as measuring only reliability of crime – ie, consistency of self-report, not validity.

So, clients underreporting drug use and off ending at structured interview, due to stigma and fear of consequences… combined with workers not asking relevant questions... will lead to… targets appearing to have been met.

Addiction Research & Theory plans to publish a peer-reviewed paper exposing this in early 2009.

ANSWER THE RIGHT QUESTIONS.

Treatment works – but we must define treatment, prescribe it appropriately, and monitor the results with both accuracy and finesse so that they can truly feedback into improvements.

* Why, after seven years, do most Dat commissioners – or even most psychiatrists and doctors – not understand the distinction between addiction/dependency and misuse? These require different diagnoses and care plans; instead most people are treated in outdated medical-model assumptions of ‘physical dependence’. Getting it right is more effective clinically and cost-wise.

* Why are we unable to find these two types of patient quantified in the NTA figures?

* Why are we also unable to find numbers of patients with accompanying mental disorders?

* Where are the figures demonstrating that more chronic, complex clients go to rehab?

* When will the figures showing drug-free clients link them with the treatment they receive?

* When will NTA staff stop saying that rehab does not work?

* If the NTA can do nothing about residential rehab, why is it doing so little about community rehab?

* What Dat systems support people in abstinent recovery? How does NDTMS measure this?

* If there is a ‘third way,’ what budgets are spent on training, and in what, to sustain recovery paths?

* What is the evidence base for this middle way?

* If Top and NDTMS do not answer these questions, they should be replaced – was Top sent out to tender? Was its review sent to tender?

IS IT THE DoH CRUSHING PEOPLE?

I was among those who regarded the NTA as responsible for only 2% of people getting into drugfree treatment, particularly as it takes credit for “getting 202,000 people into treatment” in its press releases. However, three of its senior people stated the responsibility belongs to PCT/LA commissioners. “They hold the budgets.”

The NTA annual accounts confirm this: last year, it spent £14,517,000, not one penny on treatment.

However, NTA regional manager Mark Gilman achieves outstanding good practice (in comparison; 7% of patients get the drug-free treatment they seek). Why is his paradigm not replicated nationally?

Also, the £54million to be distributed via the government’s Capital Development programme for inpatient and residential rehabilitation substance misuse (drug and alcohol) services 2007/08 and 2008/09 is not what it seemed.

Guidance letters to get the funds were sent by the Department of Health’s Nick Lawrence, head of alcohol, drugs and tobacco policy to... PCTs, local authorities and other statutory agencies – no abstinence-based services were classed as recipients.

I was told that residential treatment centres could not qualify for capital funding unless they could prove future financial stability... which rested on DAT/NTA commissioning... but only 2-3.6% of patients are referred... so the centres could not plan for future staff or financial provision... and so the Catch 22 continued, threatening the very existence of these voluntary-sector life-savers.

The Healthcare Commission is reviewing Tier 4 services, with a report due in January. It is a measure of disillusionment that we can even conceive this thought: Will it mark down rehabs for not having the funds to undertake capital renovations, and will it award points to NHS services which were given the funds to meet criteria? Clinical effectiveness is not measured.

A review by the National Audit Office is overdue.

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THE RESEARCHER’S EXPERT VIEW

Dr David Best was formerly research manager for the National Treatment Agency, so was uniquely qualified to debate appropriate treatment with the NTA CEO Paul Hayes (more details AT115,p7). He gives a summary below of his research.

􀁺 “Most clients don’t want methadone and certainly don’t want it for life

􀁺 The evidence base for England shows no reductions in alcohol or crack use – and some start both after entering methadone ‘treatment’.

􀁺 Problem drinking exists in up to 40% of methadone maintenance clients.

􀁺 Maintenance works but only when it is part of a package – people typically get seen for 1.5 hours a month and receive evidence-based psychological interventions for less than four hours a year.

􀁺 Can methadone maintenance work? Not using the NTA model of maximising numbers without delivering meaningful treatment...

􀁺 Even the most ardent proponent of maintenance has no idea about an ‘evidence-based’ model for the transition/exit from maintenance.

􀁺 Meanwhile, the client is increasingly coshed by sedating effects of the drug and its long-term impact on decision making and planning – precisely the personal resources required to overcome long-term addiction.

􀁺 For all the outcome studies, we have no data on the proportion of clients who are the “models of maintained recovery” that we hear so much about – the golden eggs of the maintenance system who are not readily found and have never been quantified by any brave scientist... and a zero score on Top does not count as reliable evidence!

􀁺 NTORS and all major outcome studies suggest that abstinence is a viable goal, achieved by large numbers in spite of the scandalous lack of funding for rehab and recovery journeys (48% abstinent after two years, compared to the NTA 2%).

􀁺 Finally, in a time of concern about children of drug-using parents and Every Child Matters, is maintenance becoming a heritable curse of stigma, underachievement and decay?

Comments

[Steve Spiegel]

Hi, Deirdre.

I hope you are well. I am just reading through The NTA: Unzipping Treatment Facts and I am very saddened. I also feel quite angry. What seems to be continually lost when speaking to staff from the NTA is the fact that we (and they) are dealing with human life.
The attitudes of many drug workers and especially their managers leaves a lot to be desired. It appears on so many occasions that their own personal agenda comes into play rather than the evidence and facts of what is best for the client/patient. They are in the main naive and are not qualified to be making clinical decisions. They are often downright hostile and ignorant.
I wonder where a funding commissioner or care manager or one of the big wigs of the NTA would send one of their own loved ones if they discovered that they had a problem with drugs or alcohol. Would they refer them onto some maintenance programme? I doubt it. They would send them to an abstinence based rehab!!!! Probably the best that money could buy.
I personally feel that initially the NTA (or how it was sold to us) was a good idea. We needed and still need a governing body to make sure that standards are set and adhered to. However this is not what I see today. I don’t believe standards have improved. Let’s be fair, DANOS is a complete joke. I would expect a volunteer to meet most of those requirements within a very short space of time.
The NTA, in my opinion, has turned into a monolithic organisation that is a law unto itself. It controls the DATs, many of whom are also shambolic entities who seem more intent on covering their own backs than actually helping their clients. There are, of course, some excellent DATs who ensure optimum care management for their clients while still working under the restrictions of the NTA.
The NTA control purse strings and dictates how we need to evidence outcomes in a way that does not reflect a true picture of what is really happening. It is almost as if outcomes are being engineered in order for people to show how successful the NTA policies are (which of course they are not) so people can keep their jobs.
Then we have good practice. The NTA demands retention figures increase and waiting times decrease. This is simple to do when dishing out medication such as methadone but when running a successful rehab which has a set number of beds it doesn’t make sense.
The treatment we offer is of the highest standard so very few people leave our centre before their treatment is completed. This unfortunately means that others have to wait for a bed; we have found they are willing to do this if it means they receive the best-quality cost-effective treatment possible.
The way round these waiting times is for us to open more and more centres, offer more and more beds which we could easily do however our quality of service would diminish and we are not prepared to allow this to happen. We are not interested in building an empire just in helping those that we can help.
We hear the NTA promoting service user involvement. In Bournemouth we have a local Service User Forum. However, it is funded by the DAT so the people who work there are hardly lightly to ruffle too many feathers!
We also hear of agencies that discharge clients and refer them back to their care team. The care team might see this person just once in the next few weeks but their file is kept open until the ‘12 week’ period is up and are then signed off as a success. We have heard of others who are actually in prison but appear on NDTMS returns as still engaging in treatment. Is it true that some places demand that nobody is discharged or breached so that the outcomes appear to be positive?
Rehabs are closing. Why? For exactly the reasons pointed out in your article. One cannot rely on local authority funding or hollow NTA promises.
How come we are always full? We originally set up to work with people who could not afford treatment but wanted it. If you look at our clientele today it has changed drastically. Over 60% are funded privately and we also have various companies and charities that use us on a regular basis whereas we hardly ever had private clients before the NTA came into existence. We have seen that more and more people are no longer prepared to have to wait for community care assessments only to then be offered a choice of a prescribing service, third rate daycare, controlled drinking regimes, foundation courses where virtually everyone is using and drinking or the other substandard treatments on offer.
So many addicts and alcoholic ask for rehab but are told that funding is not available or they are not ready to come off their script!!** It is a disgrace. So they dip into savings or get loans in order to access treatment. There are, of course, those who are unable to raise any funds whatsoever and want to be clean and sober. What happens to them?
Is prescribing treatment? Would you prescribe alcohol to an alcoholic? Do people’s lives improve when being maintained on methadone or subutex? What percentage go on to gain full time employment or go onto further education? Does family life actually improve when someone is still dependent upon a substance such as methadone? What treatment is given to those using non-opioid drugs?
It’s all rather sad. Does rehab work? Of course it does. How do I know? I went through rehab many years ago and still attend yearly reunions where I meet up with hundreds of other people in recovery.
We at The Providence Projects have an annual reunion which is also attended by hundreds of people. The rooms of AA, NA, CA, GA etc are full of thousands of people whose recovery journey started out in rehab. Why do people deny this to be true??? Maybe it would mean they lose control of clients or their jobs would be on the line. Or am I being cynical?
What is the answer? Surely we should all be working together for the common good.
This could be accomplished by having an organisation overseeing us all that was totally transparent in its dealings and gleaned factual information in a way so that it could see and admit its own failings in order put them right rather than have people tick boxes so that we might all pat each other on the back and say what a wonderful job is being done when it is apparent that this is not the case.

Regards,
Steve Spiegel
Founder – Providence Projects
Providence House
17 Carysfort Road
Bournemouth
Dorset BH1 4EJ
www.providenceproject.org

[hdjemil]

Dear Deirdre

Like Steve (above) I too entered rehab long ago (1986) and have been drug free since. I entered the substance misuse field in 1993 and worked in it continually ever since in a variety of roles from project worker to head of drug treatment for all prisons in England and Wales and have done almost every job in between, including Commissioner and DAT Coordinator.

I was a dat coordinator during the consultation that birthed the nta and still think it is a good idea to have an overarching organisation for substance misuse treatment. However, any organisation that awards "very senior managers" a £10k (approx) increase in salary (quite apart from the bonus for meeting targets) and allows one of those very senior managers to be listed as a commissioner for UKDPC (which is essentially a lobby group) in my view has lost its way as in need of urgent review

Meanwhile, like many others in the field I think it is a national scandal that we spent £800m on drug treatment last year (NTA Annual Report, Page10) and so few people got the chance to access residential rehabilitation.

Under the NHS and Community Care Act (1990, which came into force in 1993) those seeking resi rehab have a right to an assessment, a care plan and where their presenting need is severe they can even be placed into residential treatment immediately and the assessment carried out as soon as practicable thereafter. Clients also have the right to be involved in the decision making process (e.g. which rehab to attend) and yet the NTA does nothing to negotiate or simply access and funding arrangements and the silence from user representatives on this issue deafening.

Kind regards

Huseyin

[roger howard]

Deirdre
It is not for the UK Drug Policy Commission to comment on your attack on the NTA. But I do need to oorrect an ongoing mistake you make in your reporting of the Vision for Recovery Consensus Statement we published earlier this year.
Firstly, the Consensus Statement was the product of an independent group convened by us and which included people from all treatment perspectives, including abstinence services along with family members and users. The UKDPC has subsequently supported & promoted the statement.
Second you claim erroneously the statement "excludes the goal of becoming drug free". It does no such thing. It allows for different outcomes, including drug free, as well as others such as those which might be achieved (for some people)through prescribed medication. The statement makes no reference to any specific treatment approach or intervention and so logically, drug free is, by implication included.
I also want to pick up on Huseyin Djemil's comments posted on 2 November. He accuses the UKDPC of being a "lobby group". It is no such thing. Apart from pressing for more independent research and analysis, the Commission has no lobbying or campaigning agenda and does not represent vested interests, unlike many of the organisations operating in this field. We simply aim to use evidence in an objective, not selective way to analyse drug policy and practice. You will be aware we have publicly stated that the current evidence supports a range of interventions, including abstinence, prescribed substitution and psycho-social. What it cannot do (yet)convincingly is say which of these is more effective, for whom and in what situations. The evidence is also unable (yet) to say which is more cost effective and which represents bettter value for money.
There may well be a case for more and better residential provision. Equally the same could be said for non-residential provision. But what is clear from all the debate about recovery is that fundamental to any improvement in the lives of people with drug problems will be accommodation, jobs, treatment for mental health problems and so on. ie the "recovery capital". Simply prescribing methadone without this adjunct support is not good treatment and certainly not rehabilitation.
I also think Huseyin should have declared an interest insofar as he was a member of the working group on addictions which produced the Breakdown and Breakthrough Britain reports for the Conservative Party.

[Deirdre]

To Roger Howard,

I have read your attacks on the NTA on the BBC website, when you used to work in DrugScope, so completely understand your first point.

As regards the second point, let me remind you of contemporaneous notes on UKDPC redefinition of recovery, which omits mention of an eventual ambition of becoming drug-free.

CONTEMPORANEOUS NOTES, EMAILED TO UKDPC WEEK AFTER ITS 2nd MEETING ON REDEFINITION OF RECOVERY:

"I thought the definition appropriate for harm reduction.
However, only 30% of respondents to a questionnaire I sent to CEOs and Clinical Directors agreed that the definition covered recovery from substance abuse.
Only 25% thought it covered substance dependence.
15% thought it covered co-occurring disorders
20% thought it covered [neurotic] personality disorders.
70% of respondents thought the definition of recovery should encompass all four.

This is a significant consensus of people disagreeing with the UKDPC definition (results of questionnaire attached, plus comments). That is before we mention the millions of people excluded from the definition, who have been using the term “recovery” in the UK since 1947 to denote abstinence. Surely a consensus should be all-inclusive?

My dream is to reach a true consensus which is so spot on that it invokes minimum genuine disagreement and much praise (!).
However, below are contemporaneous notes I took at the meeting on Friday.

Neil McKeganey and I thought the definition polarised the field rather than uniting it.
Tim Leighton argued with the retention of “control” – indeed, I noted only three people happy with this word, although this round-robin email might elicit more support. Quotes from others present (one each) were:
“The definition is flawed”
“Clearly the statement is not strong enough. It is misunderstood by all sorts of people all over the place.”
“There is a gap between intention and perception.”
“We need to state this is just a statement by the UKDPC, it is not a consensus”
“Only a partial consensus is possible.”
“People will disagree with this. They are polarised and prejudiced” [DB comment : not if the definition truly were a consensus]
“So what if people disagree? I am prepared to stand by this statement. People can disagree with it.”

Deirdre

[hdjemil]

To correct Roger (UKDPC), I was NOT a member of the working group that produced Breakdown / Breakthrough reports for the Conservative party, I was a civil servant, working for HMPS as Drug Strategy Ccordinator for London prisons at the time and gave evidence to the working group (along with many other contributers) with the express permission of my HMPS line management.

As for the lobby group comment that I made, it was not meant to be Disingenuous. My understanding of UKDPC is that they are a charity and a company limited by guarantee. They receive funds from the Esmee Fairbairn Foundation and use this to commission research to provide analisys of UK drug policy. One of the UKDPC aims (from their website) is to "Ensure this [research] is used by UK governments when considering policy" - how will this be acheived if not by means of lobbying? I certainly did not mean to imply that UKDPC lobby on behalf of a third party (I have no evidence of that), but I did mean to imply that they lobby on behalf of their interpretation of the research that they commission, otherwise what would be the point of carrying out the research if not to influence the take up of the research recommendations?

Regards

[Peter O'Loughlin]

Deirdre, congratulations on your expose of what have become a self serving, arrogant and ineffective organisation, whose sole objective now appears to be attempting to justify the unjustifiable.

In January this year I wrote an article entitled ‘The disastrous outcome of the UK drug and treatment strategy, which was published by Medical News Today, a copy of which can be seen on www.edenlodgepractice.com click on articles. In that article anumber of the important points and questions you raise were highlighted including the increasing incidence of blood born disease and the increasing number of drug related deaths which the NTA with its obsession on spin, seek to sweep on the carpet.

Nothing, apart from the increasing incidence of deaths among methadone users, has changed, nor, given the denial of incompetence by Hayes, is the situation likely to improve. I have therefore come to the conclusion that the present administration is not interested in helping people to become drug free.

Notwithstanding Roger Howard’s comments, the NTA have endorsed and promoted the UKDPC travesty of recovery which clearly promotes ongoing drug use, rather than abstinence focused treatment, a point which I made in the BMJ www.bmj.com/cgi/letters/337/sep25_1/a1762 . If as Roger claims, that definition is meant to include abstinence focused treatment for those who have been assessed as dependent within the criteria specified in both ICD-10 and DSM-1V, rather than increasing the severity of the addiction with ongoing use, I have suggested to the UKDPC that the Betty Ford definition is far more accurate, so why is the UKDPC seeking to reinvent that particular wheel, other than its ostensible reason of being ‘all inclusive’ for a condition which they fail to define, and, as I have repeatedly pointed out, lacks universal definition?

The current treatment protocols are simply not working; to suggest otherwise is blatantly misleading. However since the powers that be are declining to change to abstinence focused recovery for those who are dependent, or even bothering to work out how many of the people in treatment meet that criteria, we can conclude that the UK drug treatment policy is legalisation by prescription, the principle beneficiaries of which will be the pharmaceutical companies and those with vested interests in them.

As Melanie Phillips points out in her hard hitting article in today’s Daily Mail, ‘the legalisers have their hooks deeply into the establishment’.

[Kathy Gyngell]

The working group list for Breakthrough Britain and Breakdown Britain is clearly published in each volume, as was a full list of people and organisations who gave evidence to the entire Centre for Social Justice Policy Review Process - for Roger's information.