CAN THESE LEOPARDS CHANGE THEIR SPOTS?

RESPONSE TO THE NTA BUSINESS PLAN 2010/2011

by
Deirdre Boyd, CEO of the Addiction Recovery Foundation
Kathy Gyngell, chair of the Centre for Policy Studies' Addictions working group

With the  threat of abolition  hanging over its head, the  National Treatment Agency has cleverly extended its longevity by promising to mend its ways. It will, it announced on Friday, use the final two years of  its now-extended life to change the policy it has promulgated over the past nine years.

“We’ve got to get rid of the centralised bureaucracy that wastes money and undermines morale,” prime minister David Cameron stated in July.  But the NTA would seem to have got the last laugh, with over £42.8million of taxpayer‘s money now  allocated to it for two more years to change the disastrous system it created and has so steadfastly defended even in face of the indefensible.   

The NTA will, it promises, help people get off the methadone dependency, tier 2/3 organisation dependency and state dependency which it created via its performance-managed targets.  Its new  Business Plan 2010/11, in a truly Orwellian "four legs bad, two legs good" style, now seemingly advocates the very abstinence approach its spokespeople have repeatedly declared to be unviable.

It will even consult rehabs, the NTA graciously announced – those very rehabs it has ignored for almost a decade and of whose success in getting addicts into drug-free and rewarding recovery Paul Hayes (yes, still the NTA’s CEO) has publicly belittled, scorned or downright denied.  Could it be less than two years ago that  the NTA’s ‘first point-of-contact’ told BBC Home Affairs editor Mark Easton that “rehab doesn’t work”?  (see Comment 5th from bottom here for more derogatory comments from NTA senior managers).

But maybe this was not such a hard promise for the NTA top brass to make, as they look forward to their ‘brobdingnagian’ pension pots in two years’ time. After all, there are fewer rehabs to consult... For under the NTA regime, only 2-4% of addicts seeking help to quit drugs were actually referred to them. The result?  Financial hardship, redundancies, the closure of over 20 specialist rehabs, more wing and bed closures and a loss of the real expertise required to rehabilitate addicts. And with their own personal futures well secured, would success of change be in their interest?

There isn’t any evidence for abstinence or for rehab, they have repeated declared. This is despite two national treatment outcomes surveys - Ntors and Doris - which indicate  strongly to the contrary. It is also in face of experience. As Sir Ian Gilmore said yesterday,  the "absence of evidence" about school milk for under fives is only that; it does not mean that it is not a good thing and has not helped children’s health. All experience suggests it certainly has, he insisted. Similarly with rehab: a joint report in 2008 by the Commission for Social Care Inspectorate with the NTA itself that “residential rehabs outstrip other sectors in every outcome group we measure".

The NTA seems to have bamboozled the Department of Health and a too readily believing government.  For who have they tasked to change their policy and now shift people into ‘recovery’?  Brazenly, it has appointed as one of the duo the addiction psychiatrist most closely associated with the failed medico-clinical treatment approach of the past 20 years years, one of the the proponents and instigators of the last government's failed treating-drugs-with-drugs approach so loved by the NTA, key lobbyist for counterintuitive, expensive and ethically questionable prescribing programmes: John Strang of the National Addiction Centre.

In his capacity as a director of the UKDPC - recipient of millions of charitable funds to, among other briefs, redefine for the nation the notion of (addiction) recovery - Strang chose to use this remit to ensure that any new official definition of recovery excluded full abstinence, ignoring all expert advice to the contrary. 

Nor did he stop there. His UKDPC's plan was to use this new definition of “recovery” to replace real total drug-free outcomes as the measure for the NTA’s Treatment Outomes Profile forms, meaning that their  targets could be easily be hit. Very convenient. For, in one Orwellian sleight of hand, the NTA could claim a recovery outcome when no such thing had been achieved. A reduction in injection frequency would suffice. This would be the basis of NTA’s (aspirationless) claims of treatment success. In face of the derision this deserved, the  NTA has gone on record saying it does not define recovery at all now – despite the fact that “recovery” is the raison d’etre of its Janus-faced Business Plan 2010/2011. That all the goals and actions therein are meaningless can thus be taken as read.

For example, there is apparently no plan to replace the discredited and bureaucratically heavy Top form. It will be forced on ever more people. The NTA states, too, that it has looked at the ASAM patient placement criteria. Yet instead of contacting the creators of this highly-researched method, it plans to reinvent the wheel and spend taxpayer money developing a version for its own purposes. It also plans to spend more taxpayer money on a mutual aid directory. Yet this is already provided free by Addiction Today. Under Championing abstinence-focussed treatment in the business plan... well, for further help interpreting  the Business Plan’s double speak, read our glossary.

It is, however, commendable that Dr David Best, who has wriiten so cogently and expertly on abstinence-based recovery in the pages of Addiction Today and other professional journals, has been appointed as the other half of the recovery duo.  We wish him the very  best of luck in counterbalancing his former mentors, and getting them on the true road to recovery with a Damascene conversion. They should heed him, for he is the only person giving this exercise any credibility.

As David Cameron said in June,“There is a problem in our national health service, in that we spend too much time treating the symptoms rather than necessarily dealing with the causes... All addictions need proper attention, and proper treatment and therapy, to rid people of their addictions”.

We really would love to believe, as he and many in government must wish to believe, that we will witness the NTA's respecting the trust that has been placed in it and seeking the rehab expertise that actually helps people to get off life-destroying drugs and rebuild their lives and their families’ lives. But the serious worry is that this initiative for change get will be lost in adherence to disinformation and blowback, and submerged in intransigent ideology about the non-recoverability from addiction. Of even more concern, will its lack of understanding continue to marginalise the expertise necessary to help the 330,000 or so addicts desperate for the sobriety which is the basis for them to get back, or get for the first time, their self esteem and their lives?

We will be happy to be proved wrong. But we are not holding our breath.

Comments

[Wendy Dawson]

As a residential rehab provider, an abstinenced based therapeutic community I have for the past two years invited NTA representatives including Paul Hayes CEO to come and see first hand the work we do and speak directly with our beneficiaries. To date no-one has visited! ALL residents complete our programme into full-time employment, pay taxes and move into independent living, no longer in treatment. What better outcome could anyone, NTA, Government, individuals, tax payers, wish for. Last month we won a CSJ Award for excellence, efficiency, innovation and compassion. Rehab works but we have empty beds!

[Paul]

What is best for clients should not be a battle of idelogies and politicking but individuals assessment of need. There has been an over-reliance on long term substitution treatment just as there has been and still is a lack of variety and capacity in rehabilitation services. The basic ethos of many services does not suit a large number of clients and sending them to these services is setting them up to fail. We would benefit from not over simplifying the evidence here. The evidence that methadone maintenance has saved lives, improved health and started people among the pathway to recovery is considerable but it is only part of the answer. We should not throw the baby out with the bath water. Equally there has been evidence of the success of rehabiliation and other recovery services. But sending clients that are not ready to rehab is a recipe for disaster and will simply result in drop out (the evidence is also around for this) which will increase risks for that individual's well being and the well being of communities, as clients may well turn back to crime to fund their use.

It would be nice to regain some balance and for people to rein in their need to rubbish other individuals or organsations it is not helpful to the debate or clients.

[Laurence McM]

Well done on being the ONLY two people in England (apart from the CSJ) to speak up for what works in getting people off drugs and into recovery.

Like Paul, I used to believe there was a role for methadone - but recent research in the British Medical Journal shows that chances of recovery are in INVERSE proportion to exposure to methadone. There is such prevalent bad practice in overprescribing that it must be rebalanced; it is costing too many lives and is too heavy a draiin on the public purse.

Did Paul read the blog? How can he say too many people are offered the opportunity of rehab? Only 2-4% of people get the chance. 2-4%. This is despite the NTA's own ignored user satisfaction survey a few years ago showing the vast majority of people wanted this opportunity. And it responds with a business plan of more processes and bureaucracy. I share Deirdre's and Kathy's outrage at the loss of lives and damage to families.

The NTA is not called the National Harm Reduction Agency. It is not called the National Prescribing Agency. The National Treatment Agency has not lived up to its name.

[Mike Pattinson]

Surely what all in our sector need to be arguing for in these 'austere' times is to maintain investment into a broad, service user focused treatment system that supports people when they need it and in ways that addresses both acute crises and longer-term recovery.
It is an unhelpful polarising argument that residnetial treatment is 'good' and everything else is 'not'. We certainly need to see an exapansion of high quality and evidence based residential treatment - but still need those services that identify, support and motivate people into treatment as well when they leave in a planned or unplanned way.

[Annemarie Ward]

"but recent research in the British Medical Journal shows that chances of recovery are in INVERSE proportion to exposure to methadone"
Laurence any chance of a link or reference to this piece of work, I would love to read it.

[Laurence McM]

Annemarie,

You can read the study here:
www.bmj.com/cgi/content/full/341/jul01_1/c3172

"Results. In the entire cohort 277 participants achieved long term cessation of injecting, and 228 died... For each additional year of opiate substitution treatment the hazard of death before long term cessation fell 13% ... after adjustment for HIV, sex, calendar period, age at first injection, and history of prison and overdose. Conversely exposure to opiate substitution treatment was inversely related to the chances of achieving long term cessation.

[Annemarie Ward]

WOW many thanks Laurence!

[Steve Rolles]

again - for a more complete picture (and to highlight the old 'its a bit more complicated than that' maxim), from the BMJ study you cite:

"What is already known on this topic

- Injecting drug use is a chronic condition associated with substantial excess mortality and morbidity, but there is a lack of empirical evidence on the duration of injecting
- Opiate substitution treatment reduces the risk of death in injectors over the short term, possibly by providing a faster route to full recovery and abstinence from dependency

What this study adds

- Opiate substitution treatment, especially long term, reduces the risk of death before cessation in injectors
- Opiate substitution treatment does not reduce the overall duration of injecting
- Debates on the direction of drug policy and benefits of drug treatment should consider that there is a balance between saving lives and achieving abstinence'