Transcript What's Wrong with our national Drug Strategy

What's wrong with our national
Drug Strategy ?
Dominic Harrison
@BWDDPH
And how do we improve it?
Issues
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Smoking, Drinking and Drug Use 11-15 year olds in England
Political Culture and Drug Culture
Drugs Strategy: Doesn’t say enough
Drugs Strategy: Could say more
Managing Incidence
Managing Prevalence
Drugs & Alcohol Assets /Recovery Capital Concepts:
– Assets & Needs
– Assets and Risks
• Outcomes Frameworks
• Next Steps: NHS & Public Health Reform
• Health & Wellbeing Strategy
Reducing Demand, Restricting Supply, Building
Recovery (2010)
Key Issues to be addressed: 1. Social Harm
2. Crime & re-offending
3. Family Breakdown
4. Poverty
‘It is acknowledged that all of the above cause misery to individuals, destroy families and
undermine communities’.
Ambition – To stop people taking drugs
3 main themes
1. Reducing demand
2. Reducing supply
3. Achieving recovery.
Overarching aims
1. Reduce illicit drug use
2. Increase the numbers in recovery
‘Integrated services for drugs and alcohol users should be a priority (in the community and
in prisons)’
Smoking, Drinking & Drug Use 11-15 year
Olds: England 2006-8
Source: ONS/NHS Information Centre
(2010)
Political Culture
DH Routemap for Sustainable Health (2011)
Better Value Healthcare (BVHC)
Political Quarterly
Drug Culture Futures?
‘War On Drugs’: R. Regan 14th Oct 1982
Drugs Futures: Economist October 1 2011
• “Britons are especially fond of
psychoactive substances. Ten
adults in every 1,000 has a
drug problem, the highest ratio
in Europe”
• …In contrast new recreational drugs
are proliferating. Some 24 novel
compounds were detected in 2009
by the Monitoring Centre for Drugs
and Drug Addiction, a Lisbon-based
outfit funded by the European
Union. The figure rose to 41 in
2010; a further 20 appeared
in the first four months of
2011.
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Economist: How recreational drug use—and the
problems it causes—are changing :Oct 1st 2011
doesn’t say clearly enough?
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There is a significant cohort of very vulnerable and ‘service
institutionalised’ heroin/ crack- cocaine users for whom competing
with other unemployed stable, well educated & ‘cheaper to employ’
citizens means an ‘economically and socially independent’ drug free
future is unlikely.
There is a larger group of drug using citizens who can attain drug free
recovery if supported with housing, employment, relationship
building and ‘extraction’ from negative local social
influences/networks or more effectively - placement within new local
recovery communities.
There are now rapidly evolving: ‘legal highs’, designer drug
capacities, smart/recreational drugs, life/personality/performance
enhancing drugs – that legislation will never be fast enough to
manage & control.
Poverty is a key driver – substance misuse will increase during
economic crises.
Reduce Incidence as well as manage prevalence.
could say more clearly?
That we need to :
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Acknowledge (with Alabama) ‘we cannot treat or arrest our way out of this
problem’
Have steady disinvestment from a treatment to public health / recovery
approach
Develop a more differentiated targeting of prevention and treatment on
integrated substance misuse /addictions including increased use of e-health
solutions at population level
Liberalise (not legalise) our approach to drug harm / control (e.g. with
penalties/awareness courses etc)
Develop earlier more integrated intervention in ‘whole household’
approaches aimed at reducing inter-generational transmission
Gradually Shift future NHS intervention investment from where it is now to
(ACE) alcohol/ cocaine/ecstacy/designer drugs.
Alcohol is the number 1 population drug use risk and should be prioritisd.
Engage more public services in Level Zero/level 1 intervention (e.g leisure
services)
What's Killing Us? : Causes of the HI Gap in Spearhead LA Areas
Components of the male <75 gap by detailed cause of death
cause specific standardised mortality gap as percentage of total England <75 mortality
other causes
other accidents
accidental overdose
violence
self harm
digestive (incl. cirrhosis)
1995
diabetes
2010
other chest diseases
copd
other cancer
prostate cancer
colorectal cancer
mouth cancer
lung cancer
other circulatory
stroke
coronary heart disease
infant mortality
-1%
0%
1%
2%
3%
4%
5%
6%
7%
8%
Recession
Impacts
Cabinet Office
Social Exclusion
Task Force (2009).
Learning from the
past : Working
together to tackle
the social
consequences of
recession. Evidence
Pack December
2009.
Managing Incidence: BwD: Shifting Population Alcohol Consumption and Risk
24- 25,000 (24% population)
Alcohol treatment
Safe/moderate
Alcohol free
(14%?)
21 Units men
14 units women
Hazardous
Harmful
Up to 50 Units
Over 50 units
Managing Incidence: BwD: Shifting Population Alcohol Consumption and Risk
10,000 (14.5%
population?)
Alcohol Free
Safe/moderate
21Units men
14 units women
Harmful
Up to 50
Units
Hazardous
Over 50 units
The conundrum of alcohol-related harm (1)
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Between 1995 and 2008, the major components of the increased gap
between spearhead and non spearhead mortality, appear to have been
alcohol-related. Alcohol-related gaps appear, however, to have narrowed
slightly since.
• If it were not for alcohol-related deaths, the objective to narrow
overall spearhead life expectancy gaps would almost certainly
have been achieved for males; and would be well on the way to being
achieved for females.
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But – from population surveys between 1998 and 2008,
spearhead and
non-spearhead populations have experienced very similar
rates of increase in average alcohol consumption and in binge
drinking (on revised quantifications of wine consumption). Surveys of drinking
tend to show similar (and dramatic) consumption increases in all income groups
except the very poorest.
The conundrum of alcohol-related harm (2)
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alcohol harm in the
two ‘worst’ deprivation quintiles has been radically different
from that in the three ‘better’ deprivation quintiles; there has
On-going clinical studies appear to find that the experience of
been relatively less increase in alcohol-related mortality over the past 15 years in
more affluent populations, in spite of their experiencing a big increase in hazardous drinking.
There has been substantial increase in mortality in the two most deprived quintiles.
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The major components of the mortality increases are in alcoholic liver disease in early middle age
(45-64); and also in digestive cancers and alcohol-related dementia in late middle age (60-74):
Killing yourself from alcoholic liver disease in middle age is hard; it takes a lot of drink over a
prolonged period, long after the experience of drinking becomes overwhelmingly unpleasant, for
the drinker and for anyone who knows them.
Recovery from alcoholic liver disease can be easy and quick; stop drinking dangerously, and if you
survive the following months, your risk of liver mortality will drop towards the population average
in less than two years.
• So what is stopping people from stopping; and why has
success in stopping become relatively more difficult in more
deprived populations in recent years?
Managing Prevalence: ‘getting ill less’ versus
‘getting ill better’
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The context for these achievements, since 2007, is that of open and shared commitments by Local
Strategic Partnerships to adopt locality-wide and cross-sectoral actions aimed at reducing incidence,
through tackling differential exposure to avoidable health risks.
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This is the conventional Prevention agenda for ‘getting ill less’.
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There has been less success in responding to increased health inequalities in alcoholrelated harm; relatively insignificant in the baseline period, but now in many localities, the major
component of their mortality gap.
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We find that areas with increased alcohol-related mortality do tend to also to have experienced increased
patterns of harmful drinking; nevertheless alcohol-related mortality in other areas with equally increased
exposure to harmful drinking has increased much less, if at all.
This suggests:
– That differential alcohol-related local mortality is not so much about
differential incidence, as about differential recovery,
– That to tackle inequalities in alcohol-related mortality, localities need
to tackle differential access to recovery assets
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getting ill better
This corresponds to the Asset agenda for ‘
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Managing Prevalence: Getting Ill better: the Asset
approach
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Differential access to personal, social and reciprocal assets is significantly associated with:
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The under-construction
of illness; persons with poor access to assets for
wellbeing tend to be recognised as ill later, to access services less appropriately, to have higher
levels of unmet health needs and to die sooner,
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to stay ill longer, to recover less completely, and to consume higher levels of
health resources
Clinical Approach to ‘Getting Ill’
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The under-construction of recovery; persons with poor access to assets for wellbeing – once recognised as ill – tend
Become ill when you are diagnosed as having a pathological condition by a doctor or health professional,
When the doctor or specialist has finished with you, your are ‘discharged’, long-term illnesses do not have a limited
duration, so long as the underlying pathological condition (e.g. diabetes, cancer) persists,
Clinician seeks to discharge patient, so far as possible, the way they were,
‘Recovery’ is only recognised in relation to addicts and alcoholics.
Asset Approach to ‘Getting Ill’
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Become ill when you are recognised, and can recognise yourself, as ill within your social context; you are then
‘constructed as ill’ allowing you access to illness resources and assets,
Recover from illness when you are able to function within your social environment of choice;
long term illnesses can have a duration; indicated as experiencing condition as non-limiting,
– Full recovery is associated with control; having access to a state in which the
condition will not recur,
– Recovery is normal and real; and is a contagious condition (as is nonrecovery)
Assets & Needs
Assets
High
Blackburn with Darwen
NW City
High
Low
Low
Needs
ASSETS
reducded increased
Assets and Risks
Body mass overweight
Adult social drinking at hazardous levels
Teenagers making their own way to school
Teenagers cycling and walking
Teenage recreation away from home
Light adult recreational participation
Adults attempting to quit smoking
High adult time commitment to home life
Going out at night
Body mass normal weight
Adult social drinking at moderate levels
Teenagers abstaining from alcohol
Non-smoking – adults & teenagers
High recreational participation
Joining local groups (esp. sports & religious)
Social contact and trust with neighbours
Adult satisfaction with work/life balance
Continuing participation in education
Satisfaction with long-term relationships
Body mass obese or underweight
Adult drinking at harmful levels
Any under-age alcohol consumption
Cigarette smoke, active and passive
Sedentary lifestyle
Not joining local organisations & groups
Low recreational participation
Sub-standard housing or neighbourhood
Worklessness in adults of working age
Living alone
Adults abstaining from alcohol
Teenagers taken to school by parents
Teenage use of parents’ car transport
Teenage recreation at home
Adult mistrust of teenagers ‘hanging around’
Parents’ mistrust of non-household adults
High adult time commitment to work
Staying in at night
increased
reduced
RISKS
Delivery Plan: Short, Medium and Long Term Focus
Health and Wellbeing Strategy Framework
Health Outcomes Frameworks Alignment:
Public Health, NHS and Adult Social Care
Public Health
Adult Social Care and Public
Health:
Maintaining good health
and wellbeing.
Preventing avoidable ill
health or injury, including
through reablement or
intermediate care services
and early intervention.
Adult Social
Care
NHS and Public Health:
Preventing ill health
and lifestyle diseases
and tackling their
determinants.
Awareness and early detection of
major conditions
Adult Social Care and NHS:
Supported discharge from
NHS to social care.
Impact of reablement or
intermediate care services
on reducing repeat
NHS emergency admissions.
Supporting carers and
involving in care planning.
ASC, NHS and Public Health:
The focus of Joint Strategic Needs Assessment: shared local
health and wellbeing issues for joint approaches.
Outcomes Frameworks : Target Domains
Health
Services
Wider Social
determinants
Public Health & Social Care
Lifestyle &
Behaviour
change
NHS Public Health/Prevention Spend Transfer to LAs
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tobacco control;
alcohol and drug misuse services;
obesity and community nutrition initiatives
increasing levels of physical activity in the local population
assessment and lifestyle interventions as part of the NHS Health Check Programme;
public mental health services;
dental public health services;
accidental injury prevention;
population level interventions to reduce and prevent birth defects;
behavioural and lifestyle campaigns to prevent cancer and long term conditions;
local initiatives on workplace health;
supporting, reviewing and challenging delivery of key public health funded and NHS
delivered services such as immunisation programmes;
comprehensive sexual health services (this includes testing and treatment for sexually
transmitted infections, contraception outside of the GP contract, termination of pregnancy,
and sexual health promotion and prevention
local initiatives to reduce excess deaths as a result of seasonal mortality;
role in dealing with health protection incidents and emergencies (Annex B)
promotion of community safety, violence prevention and response; and
local initiatives to tackle social exclusion.
Next Steps
The Director of Public Health will carry out as core functions: -
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The overseeing of commissioning of drug and alcohol treatment services
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Work with local partners including the Police and Crime Commissioner, DWP, Housing, Prisons &
Probation
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Accountably to the Health and Wellbeing Board
Outcomes
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Abstinence
Prevention of drug related deaths and BBVs
Reduced Crime and re-offending
Sustained employment
Ability to access suitable accommodation
Improve mental and physical well being
Improved relationships
Capacity to be an effective parent
New Health and Well - Being Strategy
Health and Well- Being Priorities
Health and well-being services
Local Authority & Partners
NHS
Primary &
Social care (children and adults,Third sector Housing,
transport, Big Society Leisure, Education, Partnerships, Community
care
Economy, Social enterprises
General
population
Low level
advice
& support
Support
at home
Secondary
& Tertiary
care
Institutional
care
Specialist &
National
care
Acute
care
People choosing less dependent more cost-effective options
£20Bn gap
in funding
NHS “flat cash” funding