Question for Short Debate
My Lords, I am grateful to have the opportunity to raise the important issue of deaths related to drug poisoning. I thank the noble Baroness, Lady Walmsley, and my noble friend Lord Hunt for speaking on this today. The Office for National Statistics report on deaths related to drug poisoning highlights a number of concerns which I have been raising in questions and debates in this House for some time. I cannot begin to cover all these issues today. Suffice it to say that I have grave concerns that the Government’s drugs policy may have contributed to the increase in drug-related deaths in England. I am aware that this is a serious assertion and I hope the Minister will take my concerns with the sincerity with which they are meant.
Heroin is involved in more fatal overdoses than any other illegal drug. The most common form of treatment for dependence on heroin is opioid substitution therapy. Under this treatment, the street heroin to which a person has become addicted is replaced by a pharmaceutical substitute, usually methadone. The evidence is clear that this treatment can halve a patient’s risk of death for as long as they remain in treatment but, because relapse is common, the patient’s risk of death increases significantly when treatment ends. So the longer a patient remains in treatment, the better their chances of staying alive. However, rather than being evidence-based, I strongly suggest that the 2010 drug strategy reflects the Government’s concerns that there were too many people on methadone for too long—a point vigorously reinforced by the Work and Pensions Secretary, lain Duncan Smith, who said that he felt too many people were “parked on methadone”. Therefore the Government introduced a payment-by-results system to incentivise service providers to encourage drug users to more quickly complete treatment and achieve abstinence.
What is wrong, you may ask, with encouraging more drug users to become abstinent more quickly? Surely that is a good thing. However, UK and international evidence clearly shows that there are major risks in pressuring drug users to withdraw from treatment. The Government’s own Advisory Council on the Misuse of Drugs stated that there was strong evidence that time-limiting opioid substitution therapy would increase the rate of overdose death. Of course I understand that the Government’s decision-making must include public opinion and there is a fear of being seen as soft on drugs—there has been from every Government who have been in power. However, I know from working with drug users myself for many years that the first treatment a drug user receives must be about stabilising the chaos in their lives, and abstinence should be about providing the right range of treatment options at the right time. The evidence shows that heroin addiction is a long-lived condition, averaging around 10 years, so drug users must be ready to achieve abstinence, because if they relapse after they have left treatment they are at a high risk of fatal overdose, since their tolerance to heroin is obviously greatly reduced.
What has been the result of the Government’s approach? On a positive note, between 2011 and 2012 an estimated 8.9% of adults used an illegal drug. This is the lowest level of drug use since figures were first collected in 1996. The number of people who completed drug treatment, free of dependence, is at record levels. However, perversely, in 2014 there were 3,346 drug-poisoning deaths in England and Wales, the highest number since records began in 1993. Deaths involving heroin increased by almost two-thirds between 2012 and 2014, from 579 to 952.
More worryingly, Public Health England’s own network—the National Intelligence Network on the health harms associated with drug use, which exchanges intelligence on blood-borne viruses, new and emerging trends in drug use and drug-related deaths—reported in December 2015 that the number of drug-related deaths is increasing, and that the rate of increase is probably accelerating. Amphetamine and cocaine deaths have also been increasing in recent years. However, the network’s analysis showed that treatment is protective against drug-misuse deaths.
I have cited a number of facts and figures, but let me put a human face on this and highlight some wider impacts. A number of local areas have conducted their own drug-related death reviews. Some have found an increase in female drug-related deaths, some individuals are parents, some people were released from prison and needed further support and treatment. In fact, in 2010 I produced a national report reviewing drug treatment in prisons and highlighted the importance of ensuring good continuing care for vulnerable people leaving prison to prevent relapses and drug-related deaths.
More people had complex health issues involving repeated presentations to hospital wards and A&E departments. Some have mental problems requiring treatment and repeated admission to mental health wards. They have a dual diagnosis of substance misuse and mental ill health. Only last week, as the Minister will know, we heard that the number of deaths annually among mental health patients in England rose by 21% over the past three years, from 1,412 to 1,713. The number of those killing themselves or trying to do so has also increased, by 26%, from 595 in 2012-13 to 751 in 2014-15. I wonder how many of those people had a dual diagnosis.
In light of this, will the Minister agree to see if an investigation can be set up to look into the causes of the drug-related deaths and the mental health deaths, and to see how many had a dual diagnosis? I understand that an update of the UK clinical guidelines on drug misuse and dependence is expected this year. In fact, I thought it was going to be published by February. These are essential guidelines for all clinicians who provide pharmacological interventions for drug misusers as part of their drug-treatment programme. This is a positive move, but I strongly suggest that it is also time that the Government carried out not just an annual review but, more importantly, a full impact assessment of the current drug strategy. Will the Minister therefore agree to ask the relevant government department that a risk and impact assessment of the current drug strategies be carried out, ensuring that an evidence-based approach be developed that tackles the failures and weaknesses of the current strategy, including, obviously, reducing drug-related deaths; training, employment and housing for drug users; integrating prison and community services; and, as I have already mentioned, the important issue of provision of dual diagnosis?
Finally, we know that there is a major funding issue within the NHS, and this is having an impact on services that work for these vulnerable people. Drug and alcohol treatment are no longer part of the protected NHS spend, but will have to compete for resources in the much harsher local government public health environment, which is likely to result in a reduction in services. In fact, I have seen a reduction in services in many environments already.
As for mental health, suicides among people in touch with crisis resolution home treatment teams, which are there to support people in crisis to stay in their own homes rather than being admitted to hospital, have increased significantly. It has been reported that these teams have lost their funding and have been disbanded or merged into community teams. So their specialist function has been lost, at a time of increasing demand. We also know that the number of specialist mental health nurses has fallen by more than 10% in the past five years.
In conclusion, I ask the Minister to say in his reply what steps are being taken to tackle the lack of funding for drug misuse and mental health services, which deal with some of the most vulnerable people in our communities, particularly those with a dual diagnosis of drug misuse and mental health problems. Because I have the time, I shall also make one other point. I understood that the evaluation of the payment-by-results pilot studies was to be published either last year or early this year. Can the Minister update me on when publication will happen? I look forward to hearing from other noble Lords, and to the Minister’s response.
My Lords, I thank the noble Lord, Lord Patel of Bradford, for raising this important issue. The increase in the number of deaths from drugs poisoning is a matter of great concern, since every single death is an indication of failure—failure of individual services and failure of the system of health and care to look after that patient. I refer to “the patient” because my party has always believed that individual drug abuse should be regarded as a health issue, and is not always a police issue. The pushers and dealers, however, are a very different matter.
As has been said, although some are suicides, most of these deaths are accidental, caused by lack of knowledge of the strength of the drugs that people are taking, or someone’s lack of understanding of their own body’s ability to process the chemicals. I will return to that point later. Accidental deaths also occur when a person is not in full possession of his or her faculties and has a fatal accident. I have read the various reports that have tried to analyse the statistics, and that is clearly a very complicated and difficult task, because in many cases there are several causal factors and they are hard to untangle. Few of those who die from drug use have one single simple problem. About one-third of patients abuse alcohol as well as banned or prescription drugs, and many have mental health problems. There is clearly interaction between the various issues.
A recent report called “Solutions from the Frontline” by MEAM—Making Every Adult Matter, an alliance of mental health charities chaired by my noble friend Lady Tyler of Enfield—calculated that there are 58,000 people who face homelessness, substance abuse, mental health problems and offending behaviour, distributed all over Britain. Of course, not all of them are at risk of accidental death because of their drug problems, but clearly their risk rises because of their multiplicity of needs and the great difficulty that services find in reaching and helping them. The problems get worse because people experiencing multiple needs are also likely to live in poverty and experience stigma, discrimination, isolation and loneliness—and, of course, loneliness is a great mental health and suicide risk. Although the ONS report indicates a large protective factor when people are in treatment, which is encouraging to know, those services are suffering, as we have heard from the noble Lord, Lord Patel of Bradford.
I shall concentrate my remarks on dual diagnosis, and on offenders and ex-offenders. According to MEAM, people experiencing multiple needs often have ineffective contact with services, as in most cases services are designed to deal with one problem at a time and to support people with single severe conditions. This can mean that people with multiple needs are more likely to access emergency, rather than planned, services, such as going to accident and emergency rather than their local GP. Accessing services in this way is costly as well as risky: estimates suggest that costs for the 58,000 individuals nationally are between £1.1 billion and £2.1 billion per year. So it is absolutely vital that people who are registered as being addicted to drugs, especially the depressive opiates such as heroin, have their mental health needs assessed and addressed. This is not always happening, partly because of cuts and partly because of shortages of staff with the right experience. Many patients claim that mental health crisis services are not there for them and many have to wait far too long for routine therapies. I do not underestimate the difficulty of dealing with these patients but we must make more effort to do so, for their own sake as well as for the sake of the NHS budget.
The recommendations of the MEAM report include asking the Government to ensure that funding structures prioritise recovery and rehabilitation and allow local areas to develop a flexible response. As part of this, they should consider a new national focus on multiple needs. Locally, commissioners should be accountable for ensuring that local areas have joined-up services and identify where people with multiple needs could fall through the gaps. At the front line, services should involve staff and people with multiple needs working together in designing programmes and the environments where they are to be delivered.
As for drug-using offenders, of course there are a lot of treatment programmes in prison although we know that security in many prisons is poor and they say you can access any drug you like in most prisons. It should, of course, be easier to help addicts when you have them incarcerated in prison than it is when they are part of the general population, and a lot of good work is done. However, I am not convinced that the underlying mental health problems are always addressed in the same way. It is difficult for a lay person like me to understand whether it is the mental health problem that brings people to take drugs in the first place or the drugs themselves that cause mental health problems. I understand it can be either way round, but what matters is to accept that dual diagnosis is not always properly addressed; it is very risky, and we need to do something about it.
The other issue that I would like to raise is continuity of services after release. There is supposed to be a seamless transition into community services but too often that does not happen, perhaps because the services are not there, the person drops out, or the professionals concerned are too busy to work with each other and do not realise how important and effective that is. A very senior psychiatrist told me only yesterday that, if someone gets clean while in prison and then comes out and starts using again, they are at greater risk of dying. While they are under treatment their liver stops having to process the poisonous chemicals in the drugs, so it stops being able to do so. If an ex-offender then starts using again, they should be advised to start on a very low dose and build up, but actually they tend to go back on the high dose they were used to using before they went to prison. This is too much for the body to cope with and it kills them. The dose they were accustomed to before prison now becomes an overdose.
Obviously, we do not want ex-addicts to come out of prison to start again at all but, if they do, they should be made aware of the danger and they should have continuity of care until their rehabilitation is well embedded. Often a patient has very good motivation to keep off drugs but, if something goes wrong in their life, such as losing a job or becoming homeless, the mental health problems recur and they do not have the support or resilience to resist self-medication with drugs that make them feel better.
The mention of resilience brings me to my final point. The roots of mental illness often go back a very long way. We must address the issue we are debating today in the very long term. By that I mean that we need to focus on two things in schools: education about the harms of drug and alcohol use and prevention of mental ill-health among children and young people. We need schools to be able to recognise mental health problems and know how and where to get help. They should also positively promote good mental health and well-being and help their pupils to develop resilient personalities. Of course, we should also go even further back in life and provide mental health therapists in all maternity units and help new mothers bond well with their children, given the crucial importance of attachment to the child’s future mental health. I wonder whether the increase in deaths is not because more people are taking drugs—from what the noble Lord, Lord Patel of Bradford, said, that is not the case—but are we getting more mental health problems that push users over the edge?
Good mental health does not happen by accident any more than good physical health. Just as we need to foster good physical health through diet, exercise and avoiding risky behaviours, so we also need to be aware that good mental health can be fostered. This should be part of the healthy community plans of all local authorities as well as schools, but sadly it is often at the bottom of their priority list because they have the money to do only what is mandatory. But by ignoring this we are storing up problems for the future. I would ask the Minister to be kind enough to comment on the points I have made and let noble Lords know how the Government are dealing with them.
My Lords, I warmly endorse the comments of the noble Baroness, Lady Walmsley, and welcome my noble friend’s introduction to this very disturbing and important debate. We have all studied the ONS figures and noble Lords have already referred to the fact that the mortality rate from drug use has been recorded as the highest ever. My noble friend referred to how deaths involving heroin and/or morphine between 2012 and 2014 increased by almost two-thirds, while other figures from the ONS also show increases. It would be fair to ask the Government what their current analysis is of the reasons for that.
My noble friend has said that he is concerned that a change in government policy, because they felt that too many people were, as he put it, “parked on methadone”, has seen the introduction of an incentivised programme essentially to encourage drug users to complete their treatment more quickly and achieve abstinence. However, that has brought with it some perverse consequences. One thing it shows is that there are always risks in trying to incentivise clinical behaviour through some kind of payment or lack of payment, so we need to be very careful. What risk assessment was undertaken of the impact of this change, because it is important not only in itself but in relation to the future direction of government policy?
My noble friend asked two specific questions: whether the Minister will agree to set up an investigation into the causes of these drug-related and mental health deaths in order to see how many had been given a dual diagnosis and, as I have mentioned, a risk assessment of the decision to bring in, as he called it, a payment-by-results approach to discouraging the use of methadone. He asked for another risk/impact assessment of the overall current strategy, and I must say that I very much endorse his recommendations.
My understanding is that Public Health England is investigating the trends around drug misuse deaths. I have looked at its recent publication, but what I could not find was any reference to the issue raised by my noble friend—the policy change to payment by results. In the light of this debate, is PHE investigating that specific issue? Will PHE, which is after all a part of the Department of Health, explore that area?
My noble friend and the noble Baroness, Lady Walmsley, also talked about the issue of drug treatment funding and the role of local authorities. I was interested to see the NICE guidance, or at least the local government briefing it produced in May 2014, which provides a lot of good advice for local authorities. I know that advice to local government from NICE is not at all mandatory in the way in which a technology appraisal might be for the NHS, but what is the Minister’s analysis of how far local authorities are following that guidance? Do the Government or NICE itself have any responsibility at all to make sure that local authorities are doing the right thing here?
One then comes to the issue of funding. On Monday, the noble Lord again referred to the amount of additional money put into the health service. He will know that around half has come from other pockets of Department of Health expenditure, including of course the public health budget. Clearly, the concern is that there will be an impact on those services where we depend on local authorities for funding under a public health banner. Again, what assessment has his department made of the impact of the reduction in funding for public health on the kind of community services that are so much more important?
None of this can take place without echoing a concern around mental health issues more generally. We all signed up to parity of esteem. The Government have said that they are committed. I believe that they have issued instructions to clinical commissioning groups about mental health service funding, but word reaches us that the reality is somewhat different. My noble friend Lord Patel has raised an important, difficult specific point. It cannot be divorced from overall considerations about mental health policy. If one considers the four-hour A&E target that is not being met, we know that a lot of people who are coming to A&E one way and another have mental health issues. I cannot help wondering whether for CCGs to reduce funding to mental health services has not been counterproductive in terms of the pressure that it has put on other parts of the system. I accept that my noble friend has raised a specific, serious point. If the Government cannot answer the exact point today, I hope that they will agree to some kind of review so that we see the outcome.
My Lords, I thank the noble Lord, Lord Patel, for raising this issue. It is clearly hugely important. He said that this rise in deaths was a direct result of government policy. We should take that very seriously coming from someone who knows so much about the issue. I also thank him for warning me earlier about the likely thrust of his comments.
This debate is particularly timely as we are currently finalising our new drug strategy and thinking about what it needs to say in relation to this important issue. It will take a very close look at the impact of the current strategy. It is due to be published later in the year. The noble Lord’s comments today will certainly be taken into account.
We are especially concerned about the increase in drug-related deaths. Separately, Public Health England is now convening an inquiry into the reasons for the rise. I encourage noble Lords to give their views to PHE. A key part of its inquiry will be an in-depth analysis of the drug-death data. A national expert group will rapidly review the data, including the ONS data, and local experiences to better understand the causes of these deaths and how they can be prevented. That report is expected in a few months. This is not a Chilcot inquiry; it will be out in a few months, and it will include looking at dual diagnosis.
Although my comments today will largely cover England, since health is now a devolved matter, the PHE inquiry will look at experience in Wales and Scotland. Interestingly, both countries have widely differing results, so if there are lessons that we can learn from them, clearly we will do so. I will come back to the specific question about payment by results, if I can, towards the end.
As the noble Lord said, the ONS reports of 2013 and 2014 showed that registered drug-misuse deaths increased in England very significantly from about 1,500 in 2012 to 2,120 in 2014. They are a matter of huge concern and highlight the need for further national and local action. A small part of the increase might be explained by changes in the speed of registration of death. That is probably not significant, but it will be looked at in the PHE review. We are assuming that it will not be material.
Overall, fewer people are using drugs such as heroin. Those that do form an ageing cohort, which means that the health harms from the use of heroin are increasingly concentrated among older, more vulnerable users, particularly men aged between 40 and 49—the “Trainspotting” era, in a sense—and those who have not had recent contact with the treatment system. We may need to accept that because of their long-term drug use, the health problems associated with that and the recent availability of purer heroin, all of which can contribute to a much greater risk of death, deaths may still rise in future years, despite our best efforts to reduce them. Again, that is something that PHE will be looking at very carefully. This means that although overall drug use has declined in recent years and the treatment system has helped many more people to recover—some 70,000 in 2014-15—we need an enhanced effort to help these entrenched users and thus reduce the number of deaths.
Local authorities are best placed to be responsible for drug prevention and treatment because of their knowledge of the local population and its needs. They can approach a system on a place and local population basis, bringing together their experience of local employment, education, housing, social services and the like. That is the reason why this has been devolved to local authorities. Much improvement has been achieved, and the Government are determined to continue that improvement. We have therefore added a condition to the central public health grant which requires local authorities to further improve the take-up of the drug treatment services they provide and to achieve improved outcomes. I will turn to funding later on, if I can.
About half of the deaths involved opiate users. PHE analysis found that most of those who died from opiate overdose were not in treatment and, in most cases, had not been receiving treatment for some time. This emphasises the need to encourage drug users to engage with treatment services, because treatment has a protective effect, as the noble Lord referred to in his speech, and can help prevent deaths. It also emphasises the need for local authorities to ensure that vulnerable drug users outside the treatment system are given advice on how to reduce the risks from drug misuse and are encouraged into treatment—all the more so as heroin is becoming purer.
As mentioned earlier, Public Health England is convening an inquiry into the recent rise in drug-related deaths. The national expert group will rapidly review data and local experiences to better understand the causes of those deaths, how they interplay with other health issues such as mental health, and how those deaths can be prevented. We know that some parts of the country have much higher death rates than others, and PHE’s local centres are working with those areas to understand the factors contributing to those higher figures and what can be done to reduce them: for example, by spreading best practice.
We have also asked PHE to work with local authorities to make sure that services are available to anyone who needs them. So PHE is working with local commissioners and providing them with expert advice, evidence and management information, including outcomes and value for money data. This helps to ensure that services are evidence-based, effective, available, integrated with local health services and supported by local housing and employment policies.
In October 2015, we changed medicines regulations to widen the availability of naloxone. Naloxone is a medicine that almost instantaneously reverses the effects of opiates, and we have made it easier for drug services to supply naloxone to more people who might witness overdoses and could use it to prevent overdose deaths.
Turning to prisons, the thematic report by Her Majesty’s Inspectorate of Prisons, Changing Patterns of Substance Misuse in Adult Prisons and Service Responses, published in December 2015, acknowledges that substance misuse treatment provision in prisons has improved very significantly over the past 10 years. I am told that there is strong evidence that evidence-based commissioning by the NHS has had a positive impact on prison health more generally, as well as in this area.
PHE, NOMS and NHS England are working together under the auspices of the National Partnership Agreement to tackle the new challenges presented by new psychoactive substances and the misuse of prescribed medication. PHE recently published a toolkit for custody and healthcare staff to support their response to NPS and is currently delivering a national training programme across the prison estate.
PHE is working closely with the National Offender Management Service and NHS England to improve “through-the-gate” arrangements between prison and community services, including improved commissioning of services. It is also using new post-release supervision arrangements and licence conditions to make sure that prisoners are more effectively engaged in drug treatment after release. As the noble Baroness, Lady Walmsley, said, when people have been off drugs and then come out and go back on to drugs, that can have very severe consequences.
As I mentioned earlier, engagement with good-quality drug treatment has a protective effect. It stabilises people and helps to improve their physical health and well-being. For example, people in treatment for their opiate use are less likely to inject drugs, experience overdose or transmit blood-borne viruses such as HIV and hepatitis C. People in treatment are also more likely to be tested and treated or vaccinated for blood-borne viruses. There were nearly 300,000 adults in contact with treatment services in 2014-15. Over half of the 130,000 patients who left treatment in 2014-15 had successfully completed their treatment free of dependency. This is an improvement on past performance and is helping people to achieve their potential and live a fuller, more rewarding life.
We have commissioned and received advice from the Advisory Council on the Misuse of Drugs about the contribution that opioid substitution treatment such as methadone can make to helping people recover. This is not in the least at odds with long-term prescribing of methadone to protect the health of those who are not able, or not yet able, to achieve full recovery. A question was raised as to whether at the time the policy was implemented—in 2010, I think—an assessment was done of the potential perverse consequences of that policy. I am not aware of whether such an assessment was done, but I can revert to the noble Lord about that afterwards.
Over the last decade, treatment outcomes have steadily improved, but have slowed in the past couple of years, most likely because the people remaining in treatment are those with more entrenched drug use and long-standing and complex problems. This is why recovery remains at the heart of our approach, with the key aim to support people to free themselves from drug dependency for good. We have moved our focus beyond the treatment system, to look more holistically and to include factors that help people recover from drug dependency and fully integrate back into the community.
We know that mental health can be a particular issue for many drug users. Some may use drugs as a form of self-medication for a mental health problem. Some will find that drugs exacerbate or cause mental health problems. PHE is encouraging substance misuse and mental health commissioners to work together at a local level to ensure that the services they commission are responsive to the needs of this client group, and there are clear specifications and transfer arrangements that describe how they will be effectively co-ordinated and delivered. I do not have time to talk about prevention; I thought I would have more time but I have only two minutes left.
The issue of funding is an important area. The noble Lord, Lord Patel, mentioned that the number of specialist mental health care nurses was down 10%. This reflects a more fundamental problem that over the past five to 20 years so much of the budget has gone into acute care. Community and mental health care has unquestionably suffered over that time. It illustrates a much broader problem. It is clear from the mandate of NHS England that parity of esteem is a key part of our policy over the next five years. Each clinical commissioning group’s spending on mental health will increase in real terms. There will be more money available for mental health care.
However, it will still be tough. There is not a lot of money in the system, but we are prioritising mental health care, and I think that, together with the public health grant, which is ring-fenced in local authorities, there will be resources available to tackle what I accept is a hugely difficult, complex and, as we have seen from the figures today, tragic area in which society, not just healthcare, has so dismally failed.
Briefly on the PBR point, the DH has done an evaluation on the payment by results pilots for drug and alcohol recovery, which will be published later this year. The preliminary evaluation, which is already published, suggests that the pilots did not lead to inappropriate pressure to discharge people from drug treatment—but it is preliminary and the full results will be published later in the year. I was going to say a little more about prevention but we can discuss that at another time.