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Home Affairs Committee - Drugs: Breaking the Cycle - Minutes of EvidenceHC 184-II
HOUSE OF COMMONS
TAKEN BEFORE THE
Home Affairs Committee
Tuesday 21 February 2012
Paul Tuohy and Maryon Stewart
Wendy Dawson, Dominic Ruffy and Adam Langer
Professor John Strang
Evidence heard in Public Questions 88 - 164
USE OF THE TRANSCRIPT
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Taken before the Home Affairs Committee
on Tuesday 21 February 2012
Keith Vaz (Chair)
Mr James Clappison
Dr Julian Huppert
Mr David Winnick
Examination of Witnesses
Witnesses: Paul Tuohy, Mentor, and Maryon Stewart, the Angelus Foundation, gave evidence.
Q88 Chair: This is the next session in our inquiry into drugs, and I welcome Paul Tuohy and Maryon Stewart who are giving evidence to the Committee. Could I ask members of the Committee to declare any interests that are not in the Register of Members’ Interests?
Nicola Blackwood: I am a patron of the Ley Community, which is a residential rehab centre in my constituency.
Chair: Thank you. Mr Tuohy, Mrs Stewart, thank you very much for coming to give evidence to the Committee. I am sure you have read the terms of reference of the Committee. This is quite a wideranging look at drugs and the Committee is very keen to hear from both of you about what your organisations are doing, especially with the focus on education. Mr Tuohy, do you think we have it right as far as drugs education is concerned or is there more that we can do?
Paul Tuohy: Do we have it right? Absolutely not. Is there more we can do? There are vast amounts more we can do.
Q89 Chair: What?
Paul Tuohy: First of all, I think it was a great shame that the issue around PSHE in schools did not make it as a statutory requirement.
Chair: You need to explain what that means.
Paul Tuohy: Personal social health education is the area where young people are taught about sexual health, drug education and so on and so forth. It is not a mandatory requirement in schools, therefore it hardly gets taught. Our estimate at Mentor is that 60% of schools do PSHE for one hour a year, if at all, and partly the reasons for that are obviously the fact that teachers have an awful lot to do in their curriculum, but we feel very strongly that the rest of the curriculum would be greatly enhanced if the protective factors of good PSHE was brought into the curriculum, firstly, to be statutory, and secondly, that the teachers were given the proper training to deliver good PSHE. Ofsted, in their recent report, did not give one school an outstanding mark with PSHE, not one. That is a disgrace.
Q90 Chair: You have visited the United States and you have looked at some of their prevention techniques, and the focus of your organisation is very much on prevention, I believe. What can we learn from them? This Committee will be going to the United States to look at their programmes, but is there something particularly you would like to draw our attention to in respect of what they are doing on prevention?
Paul Tuohy: We went to Washington to look at some community-led programmes there. In the States they are looking at how prevention itself can be ingrained, not just from an educational point of view in a school but in a whole community, so from the policing establishments through to the schools through to parents, and it creates a different change in culture. From where we are, I think we are not at first base yet. One of the key areas for us at Mentor in terms of the learnings we have was simply to make sure that there are evidence-based programmes put into the schools, which they have a lot more of in the USA. Nearly all the research that we draw upon for evidence-based programmes comes from the USA. We hardly do any research here.
Having said that, on the positive side we do know that there are some very good programmes such as the Good Behaviour Game, which has been running in the United States for many years. The Good Behaviour Game works with children from the ages of five to seven or eight, and it builds up preventative measures that can build up that resilience that they need for the rest of their education. A study over 15 years showed that with children who went through the Good Behaviour Game, against those who did not, there was something like a 60% difference of those who obtained a university place to those who did not. The interesting thing about that particular programme is that it does not talk about drugs at all, even though that is one of the resilience factors it is building up. It is just building up resilience of youngsters to do well in terms of their aspirations and so on and so forth. If you have a child coming in to education at age five who is bouncing off the walls and needs to calm down, the Good Behaviour Game is giving techniques to teachers to do that, and consequently the children are easier to educate and they become better pupils.
Q91 Chair: Mrs Stewart, it is now three years since the death of your daughter, Hester, which of course led you into this whole area, and on behalf of this Committee our condolences. This is a terrible loss, which you must still feel very strongly indeed after this period of time. Do you think that our approach on education is the right approach or do you agree with Mr Tuohy that much more needs to be done as far as young people are concerned? Your daughter died at the age of only 21.
Maryon Stewart: Yes, she died in April 2009. It has been a very big learning curve for me since her death. I had absolutely never even heard of a legal high when she died, and my first intention was to try and get things banned, which we did, and the Angelus Foundation was formed, but we very soon came to realise that banning was not the way to travel, because as fast as you do that there are new substances-the molecules are tweaked and new substances go on the market. From our perspective, we now have a group of over 20 world-class experts on the Angelus advisory board, and our joint perspective is that the only way to deal with this awful epidemic is to educate and raise awareness.
Q92 Chair: At what age do you think it should start?
Maryon Stewart: I think the research shows that the earlier the better. As Paul was saying, there are programmes for kids as young as five and six, but equally there are programmes-there is a programme called Preventure, for example-that aim at young teenagers, and that has also been shown to dramatically reduce the use of drugs and alcohol. The thing that really shocked me, I suppose, on this learning curve, is that there have been some interventions put in place in the not so distant past that have had negative outcomes-in other words, they have resulted in more kids taking drugs. In this day and age I understand that the Government are not giving direction to the regions but I very strongly feel that in this case there should be some direction because I don’t think the regions can be expected to know the difference between a positive intervention and a negative one.
I have had lots of meetings with lots of Ministers. I have even had emails from the Prime Minister offering support for all that the Angelus Foundation stands for, all that we are hoping to achieve, but what I see very clearly is that the Departments are all passing the buck.
Q93 Chair: Do you think there are too many Government Departments involved in this and therefore there is a tendency, for example, for the Home Office to say it is a Health Department issue, and the Health Department to say it is an issue for somebody else? Do you think that is the problem?
Maryon Stewart: That is exactly what is happening, and everybody is nodding and saying this needs to happen. There is good science to show that you can educate kids properly. There is good science to show that you can teach parents how to have wise conversations with their children. There is plenty of information out there, but the Departments do pass it from one to another. We have been speaking to Baroness Meacher and her All Party Group on Drug Policy Reform, and we are looking at talking about the French model, where they have a separate Ministry that gets its own independent funding and reports directly to the Prime Minister. Since they have had that in France, they have had a dramatic reduction in deaths and harm from alcohol and drugs. I think that that is going to be the way that we should be thinking in the UK, because even President Obama said last year that the legal highs and party drugs have now reached epidemic proportions.
Q94 Chair: Going back to the legal highs-and this is a final question to you on this issue-it took you a long time to ban GBL. Do you think that that process ought to be speeded up?
Maryon Stewart: Yes, we had hoped that it would be done by this-
Chair: How long did it take in the end?
Maryon Stewart: The statutory instrument should have been done within a matter of 72 hours, but the problem was that the Home Secretary had already entered into a dialogue with the chemical industry and therefore had to wait for three months, and then Government went into recess. Eventually it did not happen until later in the year, so it was about six or seven months. The problem is, what is happening now is that there is a special banning order in place so that things that look suspect can be banned, but you are talking about a year or two years. We are on the back foot. I happen to know that there is a warehouse in Manchester that supposedly has 400 substances in there. The people who are selling them are living footballers’ lives. Our kids are going out thinking that this stuff is safe and taking it for fun. They are being pushed into it by their peers because they don’t know any better, and we have not taught them any better.
Q95 Chair: What should be done about that? Is it a failure of the police? Is it a failure of the local authority?
Maryon Stewart: I don’t think it is a failure of any one person in particular. I think the fact is that we as adults, we as wise people, Government Departments and individuals, should get together and work out the best way to sort this situation out, because it really is not being sorted out. In fact, at the House of Commons on 5 March we are announcing our forthcoming Wise Up campaign.
Chair: This is the Angelus Foundation?
Maryon Stewart: Yes.
Chair: Very, very helpful.
Q96 Dr Huppert: Firstly, if I could declare what I should have declared earlier, that I am Vice Chair of the All Party Parliamentary Group on Drug Policy Reform with Molly Meacher as well. Just to be very clear, the Government’s drug strategy states that all young people need high-quality drug and alcohol education. I suspect I will receive a yes or a no-is this currently happening?
Maryon Stewart: No.
Paul Tuohy: Absolutely not.
Q97 Dr Huppert: That is what I expected. I just wanted to make sure that we were very clear on that. There was an interesting conversation there about who leads on drug policy. Currently, Britain is quite rare in Europe in having a Home Office or equivalent lead. Do you think that inhibits the ability to do proper drugs education and it should be refocused either in the Department of Health or in a separate ministry?
Paul Tuohy: Picking up on what Maryon said, if you start talking at the end part of the issue when it has already manifested itself in terms of recreational drug use and legal highs and so on, you have young people who are taking substances they know nothing about, young people binge drinking when they don’t understand quite what they are doing, this all boils back to what we are doing with young people almost from the moment they are born. It is about our culture and behaviour. The Government has made it very clear that they are in favour of really strong, good drug education. What I am wondering is where is the evidence for that. The Drug Education Forum, the main central repository for information in this country about drug education, introduced by the Conservatives in 1995, is set to close next month through lack of funding, for just £80,000, a drop in the ocean.
We are looking at prevention programmes that have been about for many years that we have been pushing at Mentor. Preventure was already mentioned by Maryon. We have been trying to get Preventure into schools for a number of years and we have not succeeded. I think at the moment the culture appears to be that the Government is very interested in treatment, which we would say is great, but we have 320,000 drug users, costing maybe £15 billion. That is an area you need to tackle, but if you put all your money into treatment, you are not turning off the tap in terms of prevention, because for every one that you get off drugs another one is ready to come in. That is why we need to see a consistent programme in schools, from the age of five all the way through, not just a one-off programme like the Good Behaviour Game. With other programmes, for example with the Department of Health and their Responsibility Deal, Mentor have put together the best four or five programmes that we consider are available in the UK and we are saying to the Department of Health that as part of that Responsibility Deal, "This is what should happen", because at the moment we are not doing any of those. We are spending the vast majority of the money we do spend on drug education on programmes that don’t work.
Maryon Stewart: I agree totally with that. I was talking to Paul outside before, and he mentioned that it would cost an extra £500 per child to educate them on drugs, and when you think of the fact it may cost in the region of £1 million for each child who goes down the drug route by the time they are 30, you don’t have to be a mathematician to know that it is a good idea to invest that £500.
Q98 Dr Huppert: Would you support diverting resources from the policing of low-level use-still keeping a focus on organised crime and the major dealers-towards investing in both treatment and better education?
Maryon Stewart: Sorry, I am not quite sure what you mean.
Dr Huppert: There are finite resources. Currently a lot of money is spent on policing and the criminal justice system for relatively small-scale users as well as organised crime. If one diverted the resource that was used to pick up people with small amounts, that sort of scale, if that money was diverted into education programmes, treatment programmes, is that something that you would support?
Maryon Stewart: Yes, I think that would be useful. Also bear in mind how much it costs for an ambulance callout. We worked out that if we saved just 100 ambulance callouts a week and 100 hospital beds a week, we would be saving nearly £4 million a year just on that, and then I saw a statistic last week in the press about 200,000 kids being admitted to hospital for alcohol-related problems. You would be saving vast sums of money. I think if someone did the sums, you would not be spending any more money, but you would be educating kids, and allowing them to fulfil their potential in life and to live happy lives. The side effects of some of these horrendous substances is absolutely beyond belief: psychosis, flashbacks, depression, heavy nosebleeds, difficulty breathing, and I have even interviewed kids who are now in wheelchairs as a result of having their drinks spiked. It is truly horrendous.
Q99 Chair: I am still thinking of this warehouse in Manchester, but of course all these substances in the warehouse in Manchester are legal.
Maryon Stewart: They say they are legal, and that is another problem, because our toxicologists are of the opinion from the little testing that they have done-they are limited again because of lack of resources-that very often these substances are a combination of class B drugs and other chemicals. They don’t have proper labelling, and also the contents vary from batch to batch and month to month and region to region. So we don’t know what our kids are taking, and they are literally playing Russian roulette with their lives.
Q100 Michael Ellis: As you have acknowledged, it is clear that the Government are in favour of drug education and have been vocally supportive of improving education when it comes to the misuse of drugs, but I think most people would accept that Governments have not historically been terribly good at getting messages to young people about drug abuse, and in fact communicating with young people on such subjects is very difficult to do. Would you accept that?
Maryon Stewart: Yes.
Q101 Michael Ellis: The question I would ask both of you is, what would your advice be about how best to get the message to young people about drugs? When do you think it should start? When do you think it should finish? In what avenue do you think the message should be transmitted? Should it be transmitted at school? Should it be transmitted by television messages or some other format? Can you elaborate on that?
Maryon Stewart: Do you want to talk about schools and I will talk out of schools?
Paul Tuohy: Yes, fine. If I start with that one then, it is a very good question. I am so pleased you asked it. I think first and foremost what we have at the moment is people going into schools ad hoc, police officers, ex-users, weird organisations, and the schools will just say, "Come on in," and that is because they are not trained to do it themselves. So when it comes to drugs, "Yes, come in and do that." We know at Mentor that, as all the research-well publicised-shows, this does not work. Even now we are hearing some concerning stories from ministerial level about ex-users, people who are off treatment, going in to talk, and this kind of intuitive thinking is well-meant but it is not the way to go, in our opinion.
The best people to deliver drugs education in schools are the teachers, because they do other subjects really well. They do maths and English and French very well, but you don’t ask the French teacher to go in and teach maths, but because PSHE is not a fully trained, recognised subject, there is a problem. It is a really simple fix. We were that close to PSHE becoming statutory a couple of years ago. That needs to be put back on the agenda.
Q102 Michael Ellis: What stopped it from becoming statutory?
Paul Tuohy: I think the slight change in Government might have had something to do with it. All I am saying is that the political will was there, and I don’t know in terms of the process-Keith, you will know far better than me-but it was right on the cusp and it did not happen, and we would urge that to be relooked at. That sends a message to teachers, and teachers are very good, the education system is very good, at picking up a lead when Governments say things like that.
Q103 Michael Ellis: I think you were going to answer the-
Maryon Stewart: Yes, I was going to do the out of school bit. I agree with you totally. I think it is a very big challenge and I have come to understand in the process of all this that there are different voices for different age groups. What we are looking at doing at the moment is, we have made a whole series of films of kids that have been harmed and bereaved families and so on, and we have been going into schools and surveying to see which kind of thing touches different age groups. We are in the process of doing that at the moment, and we are doing focus groups, because I just don’t think it has been done before. What we are trying to do is find something that won’t shock the kids, because we know that shocking people does not work, but will touch them to the point where they will rethink.
Q104 Michael Ellis: Yes, because one has to be careful. You have already alluded to the negative outcomes, and sometime when Governments and very large entities try and communicate with young people it has the reverse effect of that which is desired. It makes something cool or fashionable.
Maryon Stewart: Yes. We are working with a group of young people and other charities that look after young people to do the focus groups and the surveys, and then to put together a programme that is run by young people for young people.
Q105 Michael Ellis: Just very quickly, are you in touch with the Prince’s Trust, for example?
Maryon Stewart: Yes, the Prince’s Trust-
Michael Ellis: It is an excellent organisation.
Maryon Stewart: They have asked us to train their trainers and they are testing our material for us. We are working with a number of charities including Youth-
Q106 Nicola Blackwood: I was interested to hear your comments about your opposition to ex-users going into schools. Obviously that needs to be carefully managed, but can you explain to me why pupils hearing first-hand experiences of the damage that drug use does would be bad for students?
Paul Tuohy: We are running a programme called the London Youth Involvement Project at Mentor at the moment, and we had a seminar last week. This is a programme where we listen to teenagers about what they think about drugs education. It is something we have been running with the Cruddas Foundation who have supported it for two years. We invited health professionals, teachers and so on, and they ran the seminar and they told us what they wanted. I am not a 15-year-old and so I can’t answer that from their perspective, but what they said, in terms of answering your question, is that the kind of information they get about an ex-user’s experience does not build up any resilience to them coping with the peer pressures that they might be under in certain situations to get involved in drug taking.
What they want is not to have education that talks about, "This is a class A drug and this is a class B drug, and take a look at it. This is what it is. It can be bad for you and I used to do it but I am okay now." That does not work in terms of protective measures for young people. What we have to do is look at what evidence there already is out there where programmes like Preventure, like the Good Behaviour Game, Unplugged-
Q107 Nicola Blackwood: How much evidence is there associated with the outcomes for these programmes? How many studies have there been? Are they available? Are we able to see them? It would be very helpful.
Paul Tuohy: Substantial evidence. Yes, all available. Yes, you can, absolutely. For example, the Preventure programme, which is a targeted intervention, was trialled in Thamesmead in southeast London to 2,000 children. They were tracked over two years, and that stopped the onset of their first alcoholic drink or drug taking by 30%. There is no other programme-
Q108 Nicola Blackwood: How was the reporting done? How did you know whether they have-
Maryon Stewart: It is all published in medical journals and peer-reviewed.
Q109 Nicola Blackwood: It is published, yes, but how did you find out whether they had or had not taken their first alcoholic drink? Did the students self-report?
Paul Tuohy: That was part of the study. These are clinical studies.
Maryon Stewart: There were psychologists involved in the study, and they were properly surveyed.
Nicola Blackwood: Psychologists. I am just trying to understand.
Maryon Stewart: Those programmes are now being implemented in Canada and in Australia very successfully.
Nicola Blackwood: That is very interesting. Thank you.
Q110 Alun Michael: You gave the example that there is not a single department or agency to deal with drug use and abuse, and Paul Tuohy mentioned earlier that you believed there is too great an emphasis on treatment. Creating a single agency implies a single budget and therefore priorities. On the one hand, that implies being joined up about how you deal with drugs policy but, as I say, it also involves priorities. What sort of proportion of spending on drug policy do you think should be in the education pocket, and how do you think we should be joined up about that and other aspects, for instance of getting people quickly into treatment?
Paul Tuohy: If you look at the costs in terms of the health costs, the sort of money we are talking about is quite extraordinary. I think that has been well documented. I don’t think it is a question of more money. This is a question of where you are spending existing money, and I think the fact of the matter at the moment is that we are spending existing money in areas that are not effective. I think it is more about looking at the areas that are not effective and moving into the new areas that we are suggesting here, to find that budget from the educational point of view.
Q111 Alun Michael: Could you spell that out for us? What would you stop doing and where would you put the money?
Paul Tuohy: I don’t know specifically what Government budgets are spent on the NHS that are not working. What I do know is that, in the treatment area for the last five years, we have had the same number of drug addicts, 320,000. That has not moved. So, something there is not working, and when you look at the extraordinary cost of that it would take only a tiny percentage of that to be diverted into education to stop that influx of people. It is £71,000 to educate a person in this country but for £500 more you could have protective measures in drugs education.
Q112 Alun Michael: When we looked at justice reinvestment, in other words are we spending money in the right way, as part of a piece of work by the Justice Select Committee a couple of years ago, one of the lessons appeared to be that people have to wait too long to go into treatment rather than being straight into treatment, for instance when a problem is identified, whether it is by the police or a court. So, if you like, the money was being spent but not necessarily on the right people receiving it in a timely manner. You are suggesting a shift from health into education, but what guarantee is there that that spending would be effective in having the outcome that you are suggesting would follow?
Paul Tuohy: The guarantee, for what one can say, is that all of the clinical studies done on the preventative education programmes, which are currently sitting on shelves not being used, when they were trialled showed significant-I am talking 30%, 40%-reductions in young people taking drugs or drinking alcohol. The fact at the moment is that we don’t do any of it. We don’t have PSHE as a mandatory subject to send the right messages to teachers. We do not have teachers trained to deliver it. It is all there waiting to happen and it would not cost a lot of money, and you would start to get your returns very quickly.
I think one of the issues might be if in a course of a term of Government you are there for five years and you want to make an impact, it would make reasonable sense to say, "Let’s get involved in the treatment agenda." I think treatment is incredibly important. We have a big problem with it and we need to put money into but, for example, one of the biggest NGOs that looks at treatment has a turnover of £40 million. Mentor is one of the biggest organisations that look at prevention. We are £500,000. That in itself says a little bit about the landscape, about what we know and understand about prevention measures.
Q113 Alun Michael: Inevitably there is a level of generalisation, so it would be useful, perhaps, if you were to point to the specific examples and specific studies that lead you to that conclusion.
Paul Tuohy: Specific examples-
Alun Michael: I did not mean necessarily now. If you can-
Paul Tuohy: Sure, absolutely.
Maryon Stewart: I think the other point to take into consideration is that treatment for conventional drugs is one thing, but one of the members of our group, Dr Owen BowdenJones, who is the chair of the addictions faculty at the Royal College of Psychiatry, got some funding last April to set up the first club drug clinic at the Chelsea and Westminster Hospital. So he now has a resource there for young people and their parents where they can self-refer and get help. One of the difficulties is that a lot of these new substances are addictive and they have awful side effects, and the kids have nowhere to go to get help, absolutely nowhere. That is something else that we need to look at.
The parents are just bemused and bewildered, and the kids themselves-in fact, one of the toxicologists said there has been an increase in the incidence of hanging. There have been a lot of young deaths associated with that, and they suspect that it may be attributable to some of these substances. The fact is we don’t know what the long-term harms are because there is no research, but there is a whole generation of kids waiting to go down the drug route and cost the taxpayers a fortune. If we can work out how to implement some of these interventions and turn them around so they have a different mindset, we will be protecting the next generation and saving a fortune.
Q114 Mr Winnick: In your written evidence to us you conclude by being very critical of Government policy. You say that what has happened is a terrible indictment of successive Government policies. Can you explain why, in your view, Governments, whichever political colour they have been, have not tackled this problem your colleague has just being speaking about, and you previously? Do you think it is because Government does not consider this a matter of priority?
Chair: Mr Tuohy, Mr Winnick has invited you to look at successive Governments’ policies. Could you do it very briefly, because we have other witnesses? Like 60 seconds.
Paul Tuohy: Indeed, 55 now.
Mr Winnick: Is that the amount of time Governments have spent on the problem?
Paul Tuohy: In brief, successive Governments have not looked at what is under their noses, that there are good preventative education programmes there. There are outstanding programmes, which have been well researched, which don’t cost much to implement. Currently a drug user in the course of their life costs £820,000 to society, and if we can start spending £500 in terms of good protective education to stop that, then we should be doing it. All I am saying is that successive Governments have ignored the facts. They have ignored what is under their noses. They have ignored what organisations like Mentor and the Angelus Foundation have been saying, and it is time that they started to take a closer look and work with us in a much stronger way, to stop the words that we have been hearing but start putting some real hard practice to work. It won’t take long and we will have far better protected children as a result of it.
Maryon Stewart: There has been such a huge turnover with the Minister for Crime Prevention and Drugs, if you look at the Home Office. We worked with James Brokenshire for an awfully long time, but since he went there have been two new people in post and before him there were numerous people, so there is no consistency. Nobody gets to know the area and really brings about major change.
Q115 Chair: Equally briefly, do you think that there is an argument for the reestablishment of the drugs tsar post, where there is somebody who you can go to who coordinates all this policy? At the moment, as you say, it seems a bit fractured.
Maryon Stewart: Yes, that is effectively what would happen with this separate ministry and it would have its own budget, which means it would be able to fund some of these positive interventions that we are talking about so we can turn things around.
Q116 Chair: Mrs Stewart, you have paid the ultimate price as a parent, your daughter has died, and you have set up this organisation to try and alert other people to what has happened and what may happen. Are you confident that if the kinds of policies that you and Mr Tuohy have suggested to this Committee were in place, Hester would still be alive today?
Maryon Stewart: Yes. If there had been adequate information at the time, as there was in France and Germany-they had poster campaigns saying that GBL plus alcohol equals death-and if the Home Secretary had done something similar in this country I do believe my daughter would still be alive.
Chair: I am sorry, we have run out of time. Mrs Stewart, Mr Tuohy, thank you very much for giving evidence. We may write to you again to get further information from you, but thank you. Please keep in touch with us. Thank you. Sorry, Mr Winnick, we have to move on.
Examination of Witnesses
Witnesses: Wendy Dawson, Chief Executive, the Ley Community, Dominic Ruffy, Rehab Grads, and Adam Langer, gave evidence.
Q117 Chair: Ms Dawson, Mr Ruffy and Mr Langer, thank you very much for coming to give evidence today. It is always difficult when we have three witnesses on the panel and a very short period of time, about 30 minutes. Please feel free to contribute to each of the answers that the Committee is seeking, but if you could be succinct and to the point we would be most grateful. We will try and do the same in putting our questions.
Mr Winnick: Including the Chair.
Chair: Indeed, especially the Chair. I can start with a very simple question about rehabilitation. Is residential rehabilitation the best way to deal with the treatment of people with drug problems? Mr Langer?
Adam Langer: If you want to save money in the long term, and if you want people to reestablish socially integrated lives in society, yes.
Q118 Chair: Mr Ruffy?
Dominic Ruffy: I would say absolutely, if what you are seeking is an excellent recovery outcome. The residential rehabilitation gives you that in a time-limited fashion versus community treatment, where there is no time limit. So residential rehabilitation gives you what you want in a very cost-effective and time-limited manner.
Q119 Chair: Ms Dawson?
Wendy Dawson: Residential rehab is effective because what we do is we look at addiction-we don’t just look at the drug or the alcoholic substance, we look at addiction, so it is effective. It is an opportunity for people who want real recovery to live safe in an environment for a substantial period of time in order to address the issues that led them to the substance misuse in the first place. It is the beginning of the process of a path to recovery and it is also the beginning of an understanding of right living, which is critical, and the best place to get that is residential rehab.
It is all about a balanced treatment system but residential rehab has been neglected and it is the only footing that people can start to understand right living, be abstinent right from day one and have a holistic introduction to addiction rather than just a substance.
Q120 Chair: Mr Langer, can I ask you a question about what made you turn to drugs. I realise that you have transformed your life since you originally became an addict. What was it that got you involved in drugs?
Adam Langer: At the time, I had no reason. I didn’t understand why I was motivated to do it. It just seemed like fun. Then in retrospect, and I have spent thousands of hours listening to the testimony of addicts, I find all of us have traumatic stories of one sort or another. I was listening to the education debate earlier, and education is key. I will give you an example. I worked for supported housing and took someone who was in an appalling state into a school-not a recovery champion; to be a recovery champion, you have to become a drug addict first, so you are saying, "If you want to be like me, you have to use drugs," and maybe that does not work. What we heard back from the school was how many of the children identified with things like sexual abuse and difficult home backgrounds and began to speak about these things. Methadone and the level of psychosocial interventions that are happening in the community don’t meet that need, and so, while it is really well-intentioned and it is a good harm reduction strategy, you are just building a bigger and bigger car park of people whose problems you have not dealt with.
Chair: Thank you, that is very helpful.
Q121 Mr Winnick: The number of referrals to residential rehabilitation has dropped, as I understand, quite dramatically in the past five years. Can any of you, or all three of you, give any explanation why that in fact has been the position?
Dominic Ruffy: I think you have a treatment system that for a very long time has been focused on substitute prescribing, methadone maintenance. Within that there is no exit strategy. There is no desire to have people leave treatment drug free and there has been no focus on that. When service providers were asked to start providing that service, to maintain the number of clients they had within their service, they sought to do that themselves and they do not have the expertise for the recovery people working within their organisations to deliver that outcome. Consequently you have a treatment system where the majority of providers do not want to refer on, because they will lose their client base and therefore lose their turnover and income, and therefore the residential treatment centres have suffered as a direct result of that. Broadly, it is because you have had a system that has focused on substitute prescribing.
Q122 Mr Winnick: Mr Langer, do you want to come in?
Adam Langer: Yes, I think there is a very specific reason. The specific reason is that the NTA’s target is 12-week retention and so you have a target that is equally met by someone who, essentially, has just moved his drug dealer to being the state, and sits at home watching Jeremy Kyle, using other drugs on top. You are comparing that with people who are spending every day doing group therapy, one-to-one counselling, and in terms of personal development they are changing who they are ready to come out as, and because those things are being seen as equal it makes sense to go for the cheapest version of that. The whole focus has been wrong.
Wendy Dawson: The other aspect of why there has been a demise is the fact that the NICE guidelines say that residential rehab is a last resort. It is increasingly difficult for people to jump through the hoops once they are in a tiered system.
I have been involved in drugs services for 30 years and the tiered approach was never around in the 1980s when I was a practitioner, so it means that people are kept in treatment and the previous Government drove the drug strategy through an in-treatment model. As Adam said, it was about scripting people. The problem was that we did not script people with an exit strategy; we just continued to script people. It is not unusual for us at the Ley Community to receive a referral from somebody who has been on methadone for over five years and has never been offered the opportunity of residential rehab. That is the biggest difference within the last five years.
Q123 Mr Winnick: If I could put a somewhat different question to you, in the previous evidence we had we were provided with written evidence and the criticism was that overall, bearing in mind what many people consider to be the failure of drug policy generally, there has not been the ministerial control. Indeed, it is said there have been eight Drugs Ministers in as many years. Do you feel that if there was a stronger national position where the Minister responsible stayed in the post longer it would help in dealing with the matter?
Adam Langer: I think it is a level down where there needs to be better-
Chair: Sorry, could you speak up?
Adam Langer: Sorry. There is a level down where there needs to be greater integrity. I come from Devon. The Devon DART does not have a single person with any training on working with addicts, so you have mental health workers, social workers, probation workers, from my perspective chancing their arm at working with addicts. At the level of Government, yes, maybe they will effect policy, but the important thing is that there have to be better standards of who takes this work on. Our commissioner is designing the alcohol contract for the area. He has no training; he is a manager.
Wendy Dawson: If I could just back that up. We work currently across 23 local authorities, local authority DART areas. The majority of the commissioners have been attracted to become commissioners because they like the idea of working in a health and social care field. They don’t necessarily have an understanding, apart from an academic understanding, about addictions. If they have not been in the post over the past five years, their whole experience has been through maintaining people in a system rather than enabling people into recovery, which is what residential rehab is very good at doing. So we have not invested in workforce development to demonstrate that people are in recovery.
We have Rehab Grads, and Dominic is one of them. There is a massive population of people who are in recovery and the majority of those have sustained that recovery and have had an experience of residential rehab in order to attain that and sustain that abstinence. But the workforce that is commissioning services are unaware of these people because of the tiered system, so they continue to see people in tier 3 who are just involved in maintenance or, in fact, needle exchanges.
Q124 Mr Winnick: Mr Ruffy, do you want to comment at all?
Dominic Ruffy: I think it does require a top-to-bottom approach, so you do need somebody in post who understands the agenda and wants people in recovery. That person has to be in there for a long period of time. But as the point has been made by my two colleagues here, the workforce itself that is trying to provide the treatment at the moment simply does not understand recovery. It is not their fault, it is the system they have walked into. So a large-scale re-education of that system needs to happen and organisations such as myself and others that we are working with, like RIOT in Staffordshire, are doing a lot on the ground with those service workers to teach them about recovery. In the areas that is happening it is having a significant impact on the number of referrals into treatment.
Adam Langer: These people have been in place for a very long time together. For them the change is a really traumatic thing to their own identities and careers, so there is a lot of resistance on that level because they have been doing this for so long.
Q125 Steve McCabe: What is the average length of residential period of drug rehab?
Adam Langer: I believe it is 12 weeks.
Wendy Dawson: It differs. There are so many different interventions in terms of residential rehab. You have 12-step models, you have quasi-residential. In my own case, we are a therapeutic community and we are different levels. Again, if I look at my own intervention, that is a 12 months model. It is a therapeutic community and everybody is drug and alcohol free right from day one right through the programme. They finish the programme into fulltime employment, they move back into independent living and they are no longer in treatment. The NDTMS reporting suggests that if people are sustained in treatment for 12 weeks or more they will continue in their abstinence. Where the 12 weeks came from, I am not terribly sure. Perhaps Professor Strang, when he speaks later, will be able to inform us of that.
It is all about people. We have to remember the adage, they are people, they are not statistics, and they are not all in a homogenous group. You cannot just say that somebody will enter treatment and they will be clean and sober after 12 weeks. It is about addiction and that is where residential rehab comes into its own, because what we look at is a holistic person. We do not just look at the substance, as I said earlier. 12 weeks does not really say anything. For some people the penny doesn’t drop for three months, for six months, for eight months. So it is about matching that particular person to the right residential rehab and also any other support systems that that person needs to tackle the addiction.
Q126 Dr Huppert: Firstly, in terms of residential rehabilitation, how much has it changed since the 2010 drug strategy came out? Has it made any difference?
Adam Langer: Not to the people-
Dominic Ruffy: No.
Wendy Dawson: I think what has changed is the level of referral and the inappropriate level of referral. What has happened is that we have certainly experienced a kind of panic, that suddenly the workforce and commissioners have now got to roll out and interpret a recovery model. So a lot of residential rehabs have been sent inappropriate referrals; by that I mean people who are not medically able to sustain any form of intervention other than hospital. It is not unusual for clients to collapse on entry and be sent to hospital. That then skews the NDTMS figures, because it looks like it has been an unsuccessful intervention. There used to be a field in NDTMS that said "inappropriate referrals". That was recently removed, which is slightly disingenuous for residential rehab because we are providing a service and what we accept is the person that has been referred to us. Most residential rehabs have a very comprehensive assessment process that our assessment teams do very rigorously. That is not always reflective of the information that is captured in NDTMS, and it is not always reflective of the information that is supplied to the residential rehab provider. Sometimes it is very inappropriate and that is the difference that we have seen.
We were also led to believe that the payment by results pilots would be a provider-driven initiative. When it was rolled out it actually became a systems initiative, and I am not aware that any residential rehab providers have been included in the design and the development of any of the PBRs.
Q127 Dr Huppert: Thank you for that. It leads on to one of the things I was going to ask you about. I recently went to visit the Iceni project in Ipswich. They certainly impressed me with some of the things that I saw there. One of the issues that come up there was about payment by results, the idea that we should be providing support for successful outcomes rather than just for doing something for a certain number of weeks. You have touched on that, but I don’t know if either of the other two have comments on how we should do payment by results. They were also quite interested in much more holistic therapies and also linking in with the IAPT programme, the Increased Access to Psychological Therapies talking treatment. Are you in favour of doing more about that as well?
Adam Langer: I think that is what treatment is. Stabilisation and detox is just the gateway to beginning drug treatment, which is that stuff.
Wendy Dawson: Talking therapy is throughout the therapeutic community, so that is why residential rehab is a particularly good intervention because most of the other interventions grew from several of the residential rehab models. The mutual self-aid grew out of 12 steps, because that is based on Alcoholics Anonymous. The therapeutic community also have mutual self-aid, have recovery communities. So a lot of what we have seen in terms of other treatment interventions actually grew out of residential rehab.
Q128 Dr Huppert: If I could ask one last question, Chair. Do you think there is a problem about getting people into the system? Not just about once they are there they are referred to the correct place, but is there a sense that, because of the criminalisation that we have, people are reluctant to get involved with any of these systems, or is it that the people you would like to see, frankly, are just getting involved regardless of that?
Adam Langer: I don’t think there is a problem that way. The only problem is that the three weeks boundary for people having their first appointment is way too long. In terms of people getting in, we miss people there but, no, there is no stigma or fear of consequence in that sense.
Dominic Ruffy: I agree with that. I think the problem lies in the length of time it takes to refer somebody and get somebody into rehab, plain and simply. People die during that period of time. If you are a chaotic drug user, as I was, you have a window of opportunity when I am motivated and in a space where I am ready to get up and go. You might ask me the next day and there might be some more money in my back pocket, and in that moment it is okay. That is what you are dealing with, but if somebody is engaging in your services, full stop, you can guarantee somewhere inside them they do want to get treatment. So you need to work quickly with those individuals and get them into the right form of treatment, which in my opinion is rehab.
Wendy Dawson: That is absolutely true. You have to react now and not have a waiting time. For example, a recent case study that I just learnt about yesterday was we had a referral from a chap who had asked to go to residential rehab, had continued to ask to go to residential rehab, had been continually scripted with methadone, had asked to have his methadone reduced and in fact it was increased. He then decided to self-detoxify because he did not want to take methadone any more. He did, he became drug and alcohol free, asked to go to rehab, and he was told he was no longer a priority because he was drug and alcohol free. They are the kind of barriers that we face, because we had done our assessment, we were waiting for him, and he rang up and said, "I have been told I’m not priority." It took him to relapse for his commissioning panel to allow him-and I use that word "allow"-to come into rehab. Surely it should be about choice. The Community Care Act 2000 talked about service user choice. The Health and Social Care Act 2008 talks about service user choice. Where was the choice in treatment, whether that is a community-based treatment or a residential rehab? That is the question that I would ask.
Q129 Nicola Blackwood: One of the criticisms that is usually levelled at residential rehab is the problem that comes at the end of the residential period when the service user goes back into the community and there is the disjunction, and the real risk of relapse and the consequent problems of the body reacting more strongly to the drugs at that point. How do you manage that transition period and how successful are you in preventing relapse among your users?
Adam Langer: That example of appalling kind of practice-you mentioned. community service-is common. I hear about it all the time. What should be happening is stabilisation, detox and preparation for proper treatment, and all the preparation in place before the person is referred into treatment so that their return to the community is fully planned out, whether that is supported housing projects or back into the community in domestic situations. But that is not done, and masses is wasted.
Q130 Nicola Blackwood: That is not done by the residential rehab or that is not done by the DART?
Adam Langer: No, it is not done by the community drug service. Before the community drug service refer, it should be their work to get someone into treatment and to do the preparation for when they come out of treatment, so they come out into something that is planned, not left-yes, it is missed.
Wendy Dawson: Most residential rehab providers-and again I can talk from our personal experience at the Ley Community-provide an after-care service. That is critical, exactly as you say, for that continued abstinence, because what we do is we link people into a recovery community. In our residential rehab we encourage people to stay in the geographical area in which we are. 99.9% of people do that because of our extended peer recovery community across Oxfordshire. By being close to the residential rehab place where people have got well really does sustain their recovery, because they know that they have people who are in the programme now that they can help influence and inform and they have an after-care support team who will respond to crisis or early intervention. Many residential rehabs encourage people to move out with a peer or peers. That helps to sustain recovery as well because they are living with people who have also had that same experience and are clean and sober on exit.
Dominic Ruffy: I think it boils down to communication between the tiers. As Adam stated, tier 3, tier 2 need to work with the rehabs. There has to be a whole package approach, as opposed to saying, "Rehab sits over there, they do what they do. We have sent you over there, now we can forget about you", because that just puts the addicts at risk. I would also think that the rehab sector itself has been open to accepting some of those criticisms and is actively looking at improving our own after-care programmes and so on.
Q131 Nicola Blackwood: Your assessment would be that the problem is not with residential rehab, it is a failure to co-ordinate between the different stages of recovery?
Dominic Ruffy: I think communication between all parties could improve. That does have to be underlined. There does need to be better communication between tier 3 and the rehabs, and likewise between the rehabs and tier 3. It is a two-way street communication, so it can’t all be put in one area, but there has to be strong communication.
Wendy Dawson: It is also in terms of the interpretation of "recovery". I hear a lot of community intervention people have gone through some kind of modality and have come to the end of it and they are still on a script, but they are changing from methadone to Subutex. Well, that is still substance dependent. What residential rehab achieves is absolute total recovery. There is a lot of rhetoric about what the word "recovery" means. We have been delivering our service for 40 years, and what we mean is completely substance free, not dependent on any alcohol or drug or substitute prescribing.
Q132 Steve McCabe: I just wanted to be clear about your reference to Subutex there. Do you regard that as a maintenance drug also?
Wendy Dawson: Yes.
Q133 Michael Ellis: The Ley Community has a number of staff, I think it is 25 staff, and I understand that many of them have themselves been through a drug rehabilitation programme.
Wendy Dawson: Yes, 90% of my clinical team are recovered addicts.
Q134 Michael Ellis: So you would argue that the personal experience and ability that they bring, with their own direct experience in overcoming their addiction, is something that can aid and assist those that they are seeking to rehabilitate?
Wendy Dawson: It makes a huge difference.
Q135 Michael Ellis: I think you were present-we have heard from other witnesses who seemed less convinced that people with direct experience were equipped to go into schools, for example, and talk to children about that.
Wendy Dawson: I actually disagree with that. My early history was as a detached drugs worker and a detached youth worker, and I specialised in working with children who were glue and gas sniffers in the early 1980s. In effect, we had a fantastic role of loco parentis, so I don’t necessarily agree with all of what the speaker said. I think there is a role for teachers and there is a role for youth workers, which was never mentioned.
In terms of the Ley Community, yes, most of my clinical staff are ex-addicts. They are in recovery. It makes a difference because somebody can say, "You can empathise and you can sympathise, but if you actually have travelled that road it makes a difference". It also means that you become peer role models, which is hugely impressive to a community who are trying to recover. People will often say, "I’ve tried it, I’ve tried it, I just can’t cut it," and if somebody has walked that road they can say, "Look, I’m living proof, and I’m five, I’m 10, I’m 15"-my programme director, Steve Walker, is 30 years drug free, and he is the head of that programme. What phenomenal difference does that make? It makes a huge difference, because people can look up to him and say, "What, you’ve sustained that for 30 years and you’re still working in the field and giving back?"
Q136 Michael Ellis: So you disagree quite strongly with the previous evidence that we heard about-
Wendy Dawson: I have a different opinion, and that is informed by my early experience of being a practitioner, and knowing that when I was a youth worker we did make a huge difference.
Adam Langer: For me, this shows a misunderstanding of the people who are dealing with this. You are not comparing like with like. As I say, if I go into a school and say, "I used to be a drug addict, you too can be like me," I am saying "I’ve recovered, but you have to become a drug addict first." But if I go to a bunch of people who are using drugs and say, "You too can be like me," they have somewhere to go to. You are not understanding what is happening there. So for me, although addicts make great counsellors, the important thing is that they also make awful counsellors, and I have seen horrible governance in tier 4. The important thing is to have proper training. If you have done the path, it is better, but it is the training that is the most important field.
Dominic Ruffy: I think it is worth noting that the same speaker said that he would not ask a French teacher to teach maths, so why would you ask a non-drug user to talk about using drugs and also to understand all of the underlying issues?
Q137 Michael Ellis: You understand, of course, that as a Committee we are hearing evidence from a number of different people and it is very interesting to hear experts in the same field coming to different views. Very briefly, could I ask you about treatment outcomes. The data on treatment outcomes, as far as the National Drug Treatment Monitoring System data is concerned, are you happy that that accurately reflects the situation regarding outcomes?
Wendy Dawson: Not really, because I think the first question has to be what is the purpose of the National Drug Treatment Monitoring System, in order to answer is it fit for purpose? Residential rehab providers, as I said earlier, gather a huge amount of data from the client before entry. A lot of that data is quite critical to recovery, and that is not included in the NDTMS monitoring. What is included, from my understanding from my admissions team, is that it is a statistical analysis, a data collation of PDUs or whatever the new name is, which is problem drug users, their blood-borne virus stats, their housing status, their employment status, their offending status. It does not actually capture what the intervention is that that client was going into, which for me is imperative to understand about recovery.
If you want to collect statistical analysis, the other aspect of the NDTMS that does not work is that we are not all given the same training in order to input and collate the data effectively and efficiently. Each area that receives training is trained differently, and we have only just realised that quite recently when we had a conference on 26 January where residential service providers were all under one roof. In a workshop in the afternoon we all talked to each other and realised we were all inputting data differently because our guidance had been different. The other aspect of NDTMS is that the fields change, and it is a very NHS-driven field, so it talks about triage, it talks about episodes, which is not the same as the input that we do in our own database fields. The NDTMS quite frequently change fields for no rhyme or reason that I can understand, but then I am not the data inputter. But it does not capture some of the social capital that it is imperative that we get from residential rehab recovery programmes.
Chair: Thank you. Mr Langer, Mr Ruffy, Ms Dawson, thank you very much for coming together today. We would like you to keep in touch with the Committee and to follow our proceedings, and we may well write to you with further information. Thank you so much for coming. We are most grateful.
Examination of Witness
Witness: Professor John Strang, Director of the National Addictions Centre, gave evidence.
Q138 Chair: Professor Strang, thank you very much for giving evidence to this Committee this morning on our inquiry into drugs. The policy area of drugs is going to move to the Department of Health. Do you think this is a positive development?
Professor Strang: First of all, a disclaimer that I am not in the political realm so I might not be the best person to judge, but I would see it as a healthy move, in that the way I would see the disorder, if we are talking about people who develop problems with their drug and alcohol use, then I would conceptualise that in a health and social care domain, not in a criminal justice domain. I would see the criminal justice aspect as being hugely important to society, but I would see it as a manifestation of or a result of the disorder. So I would see that as generally healthy.
Q139 Chair: The new health and wellbeing boards are going to be created. Do you think that this is going to be a helpful sign for those who are involved in this area?
Professor Strang: I am probably less certain about that, probably because I am less certain how they will eventually pan out as an organisational system. The worry I would have is that the commitment to the field became too dispersed, and there is a resonance of that right across the field. You want the wider provision to become more sensitised to, more aware of addiction problems or drug and alcohol problems, but if you then shift too much of your commitment and energy to that generic provision, you lose the skill base for the more complex work. That would be my worry about moving to the health and-
Q140 Chair: You are a firm believer in abstinence, as opposed to people being maintained on methadone. Is that right?
Professor Strang: No. To be honest, I am interested right across the field. Along with other veterans like Wendy Dawson, I have been around a long time. Any of the interventions in the addictions field I find interesting, from self-help, abstinence movements, through to the supervised heroin prescribing clinics.
Q141 Chair: Do you know how many people are currently being maintained on methadone as opposed to getting help to recover? Or do you see that as part of the process of helping people to recover?
Professor Strang: I would like to suggest there is a different way in which you could constructively view it. I will give you an answer to the figures. Other people will give you much more accurate audit figures, but you are in the ballpark of 175,000 people on some sort of maintenance prescribing per annum. If you get correct official figures from DH then their figures are correct and I have just not reported them correctly.
But one of the things that in my view has been lost in the commitment to getting more people into treatment, which has been a drive of the last decade, is what the purpose of being in treatment is. That has to be bringing about a change in the mess that you had when you first presented to the service. I am deliberately using vague phrases at the moment like "the mess". I think one of the aspects of methadone prescribing or buprenorphine prescribing-and I view them as two versions of the same sort of approach, opiate substitution treatment-is that your purpose there is still for people to quit their street drug use. So if someone comes to me with a heroin addiction problem, if I am prescribing buprenorphine or methadone my objective is still for them to quit their street heroin use. Just as if I gave a nicotine replacement treatment to a smoker, my measure should not be, "Are they taking the patch?" My measure should be, "How does their smoking behaviour change?" That has been lost somewhere.
Q142 Chair: You are looking at a variety of ways?
Professor Strang: Yes.
Q143 Chair: On decriminalisation, we heard some very strong evidence from Sir Richard Branson and the former president of Switzerland. Is it a goer? Is it a runner? Do you think that there should be decriminalisation?
Professor Strang: My own view is that, if you look at the evidence, it is like a Rorschach inkblot. It depends what previous views you held when you look at the available evidence there.
Q144 Chair: What are your current views?
Professor Strang: If you look over the fence at the alcohol and the tobacco fields, where we have much better evidence, we know this is a price-elastic commodity, that if you make it easier for people to access these products and make it more price accessible, the levels of use will increase and the levels of harm that result from that will increase. On that basis, I would not be in favour of relaxing it.
Chair: So you are not in favour. That is very helpful.
Professor Strang: What I would be in favour of is moving away from a draconian system for how you manage somebody when they get caught up in the system. When they are caught up in the system, a diversion into a treatment or a caring response is a much better business way of handling that problem than just an incarceration option, or just a criminal-
Q145 Nicola Blackwood: I am afraid I am slightly unclear as to your assessment of the current situation for maintenance. I understand that the original purpose of substitute treatment is to initially wean an addict off their street drug of choice, with the intention of then weaning them off the substitute drug into abstinence. The claims are, however, that that has not been happening, that instead individuals have been maintained for long periods of time-we have just heard from witnesses, for five years and upwards-on substitute drugs. Is this your understanding from the work that you have been doing?
Professor Strang: Thanks for that question. I think the first bit, I would say you are entirely correct, and it is something where I think it would be healthy if there was more focus. The objective about bringing somebody into-various phrases are used-opiate substitution treatment or maintenance treatment, it is the same thing, it is just different terms, is to enable somebody to quit their street heroin use, if you are looking at opiate use. One of the unhealthy results about the preoccupation with numbers in treatment was people took their eye off the ball and they thought that the important thing was to have numbers of people in treatment. It is not, it is the number of people who benefit from being in that treatment that we need to look at. The second point you said was that there is then a phase 2 to it, and personally I would view it differently. I would view that longer bit of work actually to do with the social reconstruction work that someone is needing to do, which may or may not be helped by them stopping their opiate substitution treatment.
Q146 Nicola Blackwood: Do you think it is acceptable to remain on a substitute drug for an indefinite period of time?
Professor Strang: I fully understand that it is financially stressful to a treatment system. It is also something that an individual would not want to do if they could move on.
Q147 Nicola Blackwood: Have there been any studies as to the health impact of long-term methadone use on the individual?
Professor Strang: Yes, two aspects to it. I am not wishing to be promotional, but some of it, I think you had a PDF copy of-there is a review paper in the Lancet we had a few months ago, and I will also leave a copy of a book, which was a multi-author one about drug policy and the public good.
Nicola Blackwood: This is not a lecture.
Professor Strang: They are useful sources from multi-author groups. The long-term implications, as far as we are aware there are no long-term harmful effects from the long-term maintenance itself, so this is separate from-
Q148 Nicola Blackwood: Is that, we are aware because there have been long-term studies, or is that we are not aware but we don’t know?
Professor Strang: Yes, there have been long-term studies. People have been studied extremely long term in the US and other countries. The second issue, is it desirable? That is not what one would want to achieve, so the second issue is do we have long-term studies of where people have been actively steered off their maintenance? There is a clear separation. It is something we have been looking at recently, because of the debate. There is harm from the forced exit and there is benefit from when that is voluntarily engaged with.
Q149 Nicola Blackwood: Have there been any studies of the long-term social impacts of long-term maintenance on methadone?
Professor Strang: There are reports of huge sample sizes, particularly from North America, of the progress that people make. There is a more recovery-orientated tone to maintenance treatments in the US than we have in the UK, and that is one of the areas that I would have thought was fit for change in the UK, to be more focused on that.
Q150 Nicola Blackwood: Is that that there are studies of the social impacts?
Professor Strang: Yes.
Q151 Nicola Blackwood: Would they be available to us?
Professor Strang: Yes, they are, and some of those are. It is pretty extensively referenced. I can send specific ones through to you. But they have huge long-term follow-up studies from the States.
Q152 Dr Huppert: Professor Strang, the paper that you mentioned earlier was a very interesting read, and for anybody who has not read it it was Lancet 2012, 379, 17 to 23. It starts off with a very important point for us, which is, "Debates about which policy initiatives can prevent or reduce the damage that illicit drugs cause to the public good are rarely informed by scientific evidence". It is very important that we try and move on from that. There are a number of things in it and I don’t want to try and summarise it. You say at one point that wide-scale arrests and imprisonments have restricted effectiveness. Another point, "Incarcerating high-level dealers can be more cost effective than enforcement against retail sellers because retail sellers can easily be replaced". I think there is a lot there for us. To summarise, however, how would you compare the UK’s use of effective interventions compared to good international practice?
Professor Strang: I am grateful to you for reading out the opening phrase. The main message I hope you would take away from my evidence is that there is a lot of scientific literature out there and we don’t make sufficient use of it. So, it is not whether my opinion is right or wrong. We should use the body, particularly North American evidence. Because of the controversial nature of the field, it has been phenomenally well-studied, the whole area. We have been moderately good at utilising the available public evidence. There are areas where I think we have not scored adequately well and a lot of our provision is of adequate, but only adequate, standards. When we are looking at the issue around maintenance treatment that I was just being asked about, I think a lot of our maintenance treatment lacks sufficient drive and support to the wider recovery that people should achieve. It lacks that sense of momentum to move on. The expert group that is currently working at the NTA and Department of Health is grappling with that.
The challenge will be how you do that without having some administrative system that dictates when somebody will be ready to move on. Having a system that encourages move on seems hugely healthy. Having a system that says, "Some external agency has said that that number of months has now passed, therefore you are now ready to progress" is not how personal growth occurs and it is not how treatment will occur. That is quite a challenge. So having that greater aspiration, having more resources-Wendy Dawson referred to social capital, which is one of the phrases that has come in-those sorts of aspects will be important to foster those growths. I do not see those as in competition with whether somebody is on or not on maintenance treatment. I would see them as a sort of parallel provision.
Q153 Dr Huppert: You described our use of effective interventions as being adequate, which doesn’t sound very good. Which country do you think has the best overall intervention, the best overall set of policies? Who should we be looking at and learning from?
Professor Strang: To be honest, I think you could go to quite a number of countries, so North America, Australia, other European countries. We have slightly disadvantaged ourselves by wanting to make the treatment more widely and easily available and dispersed and hence we have self-inflicted a damage by having a lesser commitment and a lesser quality to what is then provided. You have a workforce less resolutely committed to working in the field. So I think you could look at any one of a number of countries where they have a more intensive work ethic around the work that somebody does in their treatment.
Q154 Dr Huppert: You are suggesting that the people who work in rehabilitation in the UK do not have a good worth ethic? Is that not quite what you meant?
Professor Strang: This is the terrible thing about giving evidence this sort of way. No, I am not suggesting that at all. What I am saying is that a lot of the provision of care to people with drug problems is dispersed very thinly. A lot of the people have a much lower level of contact and a lower intensity of support than would happen in other countries.
Q155 Dr Huppert: You have spoken a lot about the treatment aspect. Obviously that is not the only thing that we are looking at. Do you have any comments about the rest of drugs policy and whether there are models that we should be looking at outside treatment, rehabilitation, therapy, whatever you want to call it?
Professor Strang: By the way, when I am talking about treatment I am broadly talking about treatment and rehabilitation in a sort of basket. In the other areas like you mentioned prevention realms and such, I would want you to be bringing the same scientific scrutiny to the prevention realms and the interdiction and the law enforcement realms. It is not my area but it was the area of the other co-authors in the major report we did, and you discover in the treatment and rehabilitation fields there is much stronger evidence of benefit and a return for society for investments than in either the prevention field or in the intervention field.
Q156 Mr Winnick: Professor, if I can take you back for a moment to the response you gave-which I understand if it was a bit ambiguous, it is perfectly understandable-about decriminalisation. I would simply ask you this question. Do you think it is useful to have such a debate whether or not the community would be served better overall, although there is no panacea either way? I think you implied that quite clearly. Do you think it is useful to have such a debate in the first place?
Professor Strang: I worry that the debate becomes polarised with a typically TV-type thing of two extreme views and somehow that covering it, whereas I think the more interesting debate is in the grey area in between where you say, "With its illegal status, what are the ways of handling it that brings less use and less harm as a result of that use?" So, my answer about "with its illegal status", I would nevertheless not want to see more draconian penalties; I would want to see it being used. The Project Hope clinics of drug court diversions with mandated treatment are a clever example of where you integrate the law enforcement aspect of the illegality with a hefty nudge into changing of behaviour and becoming drug free.
Q157 Mr Winnick: Do you think successive Governments have in fact adopted the policy of having a less drastic or draconian policy?
Professor Strang: Yes. We have a more moderate view than many other countries, so it is not a criticism of where we are. I would look at small incremental changes rather than thinking that there was some revolutionary approach that was going to solve the problem, which it won’t.
Q158 Mr Winnick: There was a hue and cry, of course, when cannabis was reclassified, and then the previous Government gave in. Do you have any views on that?
Professor Strang: Yes. I have a view on various things. I don’t understand why we don’t require those people to subject themselves to a randomised trial if you really want to know does it make a difference. I am not interested in this need for public debate, political debate, or expert debate. I want somebody to do a decent study that says, "That is what it was in those cities. We changed it in those cities for two years and look at the change that occurred". I would follow what the evidence told me to do and I don’t understand why that is not similarly applied to law enforcement issues, prevention initiatives, and it could be. There are rare instances where it has been and they are a breath of fresh air when you come across them.
Mr Winnick: It would be useful if you communicated, if you have not done so, your views to the Government as well as to this Committee.
Q159 Chair: Well, the purpose of this inquiry is for us to do that.
Professor Strang: I am speaking as an individual. I am in the NHS and the academic sector. I have opportunities to give my views but they are just my views.
Chair: Thank you. That is the purpose of you coming before this Committee, so we can transmit those views.
Q160 Alun Michael: I am interested in that last remark and I wonder if you might have a look at the work of Professor Jonathan Shepherd on violence reduction in Cardiff. Perhaps it is not the sort of question that can have an immediate answer, but tell us whether you think that sort of scientific or almost engineering approach would lend itself to dealing with drug issues.
Professor Strang: I think that is exactly the sort of approach that is required and it gives you a clear finding. You have to enter it with the honesty and the integrity of not knowing which way it is going to go and you base your future practice on the evidence you get from those experiments.
Q161 Alun Michael: Could I ask you about two aspects and whether you feel that there is any great clarity. Firstly, in the provision of treatment, do you think there is enough provision of treatment for those who are addicted to substances other than heroin or crack cocaine?
Professor Strang: I don’t think there is enough treatment and rehabilitative provision right across the board. My worry about then singling out a particular group is that time and again over the years I have seen a focus on one area being achieved by removing interest and attention to those other areas. In my view, treatment services should deal with the individual who presents with the problem they present. The substance will vary over time. There has been a focus in recent years on singling out which drug. Personally, I don’t see that as particularly healthy and it creates an absurd two-track system of referrals.
Q162 Alun Michael: So you would argue more for a generic approach that starts with the individual than with the specific substance?
Professor Strang: I would do, and I would then expect to see some substances that seem particularly aggressive or tenacious in their problems as being more likely to be prominently represented. But it is the problem somebody has rather than whether it was heroin or cocaine or a pharmaceutical equivalent or GBL or something, and the nature of someone’s problem will differ.
Q163 Alun Michael: That leads very nicely to the other question I wanted to ask. I was very impressed, when I looked at these issues as a Minister some years ago, by a project in Plymouth, the Trevi Project.
Professor Strang: Sorry, I missed what you said.
Alun Michael: The Trevi Project, which sought to provide treatment in an environment where individuals, particularly young women who are involved in a cycle between prison, the streets and back out again, were able to have their children with them, were supported by other young mothers in the same situation. So you were looking not just at the substance abuse and dependency but on the whole person. Is there any evidence that projects like that, which obviously are quite expensive to operate, have better long-term social and drug dependency outcomes, or again is this an area where we don’t know enough?
Chair: Could you be as brief as possible? We are quite pushed for time.
Professor Strang: Yes, sorry. It is quite a challenging area to study because you can’t do the ordinary sorts of studies you would want to do. You get very good individual evidence of people who have transformational benefits. You then crucially want to know what proportion-
Alun Michael: It is the scale of it.
Professor Strang: Yes. There is live discussion at the moment in the UK, including myself and Wendy Dawson, about could we construct properly designed studies that gave the sort of research evidence base for the future around residential rehabs and aftercare. I think that would be a hugely worthwhile investment for the future.
Q164 Dr Huppert: Two extremely quick questions, and perhaps you may want to write with the answers. One is what evaluation have you done of the success of heroin prescription trials? The other is what are your thoughts on drug courts and whether they would be a useful thing for us to have?
Chair: You are allowed 30 seconds.
Professor Strang: It has been an area of interest, the heroin clinics. We have published a paper. There is due to be a cautious rollout from the Department of Health. I would not see it as part of a large provision. I would see it for the severe tip of the iceberg for whom it seems to have the potential for being transformative. Drug courts look like one of the most encouraging things from the criminal justice sector for a long time, but that is encouraging in what is otherwise a pretty bleak environment and we don’t really know how well they work in the UK environment. I would want to do the sort of tight stuff-I don’t see why judges can’t similarly understand the ideas of a trial design with people with exactly the same thing, some of them get one and some of them get the other. The ethics are no different from the ethics of a surgeon or a physician doing that where they have an area of uncertainty where they are willing to do a trial.
Chair: Professor Strang, thank you very much for giving evidence to us today. We will no doubt be in touch with you. This is a long inquiry and therefore we will probably be writing to you for further information. Thank you very much. We are most grateful.