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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
Thursday 22 March 2012
Professor AvEril Mansfield, Dr Owen Bowden-Jones and Dr Clare GerAda
Evidence heard in Public Questions 165 - 236
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Taken before the Home Affairs Committee
on Thursday 22 March 2012
Keith Vaz (Chair)
Dr Julian Huppert
Mr David Winnick
Examination of Witnesses
Witnesses: Professor Averil Mansfield, Chair of the Board of Science, British Medical Association, Dr Owen Bowden-Jones, Chair, Faculty of Addictions, Royal College of Psychiatrists, and Dr Clare Gerada, Chair, Royal College of General Practitioners, gave evidence.
Q165 Chair: Thank you very much for coming. We will be joined shortly by our other witness. The Committee is conducting a very wide ranging review of drugs policy and that is the reason why we have you before us today. We know that the BMA will be publishing its report later on this year and obviously we will be keen to know the outcome of those deliberations. But if I could start with you, Professor Mansfield, there is a view that the amount of drug use in this country is declining at the moment. Do you share that view?
Professor Mansfield: I think hard drugs definitely have declined in incidence.
Q166 Chair: Perhaps you would be more specific? Which ones?
Professor Mansfield: I am not an expert, I cannot tell you that but I do know that the harder form of drug use has certainly declined for new users.
Dr Bowden-Jones: Yes, we have some good evidence on this now from presentations to treatment through a system called the NDTMS and what we have seen is year-on-year reductions in heroin and crack cocaine over the last two or three years, and also a decrease in powder cocaine, so very encouraging signs that some of the more dangerous drugs that are being used are in fact on the decline.
What is less clear is whether we are seeing a group of newer drugs beginning to increase. Those drugs are sometimes known as club drugs, and they include a range of drugs known as Ketamine, Mephedrone-some of you may have heard of the legal highs. It is unclear as yet in which direction those are going, but certainly the suggestion clinically from treatment services is that those are increasing rapidly.
Q167 Chair: Where do you get this information from, Dr Bowden-Jones? How do you know this is happening?
Dr Bowden-Jones: There are various different ways you can record data about drug use. Two of the main ones are the British Crime Survey, which is a population survey asking about drug use from households, and another is the one I have mentioned, which is the NDTMS, which is a National Drug Treatment Monitoring System. That system looks at the number of people presenting to treatment, so it is people attending to services for help. Those are two different ways to measure drug use. In fact, on both of those metrics we are seeing a similar pattern, so less people saying they are using, less people coming to treatment as well for heroin, crack and more recently, powder cocaine.
Q168 Chair: One of the concerns of this Committee is the length of time it takes for the Government to ban legal highs-the process that is involved when it comes to the attention of medics that these drugs are very bad. What do you think about that process?
Dr Bowden-Jones: The whole thing is problematic. I speak with some authority on this because I have opened one of the first club drug clinics in the UK, and in the year that we have been open we have treated more than 200 people using club drugs. There are a lot of difficulties around this. One difficulty is that the substance in a particular legal high changes from one month to another, so although the branding may be the same, say it may be sold as Ivory Wave, the actual chemical contents of that may differ. That leaves us in a difficult situation in being able to assess risk.
Q169 Steve McCabe: How do your respective organisations seek to inform national and international policy on drugs?
Professor Mansfield: I am chairman of a committee called the Board of Science at the BMA, and the BMA has150,000 members. We think it is extremely important that we, as an organisation, look closely at this issue-it is after all very much a medical issue-so that our members are fully informed of up-to-date evidence and knowledge and, when we have achieved that situation, that we inform as much as we possibly can any other organisations, such as your own, that are dealing with this issue. It is a bit premature in some respects for us because we have not yet published the report. We are still working on it and I would not like to pre-empt the final report. But certainly it is very important that we, as members of the BMA, fully understand the issues, talk about it and think about it in a way that perhaps doctors have not always been able to do.
Dr Bowden-Jones: From the Royal College of Psychiatrists, we inform national policy in a number of different ways. We have bi-monthly meetings with the Home Office and the Department of Health to discuss development of policy. We also regularly produce reports on issues that are pertinent to drug policy. For instance, this year we are producing something on new addictions; touching on this issue of legal highs, over the counter medicines, and impulse control disorders.
We are also doing a report on public health and substance misuse, which hopefully will be very influential with the advent of Public Health England. Finally, we have done a report on the impact of re-tendering on addiction services. Those are the sorts of reports that we do on a regular basis to provide information to Government.
Finally, we are obviously involved in training nationally and on developing research within the field.
Dr Gerada: Thank you very much, and apologies for being delayed. The Royal College of GPs have worked over a number of years with the National Treatment Agency, with the Department of Health and with the Home Office on several fronts, including developing a national training programme for GPs, which we have now had in place for the last 10 years, and we have had over 13,000 GPs trained. Also one of our members is on the Advisory Council on the Misuse of Drugs and we are engaged in rolling out a series of education products around some of the other addictions, including gambling addiction and alcohol. So we are, through the College, clearly engaged at every level that we can.
On a personal level I used to be on the ACMD and I used to be senior policy advisor for the Department of Health in drugs and alcohol, so I take a very personal interest in all things drugs.
Q170 Steve McCabe: Can I ask about this review of Khat that the Advisory Council are undertaking? Will you be asked to contribute to that review?
Dr Gerada: Shall I pick that up, because the review of Khat builds on the Khat report that I chaired in 2005 for the ACMD, so we were asked then by the Home Secretary to look at Khat, particularly to look at whether Khat should be a restricted drug. It was particularly problematic, as you know, in some communities. Our recommendation there was not to have it as a controlled drug in the same area as the Misuse of Drugs Act, but to keep a watchful eye on it. In terms of "keeping a watchful eye on it" the use of Khat probably has not escalated in proportion to the population-clearly the at risk population has grown in proportion-but the worrying thing about Khat is it remains a drug that the elders use and the new generation are not necessarily using Khat in the way that it was used but turning to drugs such as alcohol. But we will certainly be responding. As the chair of the committee that wrote the original report I would be very interested in submitting evidence from the Royal College of GPs on that.
Q171 Steve McCabe: Will you be recommending any change?
Dr Gerada: Clearly we need to see what the new evidence shows, but if the evidence again, as I said, shows that it remains a drug that is rising because the population is rising but not necessarily its problematic use-it has problems associated with potentially domestic violence and all sorts of other issues, but I think the recommendations then of the 2005 ACMD Committee was that it should be a health issue rather than a criminal justice issue, and unless anything has substantially changed I think that would be the recommendation as well.
Q172 Dr Huppert: In terms of shaping national and international policy there are obviously resource constraints on what we can do to try to deal with harm reduction for drugs. A certain amount of resource could be allocated to the criminal justice processes, a certain amount towards health processes, a certain amount towards education processes and a range of other things. Do you have a sense as to whether that broad resource allocation is correct, the balance between those three, within the UK?
Professor Mansfield: I would not be able to comment on that, I am afraid. I do not know.
Dr Gerada: I can give you a broad comment, having been in this field now for 20 years. I think broadly speaking the more resources you give to health and the more resources you, in particular, give to prevention treatment and dealing with prevention in general terms, the more likely you are to get bangs for your money. We know that no matter how much money you throw at the criminal justice side or at enforcement and preventing drugs getting into the country, if drugs get into prisons then most borders are fairly leaky. So we know that the more money you invest in health and treatment the better your outcomes. But in respect to the exact proportions, at the moment I do not know what the proportions are.
Dr Bowden-Jones: The Royal College of Psychiatrists has been very supportive of the last decade of investment in drug treatment and we do feel that some of the changes we talked about at the beginning of the meeting in terms of drug trends may well be due to the fact that treatments have been made more available and more accessible for people, and that it is better quality. We now have a strong evidence base for what works for drug treatment and NICE guidance has produced a suite of reports saying what works and what does not. So we are in a very strong position to be able to deliver evidence-based cost-effective treatment at this moment.
Q173 Dr Huppert: Does that mean there are cost-benefit analysis-type measures for health interventions as compared with, say, education interventions, criminal justice interventions, or is it just that we have them for health?
Dr Bowden-Jones: We absolutely have them for health. When NICE did the review of both the drug and the alcohol guidance a very important component of that work was the cost-effectiveness of the interventions, and they have been shown to be hugely cost-effective.
Dr Gerada: The National Treatment Outcome Research Study, which I am sure you have heard of, the NTOR study-a fantastic randomised control study, the biggest of its kind-showed that for every £1 you spent on treatment you saved £7 to the state. The state in its broader sense, includes health and criminal justice. Some figures even put that higher and put it at £15 if you start to include everything. But for bangs for your money there are very few interventions where you get those sort of returns.
Q174 Mr Winnick: Dr Gerada, in your very interesting and informative paper you make a reference to the link between deprivation and heroin and crack cocaine use. Is that a very pronounced link for those who use in the main? Does this mean, in effect, that the majority of users of heroin and crack cocaine are in what would be described as deprived areas and are recognised as being deprived?
Dr Gerada: Yes, absolutely. In fact, again, if I can urge you to the fantastic document that was written again by the ACMD in 2000, which is called Drug Use and the Environment, which is one of the most eloquent studies unpicking substance misuse and deprivation in its broader sense. The overwhelming evidence is the more deprived the area, the more likely you are not just to start using drugs but to find that you are then unable to access the resources or have the resilience and environmental structures around you to become drug free or engage in treatment.
It is quite a complex interplay because it is an interplay between housing, opportunities for employment, parental influences, school influences, but on the whole, the more likely you are to come from, as put in its broader sense, a sink estate the more likely you are to take drugs and the more likely you are to stay on drugs.
Q175 Mr Winnick: That I can understand but why particularly should those in deprived areas go on to the worst type of drugs, the ones that I have mentioned, rather than cannabis, for example?
Dr Gerada: They probably do use cannabis as well. There is probably quite a-
Mr Winnick: It then escalates?
Dr Gerada: Yes, the gateway theory, which is that you start cannabis and you go on, is not proven but you are more likely in those areas to be offered drugs such as heroin and cocaine. You are more likely to not have the resilience or the peer support or the family structure to support you to not use, and you are more likely then to drop out of the educational system. So you are more likely to use those drugs because they are more available. The other issue is you are less likely to stop using because you do not have, as I said, the resilience, the peer support, the friendship networks, to help you through that.
Q176 Mr Winnick: That would explain to a large extent, would it not, the link between the use of such drugs, hard drugs and criminality?
Dr Gerada: Yes, absolutely. But I would like to say, and I am sure the others would say, the use of heroin has decreased considerably in recent years. It has plummeted and when I first started as a GP-I have been a GP for 35 years-every day a young drug user, sometimes as young as 16, 17, would come in wanting help for heroin use. I cannot think of the last time a new heroin user came to see me. Clearly that is one of one; I am only one person. What we are seeing now, as I am sure you will be picking up with Dr Bowden-Jones, are new drugs emerging, but over the last few years we have seen a tremendous success in the drug strategies, a tremendous success in drug treatment, and it has been played out on the ground-people like me, not seeing new drug users.
Q177 Mr Winnick: I wonder if I can put this question to your colleagues. There is an argument that those who use cannabis are law-abiding except obviously they are not law-abiding to the extent that they are using a drug that is illegal, but they lead ordinary lives. They are not anywhere near the category that we have been mentioning of criminality, using hard drugs, they have not escalated. They would consider themselves ordinary people who have a liking for cannabis. Do you feel that insofar as they do not escalate any further, there is any real danger to them?
Dr Gerada: Cannabis is not a particularly good drug to be on. It causes lung cancer. It causes oesophageal cancer. It causes failure at school. It is an addiction in its own right, so in terms of its health issues, I would not advocate a young person, or any person, using cannabis.
Q178 Mr Winnick: Indeed not, and I would be very surprised if you did. What I am asking is whether there is any particular danger? Health-wise you have explained, but would the decriminalisation of cannabis-perhaps that is more of a leading question. How far can people using cannabis lead lives without going into criminality in any way?
Dr Bowden-Jones: I think it would be fair to say that the different drugs tend to have different associated rates of criminality to them. For instance, heroin and crack cocaine have very strong associations with criminality. The club drugs that we talked about a bit earlier have very low rates of associated criminality, and in fact the majority of people who come into the Club Drug Clinic are working and holding down good jobs and have family networks and social networks. So there is a different rate of criminality depending on the drug and also the way the drug is used.
Mr Winnick: With health dangers that Dr Gerada has mentioned.
Q179 Michael Ellis: NHS reforms will be shifting responsibility for commissioning drug treatment and recovery services to local authorities. What are the opportunities of this approach to commissioning? How do you think that will play out?
Dr Bowden-Jones: I think the opportunities are around the integration of care, so it is the integration of health and housing. There are definite opportunities. With opportunities there are, of course, risks as well, and I think one of the risks would be that a health condition gets separated off from all of the other health conditions, and therefore may not be thought about as much because it has been separated. But I do think in terms of recovery there could be some huge opportunities for people with drug and alcohol problems as a result of the integration.
Q180 Michael Ellis: The integration positives, with everyone singing from the same hymn sheet and looking jointly at issues, might mean a more joined-up approach.
Dr Bowden-Jones: Hopefully.
Dr Gerada: For alcohol misuse, I think it is a real opportunity. I think we know that alcohol affects communities. I think we know that a lot of the interventions around alcohol can be dealt with and should be dealt with by local government, for example, enforcing the bylaws, looking at some of the environmental issues, transport, and so on, and I think joining it up at local government level is very good.
For drugs I have more concerns, because the effect of drug misuse is not so prevalent now if you look in your environment. I think now we see it through the health, and I would worry about the expertise of local government being able to commission health services for drug users. Recovering from substance misuse can take 20 to 30 years. That is in my experience with my patients and I have a worry that when you are on a commissioning cycle with change of local government, with change of politics, we might end up getting fragmentation and u-turns and changes in something that affect the patient down the track and would not help them. So I think it is quite a complex question that needs to be split into drugs and alcohol, rather than, as is often done, putting it under one umbrella.
Q181 Michael Ellis: The Health and Wellbeing Boards will invariably be more visible, won’t they, than the previous treatment commissioners? Do you see this as having a potential positive impact as well?
Dr Gerada: I do not know.
Dr Bowden-Jones: I think it is difficult to say. We have to always remember this is a vulnerable stigmatised group who are not very good at advocating for themselves and they tend to get lost in systems.
Q182 Michael Ellis: But having it more visible is less likely to mean that they are lost, is it not?
Dr Gerada: We have had the drug action teams, the drugs reference teams and the drugs reference groups, and we have had all sorts of health improvement plans. We have had lots of systems. We have had joint commissioning panels. I do not know, in all honesty, how the changes in the Health and Social Care Bill will affect commissioning per se for patients around substance misuse. We need to make sure that we are there in the dialogue to ensure that, as Dr Bowden-Jones says, this invisible, very needy group, do not fall by the wayside.
Q183 Dr Huppert: Can I ask a question first about cannabis and then I would like to move on to heroin treatments. There are a range of psychoactive compounds within cannabis, some of which are more psychoharmful, some of which are psychoprotective. Have you seen any changes in terms of people using stronger forms of cannabis with less of a psychoprotective component?
Dr Bowden-Jones: Yes, in short. We are definitely seeing people using stronger strengths, skunk typically is the drug we see more commonly. There is a particularly worrying trend around some of the synthetic cannabinoids, which are potentially more harmful to health and possibly cause more psychosis, although it is very early days because these have only been on the market a relatively short time.
Q184 Dr Huppert: In California, where they have effective decriminalisation, as you probably know there are lots of local cannabis shops that display information about the psychoharmful properties, the strength properties. Do you think that sort of information would enable people to make more rational decisions?
Dr Gerada: I suspect a 17-year-old walking past a shop is not going to make a rational decision about what they are going to use. They will want to spend their money where they can get the biggest bang for their buck. I suspect anybody in this room might make a rational decision but we are here, I think, to protect people from entering a life of substance misuse that could cause them harm. I would say cannabis is not a good drug to be using at any age. We have just spent the last 60 years sorting out tobacco, let us not drop in the same problem now with cannabis and make it much more available and pretend that it is a safe drug. It is not a safe drug.
Professor Mansfield: If you are asking about information being made available to the young, obviously we would support that hugely. They need to know what it is that this drug is likely to lead them to and the complications of using cannabis. On that side of it we would solidly support the increase in information being made available.
Q185 Dr Huppert: If I can turn to heroin treatments and other opiate users. There is a discussion about whether the best way for treatment is complete abstinence, whether it is substitution, I think there are also some heroin clinic trials that have been done. What is the evidence on which of those works the best, or other treatments that may be available?
Dr Bowden-Jones: I think the starting point is there is no one size fits all. What you need is a range of treatments because you have a range of patients. What we have, and we are very lucky to have, is a very strong evidence base, as supported by NICE, for opioid substitution. We know it works, we know it saves lives, and we know it can engage people in treatment and allow them to begin to make the changes they want.
In terms of abstinence-based treatments, again that is absolutely right for some people and some people do brilliantly with that. In terms of the injectable treatments you mentioned, initial studies are very encouraging for a specific group of very hard to reach individuals.
The message is that we need all of these treatments. We need a range of treatments because we have a range of complexity and severity within this population.
Dr Gerada: There are about 1,000 randomised control trials, gold standard trials, that give evidence to the efficacy of substituted treatment for the management of opiate addition. We absolutely have to say, and these go back 70 years, but as Dr Bowden-Jones says, there are also other treatments that work, such as detoxification. I chaired the NICE guidelines on opiate detoxification and rehabilitation and abstinence models, but you must not throw out the baby with the bathwater. In terms of patient lives, decreasing criminality, improvement in your social status, improvement in your health, reduction in mortality and morbidity, opiate substitution is the gold standard treatment.
Professor Mansfield: There is lots of evidence about the treatment and its effectiveness, but what matters most is that you get people into treatment, and this is where I think the BMA has a huge role to play in alerting the members of the BMA to the fact that there are a lot of people out there who need this treatment and in helping them to understand fully what that involves.
Q186 Dr Huppert: What stops people from seeking treatment at the moment? Is it that they are scared of it, they do not realise they have a problem, or that they are concerned about how it will be seen or that doctors will not be sympathetic?
Professor Mansfield: It could be a range of all those things, I suspect, and maybe people do not want to head for treatment, but I am afraid I am no expert on that. You probably know better than I.
Dr Bowden-Jones: I think treatment is scary. I think making change is scary for people and when they have had a particularly long history of perhaps poly-substance use, the thoughts of making change can often seem overwhelming.
Q187 Dr Huppert: What policy change could we have? What could the Government do differently to encourage people to seek treatment?
Dr Bowden-Jones: In some ways it has done some of the things already, so it has invested heavily in the availability of opioid substitution treatment. That has allowed people to know that they can come in and get treatment and not be sick coming off their drug. That has been hugely influential. So the waiting times for opioid treatment have come down to less than two weeks across the country. That is good for any treatment in the NHS, let alone treatment for drug misuse. Those are the sorts of changes: investment in providing good quality opioid substitution treatment with wraparound psychological treatments as a core part of that package. That has been hugely helpful over the last 10 years that I have been working in the field.
Q188 Lorraine Fullbrook: Just following on from that, I would like to ask what you think the main research gaps are in the pathways to addiction and assessing the impact of effective treatment?
Dr Gerada: That is quite broad. We know from quite a few studies, including by the Joseph Rowntree Trust, that the pathway to addiction is poverty and social inequality, and that some of the factors that give children resilience include stable parenting and good education. There is a body of knowledge.
We also know that there are certain drugs that then interplay that are more addictive and have more addictive potential than others, but that is quite a complex question that you ask. In terms of the gaps in evidence with respect to treatment, I think there are gaps. We are not mentioning that the biggest addiction we face at the moment is alcohol addiction, and as we have seen the fall in heroin we have seen a catastrophic rise in alcohol addiction. Research has to be focused on alcohol before it is too late because-not too late, but we already see today a massive rise in the under-40s dying of liver disease.
I slightly disagree with Dr Bowden-Jones in that I think there are very few barriers to treatment now for heroin addiction. I think that is the issue. We are not seeing heroin users in the underground passes that we used to see nodding off because they are in treatment. But alcohol is certainly an issue.
Dr Bowden-Jones: I have two that I think are important. The first is the rise of club drugs. We need to make sure that people are not engaging in a new type of drug use. We need to understand what these drugs are to understand what the risks are.
The second is recovery interventions. There has been a lot of talk about recovery. There is quite a thin evidence base on what that looks like and what a recovery intervention is. We absolutely need to make sure that we are spending our money in a way that is going to achieve the results we want. So recovery interventions, which are quite a diffuse group of interventions at the moment, need funding to work out what the active ingredients of that will be.
Q189 Lorraine Fullbrook: Taking that forward, what are the prospects for new treatments for addictions?
Dr Bowden-Jones: Incredibly positive because in the last decade there have been huge advances in the understanding of the neurobiology of addiction, and with that understanding I hope that in the next five or six years we will see a lot of new treatments come online.
Q190 Lorraine Fullbrook: I would like to go back to the beginning and the assertion that there is a reduction in drug use, particularly hard drugs, heroin, crack cocaine, powder cocaine. Glasgow University have done research on this and I think, Dr Bowden-Jones, you said the better test, if you like, would be the NDTMS, which is people presenting themselves to you for treatment, and the National Crime Survey. Is the reduction because people are not presenting to you with addictions, and that the drug users and the drug traffickers and the drug dealers are being smarter than the police are, so therefore they are not being caught and showing up on the National Crime Survey?
Professor Mansfield: I have no idea.
Dr Bowden-Jones: My feeling is that there are less people initiating heroin and crack cocaine, so younger people are not initiating heroin and crack cocaine. But what we do have is a cohort who are gradually getting older, who are continuing to use. The question for me is not whether heroin and crack cocaine are still being used because I think they are being used less. The question for me is: are the younger people who are not initiating on heroin crack initiating on something else?
Dr Gerada: I absolutely agree. I think that we are not seeing new drug users and you can say, "Is that being reflected in the British Crime Survey?" I think there is even less because the National Treatment Agency figures have shown a big reduction but we have improved our reporting, so not only have they shown a reduction in numbers on their database, but we know that now many more people are on that reporting, so the figures are even less than we imagine, if I am making sense. Also clinically, we are not seeing, as I said, new opiate users, new crack cocaine. You will say they are not presenting to care. They are.
Q191 Lorraine Fullbrook: Is it the case? I am not saying they are, I am just asking. Is it the case that the reduction is because of this?
Dr Bowden-Jones: Services have never been more accessible than they are now.
Q192 Lorraine Fullbrook: But what about cannabis? Do you include cannabis in your research?
Dr Gerada: I would include problem cannabis use. GPs will see any substance misuse. I will even see a Coca-Cola addict if they feel they have a problem. I do not see a lot of problem cannabis users. I know that the Maudsley runs a specialist service and there are cannabis users presenting to their service, but in terms of general practice, where I practise, which is in the Elephant and Castle and Vauxhall and keeping my eyes and ears open through my college, because we run a substance misuse unit, we are not seeing a lot of cannabis users presenting for treatment. What we are seeing is a lot of alcohol and the methamphetamine, the Mephedrone and the sort of drugs Dr Bowden-Jones is talking about.
Q193 Chair: Thank you very much. Can I end with some very quick questions, which I would be grateful if we could have some very quick answers. I am not clear what the answer was to the questions posed by Mr Winnick. You are all against decriminalisation, are you? None of your organisations believes that there is any scope for decriminalising any drugs?
Professor Mansfield: We have not formed an opinion as yet. It is certainly something we will look at.
Dr Bowden-Jones: People with health problems should not be treated as criminals. If someone has a health problem they should be treated for that health problem, and not thrown in prison. That is different from saying drugs should be legalised.
Q194 Chair: That is sentencing more than decriminalisation.
Dr Bowden-Jones: What I am saying is that we should not criminalise people who have an addiction problem.
Michael Ellis: They criminalise themselves.
Chair: Sorry, Mr Ellis, can the witness just answer.
Dr Bowden-Jones: Yes.
Dr Gerada: I am not sure what the RCGP policy on this and I would hesitate to give my own view. I would urge you to the Royal College of Psychiatrists, the Royal College of GPs, and the Royal College of Paediatrics’ publication of Drug Policy in the UK that was published in 1999 and I would say to you that of those three colleges the conclusion was we do not favour decriminalisation but we certainly do think that rather than imprison people who are engaged in substance misuse, unless they are hard-end dealers, we should be treating them through a health route.
Q195 Chair: Basically the jury is out. You want to debate, you want to make sure that these things are looked at? Is that right?
Professor Mansfield: I think we are all absolutely clear that it is a health issue and that these people must get the health care that they need, and that is the top priority.
Q196 Mr Winnick: Sending them to prison would serve no purpose?
Professor Mansfield: Unless they were getting every bit as good health care in prison, but I doubt it.
Q197 Chair: We will be coming on to that with our next witness. Can I ask another question about prescription drugs? The Committee has just returned from Colombia and Miami-
Dr Gerada: Lovely.
Chair: You should have come with us. It was not one of those types of trips, I can assure you, Dr Gerada. We had some evidence from people in the criminal justice system in the United States about the way in which doctors are just prescribing drugs and those drugs are being sold on to other people. If you look at some of the very high profile cases, the deaths of Michael Jackson and Whitney Houston recently, they were using prescription drugs. Is there a problem with either the use of prescription drugs or selling on of prescription drugs? Do you all know that this is a problem that is going on?
Dr Gerada: Absolutely, and again I would say to you that we are so far better than we were a decade ago. This is called drug diversion, and again a wonderful study was done about 12 years ago looking at this in the field, again published through the Institute of Psychiatry. I will say this now, and I will make some-
Q198 Chair: So far ahead-you are taking better control, is that right?
Dr Gerada: Far, far, far better control.
Q199 Chair: Why, what was happening? Were GPs just prescribing?
Dr Gerada: We had an escalation of prescriptions-of Benzodiazepines, of Methadone, of ampoules of Methadone. In the States you have nonsense drugs being prescribed, such as Adderall-
Q200 Chair: By doctors?
Dr Gerada: By doctors because they have a very different health service. They do not have GPs. They do not have the sort of underpinning of the National Health Service. What we have had in this country over the last decade is a fantastic training initiative, run, I hesitate to say, through the RCGP, also the RC of Psych, to educate GPs about prescribing, about safe prescribing, about giving two week prescriptions and not whole month prescriptions. I will say that in terms of diverted drugs, patients getting addicted on drugs that started life with a prescription of mine is very unusual now. Ten years ago it was very usual.
Q201 Chair: But what about the selling on of prescription drugs?
Dr Gerada: Again we have put in place supervised ingestion, daily prescribing, regular reviews, urine testing, so the risk of diversion has dramatically reduced. That is evidenced not by just me saying it but by drug related deaths that have plummeted over the last decade, and I know you will hear-
Q202 Chair: Because doctors are being charged and convicted in the United States for the mass issuing of prescriptions?
Dr Gerada: Yes, and we have also improved private prescribing of medication in this country. A few years ago we had a massive group of drugs that were coming out from the private sector, Dihydrocodeine in the north of England, which has almost gone.
Q203 Chair: I think it would be very helpful, because there is a lot of information, if you could put a note on this.
Dr Gerada: I am very happy to go to Miami and Colombia.
Q204 Chair: My final question is to the BMA about drug driving and the Prime Minister’s recent statement in the House of Commons that he was proposing legislation on drug driving. The BMA, of course, have called for this since 2002 and very much led on this campaign. Has there been any progress, as far as you are aware on this?
Professor Mansfield: The most important issue is to recognise how dangerous it is and to move forward on making it easier to test people, which is probably the fundamental thing. It is easy to test for alcohol, it is not quite the same with drugs.
Q205 Chair: You want that to happen?
Professor Mansfield: We hope it will happen, most definitely.
Q206 Chair: Because I have figures that one in nine motorists, aged between 17 and 24, have driven after taking drugs.
Professor Mansfield: Yes, I am sure you are right.
Q207 Chair: Do you think those are accurate statistics?
Professor Mansfield: I have no idea. I have never looked at those statistics but I know it is there and it certainly is a dangerous thing to do and we need to stop it.
Chair: I thank all of you for coming, in particular Dr Gerada for the service you gave to the Committee earlier on, and can I congratulate you on your appointment as a Professor, which I understand has just taken place. We are most grateful. This inquiry is going on for some time so if you have any further information that you wish to put to the Committee please write to us.
Examination of Witness
Witness: Paul Hayes, Chief Executive, National Treatment Agency, gave evidence.
Q208 Chair: Mr Hayes, you have heard some of that evidence and if you want in passing to comment on it that would be fine by us. I want to talk about the NHS reforms first of all and the way in which these matters are being dealt with, in particular the creation of Health and Wellbeing Boards. Do you think there is a case for putting Police and Crime Commissioners on these boards?
Paul Hayes: I think that the Department of Health is keen to leave it to each local authority to determine for itself what the exact membership is. That seems entirely appropriate to me. What I think is more important than who sits on which Committee is how do those Committees work together. In relation to drugs and alcohol, and particularly in relation to drugs, the most important relationship will be between the Health and Wellbeing Board and the community safety partnerships.
Up to now drug treatment has been commissioned by local partnerships bringing together the probation service, the police, health, the local authority, and through that route we have been able to ensure that health interests are looked after, crime reduction is looked after, we maximise opportunities to get people into work, to look after their children more effectively. There is a concern that if we lose that partnership approach we might, over time, have too narrow a focus on health and public health and lose the other societal benefits.
Q209 Chair: But these proposals, do they cause you concern or do you think we are going to keep this integrated drug treatment system that we have?
Paul Hayes: We are confident that the work we are doing at the moment, with the Department of Health and the Home Office, will see guidance issued to local authorities and clinical commissioning groups about how the sub-structure of the Health and Wellbeing Boards continues to work in a partnership way to make sure that the full range of benefits can accrue from drug treatment. Most importantly for the public is that our judgment is that people having very rapid access to treatment, particularly heroin users, as you have heard from earlier witnesses, is keeping a lid on 4 million crimes a year. There would be 4 million extra crimes committed each year if the heroin users who are currently in treatment were not in treatment. So it is a very significant community benefit from continuing to get this right.
Q210 Chair: I am going to ask you about prisons because you have a vast deal of experience working in the probation service as the chief probation officer for the south-east and as a probation officer in the East End. The concern that we have had, and continue to have, is the number of people who say that if you go to prison, maybe you did not have a drug problem before you went into prison-51% of prisoners appear to have had such a dependency-when you come out you certainly do have. Are prisons a problem in trying to deal with the rehabilitation of people?
Paul Hayes: They are a problem and an opportunity.
Q211 Chair: Tell us about the problem first. What do you think the main problems are?
Paul Hayes: The problem has been, up until recently, that drug treatment in prison was entirely segregated from drug treatment in the community. It was commissioned differently, it was delivered differently. In fact, until recently, we had three different treatment systems operating in most prisons. We have, over the past two or three years, brought those together with a new integrated system within prison and as part of that-
Q212 Chair: In every prison?
Paul Hayes: Within every prison in England.
Q213 Chair: Because I hear that only six prisons are piloting drug free wings.
Paul Hayes: That is a different initiative. The drug free wing initiative is a different programme from the IDTS programme. The IDTS programme is aimed at making sure that everyone that comes into prison is given an opportunity either to stabilise and then return to the community, minimising the risk of relapse and death from overdose, which used to happen all too frequently, which is why it is important to maintain people if they are on substitute prescribing, if they come in for a short time. But it is also vital that we exploit the opportunity of the relative safety of prison for those people who can achieve abstinence. In effect, anyone who is going to be in prison for more than a few months will be ushered down an abstinence route, anyone who is only going to be in for a few weeks, in order to minimise the chance of death on discharge, is likely to be maintained.
Q214 Chair: The Committee has not as yet been to a prison but we intend to do so. One final question from me on this.
Paul Hayes: If I can just finish that for a second. The challenge that lies ahead of us now is that responsibility for treatments under the new arrangements will fall to the National Commissioning Board for treatment in prison. Treatment in the community will fall to the local authority under the auspices of Public Health England, so it is very important that we use a mechanism within the new legislation, technically a section 7A agreement, to make sure that the Commissioning Board’s £115 million is aligned with the £600 million that the local authorities have to continue to deliver a seamless service that does not have people relapsing on release-
Chair: Once they come out.
Paul Hayes: -some of them dying, but even more of them re-offending and going back into prison.
Q215 Chair: But we have heard that drugs are still a major currency in prison. Drugs are entering the prison system, not just prisoners who are dependent on drugs, but through one method or the other they are within the prison system. Is that right; is that your understanding as well?
Paul Hayes: It is. The drugs are available. My understanding is that although they are available they are not as available as they are in the community, so that most-
Q216 Chair: We would be very worried if they were more available in prisons, wouldn’t we?
Paul Hayes: Absolutely. But that does mean that although some people will maintain a habit very few people will maintain a habit at the same level that they had when they went in. Now that makes them more vulnerable to overdose and death when they are released because their tolerance has diminished.
Chair: You have excited a number of members of the Committee, I will take a quick supplementary on the availability of drugs in prisons.
Q217 Steve McCabe: I just wanted to ask what the evidence base was for the assertion you have made about the availability of drugs in prison because my understanding, from talking to a range of professionals, it is probably easier to obtain drugs in prison in this country than it is on the street.
Paul Hayes: That is not my understanding.
Q218 Steve McCabe: What are you drawing from when you tell the Committee that?
Paul Hayes: From service users-the people who are drug users who are in prison, and providers as well. Very few people have access to enough heroin in prison to be able to inject three or four times a day.
Q219 Chair: But there are other drugs, are there not?
Paul Hayes: There are, but drugs are less available. Certainly if we think back 10 years ago, cannabis was much more readily available in prison 10 years ago than it is now. I think it is fair to say that there will be other witnesses who you could call from the National Offender Management Service, who will be able to give you more precise information about those mechanisms than I am able to.
Q220 Dr Huppert: I, like Mr McCabe, was rather surprised by that because it flies in the face of a lot of the written evidence and conversations that we have had. Are you, in fact, saying that for a regular heroin user it is harder to get heroin in prison than in the public as opposed to, for a member of the general public, where they might well have greater availability in prison than they would be typically exposed to? Because those are slightly different things. Presumably an established heroin user will have a very good source of heroin that they have worked out.
Paul Hayes: Absolutely.
Q221 Dr Huppert: What you are saying is it is not as easy for the already addicted but it might well be easier for everybody else?
Paul Hayes: That is an interesting distinction.
Q222 Lorraine Fullbrook: I just have a supplementary on that. I agree with Mr McCabe and Dr Huppert about the level of drugs in prisons. In your experience, whatever you think the level of drugs is in prison, what is the main route for getting drugs into prison?
Paul Hayes: Again, this is not my area of expertise but in my experience, visits, people returning from home leave and other excursions outside the prison, corrupt staff, things being thrown over prison walls and then collected.
Q223 Lorraine Fullbrook: Thank you for my supplementary, Chairman. Professor Hayes, I would like to ask you about-
Paul Hayes: Not yet, if ever
Lorraine Fullbrook: Sorry, I didn’t have my specs on. Just to go back to your delivering the seamless service. Do you think the switch of emphasis from treatment to recovery in the Government’s 2010 drug strategy will benefit patients?
Paul Hayes: I think it will. As we have heard from previous witnesses, significant strides have been made in treatment in this country over the last 10 years. But the treatment system, I think, had become unduly focused on the community’s needs and on preventing harm for individuals, not on helping people to maximise their opportunities to recover, leave the treatment system and make a full success of their life.
Clearly you have to hold those things in balance. It is important that we do not jeopardise the success that has been achieved over the last 10 years in terms of access, crime reduction, reductions in drug-related deaths, and so on, but we need to be challenging for individuals and also for service providers. Service providers became too complacent: that if people were in treatment they were less likely to die, they were healthier, they were less likely to offend. To encourage someone to leave treatment is scary, it is difficult, it is dangerous. It is demanding work. It calls for high levels of professional skill and what the 2010 drug strategy reminds us is that the benefit to society is crucial but we are talking about an individual patient.
Most people come into treatment, they want to leave treatment, they want to get on with the rest of their life. We have an obligation to try to help them do that, and we are beginning to turn the treatment system round. In 2005, 11,000 people left treatment successfully and then did not return. This year we are expecting that to be 30,000 leaving treatment and then not returning. It is absolutely crucial that we keep up our efforts to try to make sure, not just that people can get in, be stable, keep them safe, but also that they then leave treatment, and the real advantage of things like Health and Wellbeing Boards, as was said earlier eloquently by Dr Gerada, is they will be able to link together jobs, houses and other social support that make it more likely that people will not relapse once they have overcome their dependency and left treatment.
Q224 Steve McCabe: I now understand the current situation treatment programme commissioned locally by the primary care groups and the local authorities working in partnership and it is the National Treatment Agency’s role to allocate the funding and give some direction to it. I gather this all changes with the public health changes. At the moment there is evidence of some local commissioning so it is not as if it is a complete change, but obviously the major change, as I understand it, is local authorities are going to assume this responsibility and it will be part of the complex mixture of budget demands. Are you confident that the new approach will work fairly well or do you think there is any guidance that will have to be managed centrally in order to make sure that this area of work does not get lost?
Paul Hayes: I think that is a very interesting challenge for all of us because there is a great emphasis on localism, on local authorities as the people who understand their area as custodians of place, for that being the right place for decisions to be taken about commissioning to make sure things can be joined up and money can be spent as wisely as possible.
The particular challenge in this arena though is that we are providing services for a marginalised group who are not particularly popular with many of the rest of the community, who are not perhaps able to represent their interests by the ballot box in the way that other people will. So there is a risk that as we democratise we might undermine the services that have been provided, that not only benefit the 200,000 or so people in treatment but the millions of people whom they live among-the millions of people who will suffer harm around crime, around public health, if treatment investment is diminished.
So it is important that we balance off the ability of the local authority to make its choices legitimately about how it spends its money with some sort of confidence that the crime reduction benefits, the public health benefits will continue to accrue. So what we would envisage is Public Health England will need to have conversations with local authorities about their joint strategic needs assessments and about their decisions to allocate their resources to make sure that the whole range of community benefits will still be available, and that there will not be inappropriate disinvestment.
Steve McCabe: That is very helpful, thank you.
Q225 Dr Huppert: Mr Hayes, in your written submission, you highlight the fact that crimes committed by drug dependent offenders, particularly heroin and crack users, cost society £14 billion a year. You cite a couple of studies that confirm the offending path at the end of their treatment and a whole lot of public support for the treatment and so forth. Given all that, do we have enough funding available for treatment?
Paul Hayes: It is interesting that for the first time in my life I have heard three doctors talking for half an hour and none of them said, "We need more money", and I think that is indicative. We can always do with more money. We can always do with more money for anything, but if we go back to 2001, the amount of Central Government resource that was committed to treatment was £50 million a year, and the moment it is £400 million, so that is an eightfold increase in a decade. The total expenditure on treatment has gone up fourfold in that time. There is no other area of the public sector that has seen anything like that level of investment and the commitment of the current Government has been demonstrated by them holding those budgets at the same level, despite 25%, 30% cuts in other aspects of activity.
In the current circumstances it would be entirely unrealistic of me to say that we need huge swathes of additional investment into drug treatment, particularly directly into drug treatment. The areas that worry us are the areas that are reflected by the 30% cuts in local authority funding, in particular. So it is what is happening to supporting people and resources. What is happening to support for troubled families. What is happening across the whole range of other agendas that need to be brought together if we are to consolidate change, not prevent the investment in treatment being frittered away because we cannot help someone get the job, the house, the stake in society, maintain their family contact. So they are the concerns for us rather than the direct treatment funding.
Q226 Dr Huppert: We have had evidence that over the last three years there has been quite a reduction in substance misuse services nationally, particularly for young people, and that this applies at all levels of treatment intervention-residential detox, rehab, community with outreach workers. Do you think that is accurate?
Paul Hayes: No, it is misleading. It is significantly misleading, but the explanation for it is in what I have just said. The actual amount for young people’s treatment has been steady for the last three years at £25 million. What has reduced is there used to be ring-fenced funds in support of young people’s interventions around prevention, around wider social integration activities-a total of about £30 million a year; £30 million of ring-fenced money for supportive activities and prevention for young people. That has now reduced to £20 million generic funding unring-fenced, so the cuts there have been have been cuts around the supportive activity, not cuts around the core treatment.
Q227 Dr Huppert: I am concerned you say it is misleading because it is information from somebody at the Royal College of Psychiatrists, so there is a bit of a clash there.
Paul Hayes: Everyone has a different view.
Q228 Dr Huppert: Do you think that we do enough across the whole range to support young people with substance misuse problems, either at an educational level, treatment level, environmental level, any level?
Paul Hayes: One of the difficulties across the whole drugs arena is that drugs bedazzle people and tends to prevent them seeing the other problems in people’s lives. Very few under- 18s are addicted to drugs. What tends to happen is somebody has problems with offending, with school attendance, with their family, hanging round with the wrong kids, and they are also smoking cannabis and drinking alcohol, and that is exacerbating those problems but not necessarily causing them. In terms of resources the question is not, "Are we resourcing drugs enough?" The question is, "Are we supporting young people in all aspects of their lives and across the whole range of issues?"
Chair: Thank you, Mr Hayes. Dr Huppert, final question?
Q229 Dr Huppert: Thank you, Chair. Since you mentioned alcohol, do you have a sense as to how much of a problem from the NTA’s perspective alcohol is now compared with illegal drugs essentially?
Chair: A brief answer, Mr Hayes.
Paul Hayes: Other than for young people we do not currently have responsibility for alcohol, although we will soon.
Q230 Dr Huppert: Should you?
Paul Hayes: We will be assuming that responsibility when Public Health England takes over, which is one of the benefits of the new arrangements. Drugs and alcohol will be brought together, which I think is very much welcome.
Q231 Mr Winnick: Previous witnesses today said, first and foremost, drug users should be considered as a health problem and certainly not as a criminal problem although they had open minds whether or not there should be decriminalisation. Do you have any views yourself on this rather controversial question?
Paul Hayes: The first thing is that an awful lot of the people we deal with need to be responded to as criminals because they break into other people’s houses and they steal from shops, and we therefore need to respond to their criminality. If drug addiction lies behind that criminality we need to respond to that and we need to respond to that as a health issue, and the same types of treatment will deliver health benefit and community safety benefits, so there is no conflict in that.
In terms of responding to the drug addiction of someone who is not a drug misusing offender, it is absolutely vital that we respond to them as someone who needs health support but we also need to think what is likely to happen if we withdraw all the legal sanctions. My best guess is that if we withdrew all the legal sanctions we would be likely to see an increase in use. At the moment 0.6% of the adult population use heroin or crack cocaine, and it is a declining proportion. That means 99.4% do not. I think it is a very brave decision to tinker with a legal framework that is working 99.4% of the time and improving.
Q232 Chair: One final question, I will just take you back to prisons for a moment. Drug addiction assessments are not carried out when people leave prison, are they? They are when they enter the prison system but not when they leave prison?
Paul Hayes: Not routinely for people who are not seen to have a drug problem.
Q233 Chair: Do you think there ought to be?
Paul Hayes: I am not sure whether that would be a good use of scarce resources. It is more important to maximise-
Q234 Chair: What are the scarce resources? If someone is leaving the prison and they have a-
Paul Hayes: More important-the bits of the system I am responsible for-is to respond to the people whom we know have a problem.
Q235 Chair: How do you get an integrated system if you do not know they have the problem on the way out of prison?
Paul Hayes: If we assess them when they go in and we can identify who they are, and we can treat them while they are in, then we know who, when they are released, we need to ensure are integrated with the services outside. Whether in addition to that it would be sensible to screen everybody else who leaves prison, it would for NOMS to determine whether that was a sensible investment or not.
Q236 Chair: We will ask NOMS. Thank you so much, and thank you for your evidence. If there is anything more you need to add to what you have said, please do not hesitate to write to us.
Paul Hayes: Will do.
Chair: Thank you.