Recovery Ramblings

(Originally presented at the Drugscope conference 2009 and published in DDN)

When we look back at 2009, I doubt we will remember this as the point when the ‘recovery movement’ transformed the drugs field. We will remember it instead as the start of tough times after a decade of plenty.

Our world will change because the world out there has changed. The global financial crisis took us to the brink of calamity, with people well above our grade seriously believing that the entire financial system might collapse. To prevent this, our political masters have borrowed a truly vast sum of money and used this to prop up the financial system and keep the economy from folding in on itself. The difference between government income and expenditure this year is almost as much as the entire annual expenditure on the NHS, the recession is so deep it will take several years to dig ourselves out of the hole.

So far, most of us in the substance misuse sector, largely funded by the state, have not directly felt the pain. Part of the reason is simply that the government thinks it is better to borrow money to pay our salaries, than have us lengthening dole queues and keeping out of the shops.

This cannot carry on. At some point the people who are lending the money will begin to doubt whether UK plc can afford to pay it back – so the government must show it has a clear strategy to rebalance the books.

Whichever government gets in they will take radical steps to sort out government finances and this will include both tax increases and spending cuts. There might be a difference between the parties in the timing, scale or nature of cuts or tax changes, but pain will be caused and valuable services lost.

If the shadow of the axe falls across even a small part of the substance misuse field, it is going to be a big shock as we have forgotten what hard times look like.

Whilst it is true that few of us are especially well paid and the need for treatment services has always outstripped the available resources, I fear this field has long been prone to an exaggerated sense it’s our own plight.

This is not, in fact, a Cinderella sector, it is a privileged one. It is hard to think of another sector that has been so politically protected, hard to think of many other budget streams that have been so successfully ring-fenced, even harder to think of a sector of health or social care that has enjoyed resource increases substantially above inflation year on year for nearly a decade. Yes the targets we have chased have been tough, but more and more people have been employed in the sector, more services opened and more clients accessing treatment. Compared to other social care sectors, we are well paid (don’t believe me, try job hunting in elderly care or learning disabilities..) and with shortages of staff the career prospects in the field have been very good.

It is possible that this political protection will continue and our sector will be the exception to the coming health cuts, but personally I doubt it. It is possible that the year on year budget increases will resume, but I doubt it a great deal.

It seems to me more likely that the golden years are over, which raises the question: if there are to be cutbacks, where should this fall?

In the international development world, there is a concept called ‘absorbative capacity’. What this refers to is the ability of a country to receive international aid money, and actually use it well. Adding money to a country faster than it can absorb leads to wastefulness and all too often, corruption. In my view, the increase in money to the drugs field over the last decade was constantly at the limit of our ‘absorbative capacity’. I don’t believe that it result in much corruption, but am sure it encouraged wastefulness and even ‘fat’ in the system. This should be the first place to look.

I am not convinced that voluntary sector providers are bloated. On the contrary, a competitive tendering market has cut margins to the bone and most charities in the sector do not seem to have especially robust reserves. Also, charities provide the government with a cut price way of delivering public services, with the cost being borne by most of their staff being paid less and not having decent pensions.

The NHS is expensive compared to charities, mostly due to covering some higher paid employees and because the NHS has a decent pension system. It seems likely to me that commissioners will continue the trend of slicing contracts to find innovative NHS / Voluntary sector partnerships. My prediction would be a contraction of NHS provision and an expansion of voluntary sector provision – but in a very difficult commissioning climate.

It seems likely that the process of mainstreaming commissioning will continue. If I was a substance misuse commissioner right now I would be pleased if I worked for a PCT and would be trying to become a little more of a generalist, just in case it was decided that substance misuse commissioning should be fully integrated into mental health commissioning. I would expect some consolidation of functions, whether within or between commissioning authorities.

I am not sure the NTA is doomed, but think it unlikely the NTA we have in two years time will look the same as it does now. My guess is it will be slimmed down, especially under a conservative government, with the regional structures looking especially vulnerable.

All in all, it seems likely to me that the ‘infrastructure’ of the substance misuse field will be a target for cost savings, not because much of it is truly ‘fat’ but simply because it is more expendable than front line services. A side benefit of this will be some very good managers coming back to the provider side, a ‘talent drain’ that may go into reverse.

The position and status of the Residential sector has been strengthened, a little, by the recovery debate and in theory looks to gain from a conservative government.

At least some of the rhetoric from the right has been critical of the NTA’s lack of focus on abstinence and appeared to signal a wholesale expansion of the residential sector. Some of this rhetoric has been simply the posturing of opposition; some has emerged from think tanks that actually have very little traction with the party hierarchy. Perhaps their thinking simply mirrors back to the field our perennial pseudo schism between abstinence vs harm reduction, which perhaps only now is beginning to heal.

Whatever the progression of thinking within the conservative party, a wholesale switch to abstinence based services is extremely unlikely – if for no other reason that this is entirely unaffordable. Evan as a fan of rehab, I acknowledge it is an expensive option which is suitable for a minority of people. It cannot be the default form of treatment even when the public purse is full.

A more likely strategy for the conservatives is to find some shift in focus that allows them to move away from the appearance that the sole response to opiate addiction is methadone addiction. An interesting thing for this sector to think about, is whether the ‘recovery agenda’ might begin to converge with the thinking of the next government. That is, we might be able to show an incoming conservative government how to achieve a credible shift in focus for drug treatment that does not abandon the massive gains from Harm Reduction over the last 20 years.

I’m not sure this can be done, but we must try.

Unfortunately, the financial pressures might push the next government toward cheap but inadequate interpretations of recovery models; there is tremendous scope for investing in user led recovery and mutual aid groups, but we should be worried if this looks like it will replace a holistic treatment system.

So, though I might caste myself as a merchant of doom today, I think there are opportunities.

We must deal with the world as it is, rather than how we would like it to be. If this is a world of cutbacks, we must do what we can to protect clients – even if it means changing jobs or looking for a job elsewhere.

We must embrace the recovery agenda and embrace the opportunities of peer support models to both reduce the costs of treatment and improve treatment outcomes.

We must look for opportunities to influence the next government and explore what a recovery agenda might mean in straightened times.

It’s going to be an interesting few years.