I hope this finds you well. It has been a while since my last blog, with holidays, work and yes COVID, all getting in the way. But I have also been reflecting upon the general direction of travel of UK drug policy and service delivery. Back in June I allowed myself some hope that the English government’s review of the Drug Treatment system would lead to improvements. Heaven knows that things need to improve. Since then, unfortunately, policy and funding decisions have indicated very limited grounds for optimism. We have some fine words but a dearth of meaningful action. While financial resources are undoubtedly needed, some genuine leadership, political or otherwise, is essential.

Now my time working in the substance use field can be roughly split into two main parts. For the first decade (from around 1999) there was an expansion of service provision. There was an appetite to explore new approaches, work was undertaken to address housing and employment issues, and year on year things demonstrably developed and improved. Not everything was perfect by any means but in general the UK developed a vibrant substance use sector - I include colleagues in the police, probation and prison service - and there was a palpable commitment to improving people’s lives. Not only did the stats show that things were improving, but you could also “feel” it. There was a thriving community of people interested in what they could learn from each other. People from around the globe came to see what it was we were doing well.

Well not many people would visit the UK now for inspiration to develop an effective drug treatment response.

Well not many people would visit the UK now for inspiration to develop an effective drug treatment response. I know we still have some outstanding services and I salute those motivated individuals working incredibly hard to help their clients despite a broken system, but the fact is that for the last decade we have been going backwards. The harsh fact is that drugs work was no longer a priority, and we allowed systems and approaches that worked to atrophy and fade. We allowed the infrastructure that supported delivery and innovation to collapse. We lost nearly all our good community-based services, and we lost swathes of specialist experience. It also seems to me that we lost a great deal of empathy and understanding. All this with the inevitable end result of thousands of our most vulnerable fellow citizens dying and many hundreds of thousands more having damaged lives. No one in authority or power has lost their job as a result, and many have seen their careers progress despite the woeful outcomes being achieved.

We lost nearly all our good community-based services, and we lost swathes of specialist experience.

And I feel a sense of guilt here. While I and others did raise concerns, write to the government and point out the inevitable consequences, we were very cautious. We pulled our punches, we allowed ourselves to be persuaded to not rock the boat too much, that we could make things worse, that there would be jam tomorrow. I don’t know that making more noise would have changed things, but it may have helped. Playing by the rules certainly didn’t save my organisation, the London Drug and Alcohol Policy Forum, from having its funding terminated. But I do find myself wondering about systems and structures that allow this kind of thing to happen.

Revitalising the UK drug and alcohol sector will not just require heavy investment - we should never lose sight that a great deal of innovation and service development happened before there was significant central investment. It happened because individuals and agencies recognised a need and realised that they couldn’t wait for someone else to start doing things. They were often sailing uncharted waters. Here in 2021, we have a much better idea of what works and what is worth doing.

Those who work in the drug and alcohol treatment sector are used to their clients coming at the bottom of the pile. They are not a politically powerful lobby, nor do they always attract much public sympathy. But overlooking what is happening to disadvantaged groups is not only morally wrong, it is also bad policy. Just as canaries in the mine provide warning of danger, so we should take note of increases in death and disease in our vulnerable populations. The major factors and determinants at play don’t restrict themselves to just one small group or section of society. Sooner or later, they impact on a broader swathe of society. Helping the vulnerable helps everybody.

There have been a number of recent stories about reversal in life expectancy in the developed world, much of the blame being attributed to COVID. Now clearly the pandemic has had a significant impact, but it’s not solely to blame, and we should be wary of accepting simple alibis. Prior to the pandemic the USA had already seen a drop in life expectancy since 2014, falling behind many other first world countries despite spending more on healthcare. More than one factor is at play here, but drug deaths, suicide and homicide rates are all involved, and many of these are underpinned by economic inequality.

Other countries have also seen increases stall, notably the UK and Canada. Both have seen increases in what are grimly referred to as “deaths of despair” (mortality linked to alcohol, drugs and suicide). Now I know I risk upsetting my data analyst friends by pointing out that the near stalling of increases in life expectancy (England and Wales) dates from 2011, which links closely to the growth in drug related deaths we have seen since 2012. It takes time for trends to become clear, but I remain shocked, and yes, angry, at how little response we have seen to a decade of year on year increases in drug deaths – I am also gobsmacked at how little has been done or said about life expectancy. Surely this is as fundamental as things get? Surely it deserves a fundamental reappraisal about how things are done, about whether sight has been lost of real people and real lives. Now while I have focussed here on the UK, USA and Canada, I think it clear that these problems are widely evidenced around the world.

So, what do I suggest we need to do? Well money is always nice, but we can start by improving how we work with communities, by understanding their needs and aspirations;

  • Don’t impose externally decided targets and outcomes;
  • Work with them where they are;
  • Recognise the potential that harm reduction provides for real and sustainable health improvement;
  • Encourage genuine empathy, and don’t show disdain for the key populations that most need help;
  • All vulnerable communities possess an energy that professionals can never provide, but it needs to be tapped and nurtured.

There is also much that we as practitioners, policy makers, front line workers or researchers can do. We should stop waiting for permission to do the things we know work and we should forge the alliances and networks which enable and empower us to deliver. We need to rebuild from the ground up and not the top down.

Becoming more active in GPHN would be a start – readers of this blog can help by providing us with blogs and article on your work and experiences. I am also delighted that the 11th City Health International conference is being held on 29 and 30 November in Warsaw. Whether you join us in person or online this can be the start of reclaiming public health for those most in need of it.

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