The Care Quality Commission recently published the results of an inspection of 68 drug and alcohol detoxification facilities.
These are services that should provide medically supervised withdrawal from drugs and alcohol in residential settings, stabilising them as a step on the therapeutic journey.
The review found many of the independent services inspected were “not providing safe or good quality care”. In some places staff administered medication, including controlled drugs, without appropriate training; there was lack of planning for patients having seizures; there were deficits in training for life support and safeguarding; and even things like paracetamol were being given too frequently, creating additional risk of liver damage in a population already at greater risk.
Cue a British Medical Journal blog authored by several members of the addictions faculty of the Royal College of Psychiatrists, one of whose authors is an adviser to the CQC (but who claims not to express CQC views). It called for detoxification services to be returned to the NHS. The RCP’s view for some time has been to call for drugs services to be taken out of local authority commissioning and put back into the NHS. “The policy experiment with addiction services has failed. An urgent review of commissioning is needed,” the blog said.
I don’t share that view. Neither, it appears, does the government. While the blog has helpfully highlighted the damaging impact of government cuts to public health (but says nothing about cuts to social care, preferring to complain about NHS training posts) I have a long memory in this field, and remember detoxification services, both NHS and independently provided, having quality problems repeatedly over the years. Shifting the deckchairs around in a system under challenge is not the answer. In fact, this call is a distraction from getting the system right.
Among other things, the BMJ blog selectively argues drug-related deaths as a reason for transfer. This ignores much of the good work councils do to reduce drug-related deaths and that the national review of drug-related deaths concluded there were multiple causes, which had been increasing since before councils assumed responsibility. The national roll-out of naloxone by councils to reduce opiate deaths was recognised as just one success in reducing drug-related deaths. Without work already done by councils and providers together, drug-related deaths would be even worse.
For a profession that claims to be evidence-based, this kind of selective post hoc justification of ambitions, which are essentially political and about getting services back in the NHS, is neither helpful nor edifying. But to dismiss this as another example of simplistic ‘council commissioning bad’ rhetoric, which is not borne out by outcomes data, would miss the opportunity this blog gives us. We need to get the system right and councils are trying to play their part. Now what we need is to join up.
In 2014 a joint report by Public Health England and the Association of Directors of Public Health saw that, largely, councils were taking their commissioning roles very seriously and were trying to improve quality, outcomes and value for money.
This report was followed by a Public Health England evidence review in 2017, which found English treatment systems were “comparable with or better than other countries’”, a point conveniently left out by the BMJ blog.
Getting the system right means we need to make sure everyone plays their part. Councils are, largely, taking their commissioning responsibilities seriously. Many treatment providers are showing significant leadership in improving outcomes for people. The CQC has brought valuable transparency to a bit of the system in which we need to do better and we should welcome that. We still need to sort out clinical training, and Health Education England needs to work more closely with us on this. We have more work to do on people with co-occuring substance and mental health issues. We need to do more to get people off dependency and back into education and employment.
Despite a lacklustre national drugs strategy and continued financial strain, there is much we can do if we work together. New evidence and treatment guidelines provide us an opportunity. We should welcome CQC oversight of detoxification services in the same way as we welcome CQC oversight of all drug and alcohol treatment and care services.
It’s time for a joined-up conversation based around outcomes for people. Knee-jerk calls for moving the deckchairs around because some folk don’t trust councils to do the right thing are a distraction.
Jim McManus, director of public health, Hertfordshire CC