We were delighted that Professor Dame Carol Black was able to deliver the iOH Ruth Alston Lecture, which focused on her recent independent review of illicit drugs, commissioned by Government in January 2019 and researched and written in two Parts over two and a half years. This is a summary of her lecture.
It all started in 2015 with work, the benefit system, drugs and alcohol. I was then Head of House at Newnham College in Cambridge, but still deeply engaged with the Health and Wellbeing agenda, and still advising Government in this space.
I received a phone call from Ian Duncan Smith, then Secretary of State for Work and Pensions, asking whether I would undertake an independent review of long-term conditions, particularly drug and alcohol addiction and obesity, to consider how to support sufferers back into, or to remain in, work. The Government wanted to understand the causes of worklessness and the associated costs; the barriers to work; the pathways taken through the healthcare and benefits systems and the role of providers and employers; and the availability and cost-effectiveness of treatments and interventions.
It was a tough assignment.
We identified three main areas for action:
- Treatment, in itself not ensuring employment;
- The Benefit System, hampered by severe lack of information on health conditions, and poor incentives for staff to tackle difficult or long-term cases;
- Employers, without who’s co-operation employment for our cohorts is impossible, reluctant to hire people with addiction and/or criminal records, so that decisions to recruit needed to be de-risked.
We came to appreciate that work is crucial to recovery for many individuals – and we sought to understand the perspective of people experiencing these conditions.
These complex, often disorganised, individuals have chronic health conditions, are disabled in many ways, and in need of personalised services, of innovation and investment, and opportunity to find purpose in life. Their stories were powerful, and send a clear message – within and after treatment for addiction there must be meaningful activity, preferably work, otherwise the void and boredom will soon be filled by a return to old habits.
There is a mutually-reinforcing relationship between employment and recovery – being employed at treatment start improves chances of completing the treatment successfully, and completing treatment well improves the chances of finding work. Also employment can moderate relapse. Only 1 in 5 of those starting treatment are employed, and these tend to stay in work throughout treatment – but few who enter treatment without being in work find employment during or after treatment.
I talked to many OH colleagues and employers at that time, and we took evidence. While I could see that good employers supported by OH colleagues would do their best to support their own workers who ran into trouble, especially with alcohol, drugs were not so easily tolerated. We knew from work by the UK Drugs Policy Commission a few years earlier that employers are generally reluctant to take on ‘risky’ applicants, and that recruitment processes are used to manage perceived risks, from ruling out drug users altogether to taking more discerning steps. In considering whether an individual is fit for the job, ‘fitness’ was perceived in various ways, with stereotypes and prejudices, and some employers wanted updates on progress with rehabilitation or treatment. A criminal record was also a barrier.
Our work on the 2016 review confirmed this – we needed to show employers and the OH community that giving such people a chance was worthwhile and do-able – but they needed more evidence, there was no easy fix. We came to the conclusion that we needed to find evidence that drug- and alcohol-dependent people could return to work, and one of the most powerful recommendations in that review was to study the value of IPS for such people, Individual Placement and Support being, as you know, an intensive employment support intervention with an established evidence base in the Mental Health sector.
“Government should conduct a trial of the IPS approach, including a comparison with a time-limited version (IPS-lite), with JobcentrePlus work coaches co-located in treatment services providing employer support, with appropriate financial support for small employers”.
The Government did this, with a randomised trial in seven Centres across the country, commissioned by DWP and executed extremely well by PHE. It started in 2017 and finished in 2021, with results to be published soon. This is a vital part of the jigsaw, important to my continued interest and the subsequent review. From 2017 to the end of the IPS trial I was in regular contact with PHE and the Centres, and visited them more than once. I learned of their work, and also learnt more about drug and alcohol dependency, and was frankly upset by the ever-declining quality and quantity of treatment. Thus the request in January 2019 to do the review of illicit drugs was welcome.
I produced the drug report in two Parts, Part 1 published February 2020 looking at Supply and Demand, and Part 2 published July 2021 exploring Treatment, Recovery and Prevention.
During this work I became convinced that tackling drug misuse is the single most important thing that can be done to reduce crime.
Half of all homicides, and half of serious acquisitive crimes, are related to the drugs market.
One third of our prison places are accommodating people who are drug-dependent.
Drug-dependency is a complex stigmatised problem. Until now those dependent on illicit drugs have not been properly ‘owned’ by any one Department of State – they are too messy and difficult, while of course causing personal, family and societal misery, and costing the Government some £19 billion per year.
Let me tell you something about Part 1 of my independent Review.
Part 1 addressed supply and demand for illicit drugs, and involved many months of rigorous and ground-breaking analysis to understand the complex and overlapping markets for illegal drugs. I took a market approach because the supply of drugs is driven by profit, and violence is often the result of competition for market share. Only by understanding the market and the drivers behind it could Government hope to disrupt it. For example, the growth in county lines appears to be largely caused by market saturation in the big cities. It has exploited vulnerable people, especially the young. Some 27,000 young people in London identified as gang members, many drawn into drug dealing, often with deadly consequences as the supply and distribution of drugs have become increasingly violent.
There is a very tragic human story behind this market analysis. Drug deaths in 2018 were the highest on record, and they are now even higher. Since 2012 heroin-related deaths have more than doubled, while deaths involving cocaine have increased five-fold. We have the highest number since records began of rough sleepers dying on our streets from drug poisoning. Long-term drug users often cycle in and out of our prisons, at great expense but very rarely achieving recovery or finding meaningful work. Many of their children are taken into care. Problem drug use is highly correlated with poverty, and these problems blight our most deprived communities – highlighting the need for ‘levelling up’.
A perfect storm
I saw first-hand, in prisons, schools, youth clubs and charities, the effects of increasing supply, greater drug purity and easier availability. This has combined, due to cuts in Police, border control, the National Crime Agency, schools and local authorities, with the loss of many protective factors that had kept children, young people and at-risk families away from danger – resulting in a perfect storm, to abate only if the Government takes action.
I noted that treatment services had been curtailed by cuts in local government funding. The total cost to society of illegal drugs is around £20 billion per year, but only £600 million was spent yearly on treatment and prevention. So the amount of un-met need was growing, some treatment services are disappearing, and the treatment workforce is declining in number and quality. I said that we need to transform our approach to treatment, investing in it but also innovating so that treatment services are able to respond to today’s drugs market and future developments.
Previous Governments have de-prioritised these problems – from preventing drugs entering the country right through to helping drug users access appropriate treatment and achieve recovery. I intended Part 1 to provide a firm platform for decisive action by the Government.
In Part 2 of the Review, on treatment, recovery and prevention, I found a system unfit for purpose and broken :
- funding cuts have left treatment and recovery services on their knees, with little MH or trauma treatment, and inadequate support for housing or help into employment;
- commissioning has been fragmented, with little accountability for outcomes, and partnerships between local authorities, health and criminal justice agencies have deteriorated;
- workforce depleted and demoralised, with falling numbers of professionally-qualified people;
- services cut back, particularly in-patient de-toxification, residential rehabilitation, specialist services for young people, and treatment for users of cannabis etc; and
- Ministers and departments had I believe not worked sufficiently well together in a determined and sustained way.
The situation is intolerable, and significant changes must be made in several areas.
In addition, too many drug offenders go to prison, with no positive outcome.
- A more cost-effective alternative to short prison sentences is needed, with more people diverted into drug treatment and recovery services where appropriate. In the last seven years referrals to treatment from the criminal justice system have fallen substantially, and there has been marked decline in use of community sentences with Drug Rehabilitation Requirements.
- The period immediately after release from prison is challenging. Those released, often driven by renewed desire for drugs, are at high risk of overdose and re-offending. Only a third of those referred for further treatment in the community go on to receive it within three weeks. Delays in accessing benefits also contribute to an individual’s vulnerability to temptation and relapse. Housing support and opportunities for work or training have been negligible. Shortcomings noted in the crucial Probation Service have been confirmed in the recent report by the Chief Inspector of Probation.
With this dreadful picture of where we are now, and the challenges ahead, my report recommends a whole-system approach. I put the drug-dependent persons at the centre, and asked: What do they need to stand a reasonable chance of successfully moving off drugs ?
- Pharmaceutical medical intervention to replace e.g. the heroin
- A recovery plan and support
- Mental Health and trauma-informed services
- Clinical medicine for additional problems – HIV, ulcers, hepatitis, lung disease etc
- Housing support
- Work – as they seek something meaningful to do
This requires six Departments of State to work together in a co-ordinated way with a Central Unit, conductor of the orchestra, linking to local delivery of services and treatment.
My ‘whole system’ approach leads to 32 recommendations. I will not – you will be relieved to hear – read them all out, but to give you a flavour, when consulting the Review you will find:
- Central Unit (the Joint Combatting Drugs Unit, JCDU
- Allocated money ring-fenced
- Commissioning reformed, with standards and outcome frameworks
- Accountability strong
- Workforce rebuilt
- Treatment and Recovery re-vitalised, with innovation and a new workforce strategy.
- Diversion from prison, and care after release
- Housing, more and targeted
- Work or at least activity
- IPS for the whole country – the trial is positive, it was worth doing and worth waiting for
The Government responded to my Review on 6th December 2021, with a new ten-year strategy against drugs, accepting 31 of the 32 recommendations and allocating an additional £782 million over the first three years to support Treatment, Recovery and Prevention.
Work is now an integral part of this. Every area of the country will have an Individual Placement and Support service – but this will require more employers to step forward. There will also be peer mentors in each Job Centre.
The question I leave with is:
What should be the role of Occupational Health professionals in supporting and enabling this highly-stigmatised group of individuals to get the opportunities that they and society need them to have? Will you get engaged with this agenda, and enable them to find work?
Written by Professor Dame Carol Black
Professor Dame Carol Black, DBE, FRCP BSD, was the Principal of Newnham College, Cambridge, until 2019. She was an adviser to the British Government on the relationship between work and health from 2006-2016. She is a medical practitioner and an expert on the disease scleroderma. She is currently Chair of the British Library, the Centre for Ageing Better, and Think Ahead, the Government’s fast-stream training programme for Mental Health Social Workers. She co-chairs NHS England/Improvement’s Expert Advisory Group on Employee Health and Wellbeing.