NTA REHAB REPORT: FIRST 26 QUESTIONS
… WHICH MUST BE ANSWERED TO STOP BUILDING ON QUICKSAND
For government and local authorities to spend taxpayer money wisely, they must have accurate facts on which to base decisions. But Addiction Today has been contacted by providers disagreeing with the NTA’s latest documents on drug-treatment implementation, says Deirdre Boyd.
Download AddictionToday138-NTA rehab report-26 questions
Days before politicians recessed parliament for summer and the Olympic Games, the National Treatment Agency for Substance Misuse published reports titled The role of residential rehab in an integrated drug treatment system and Medications in recovery, Re-orientating drug dependence treatment. In March 2011, we published a list of ‘bear traps’ for government on How drug policy will fail and how recognition of this led to the formation of the Concordat of drug-free recovery providers.
Over two decades, time has proven ARF predictions overwhelmingly accurate – but the NTA reports seem to have ignored them, or at least not to have tackled the potential pitfalls.
The NTA states that “The role of residential rehab in an integrated drug treatment systems has been submitted to the Commons home affairs select committee as part of the NTA’s evidence to its inquiry into drugs policy”. We have also, alarmingly, heard from recovery-treatment providers large and small that local commissioners are refusing to commission them based on NTA NDTMS figures and interpretations. Lack of appropriate treatment from decisions built on NTA statements can endanger lives and misdirect funding. So there is a public-interest urgency in disseminating the facts, in debunking myths.
Here, I must make an apology: there was not enough space in Addiction Today journal (September 2012) to correct all the statements in the NTA’s documents, despite the fact that giving government and local commissioners, the general public and media information which is not misleading is a public-interest priority. What we can do is give you the results of our initial survey, so you can start to ask your own questions. We will also undertake to investigate this further, with researchers and rehab providers – and offer anonymity to those who request it for fear of reprisals, sadly something which continues.
“THE ROLE OF RESIDENTIAL REHAB”:
10 NTA STATEMENTS, 26 INITIAL QUERIES
Statement 1. “Residential rehab is an integral part of any drug treatment system, a vital option for some people requiring treatment for drug dependence. Anyone who needs it should have easy access to rehab, whether close to home or further away.”
We agree. So why has it not happened in the 11 years the NTA had responsibility for this?
S2. “Many different types of residential rehab are available. The most common factor is that residents have to stay overnight to receive treatment, and are expected to be abstinent before they start the programme.”
Question 2. If the NTA was correct in claiming that residents “are expected to be abstinent before they start”, why have so many rehabs invested in their own detox units and staff? When I was in rehab over two decades ago, detox was part of the service – and still is.
Q3. Why did the NTA not mention that rehab detox is cheaper than in the NHS?
Q4. Or that it is can be more effective, as recovery staff are on the premises to transition patients to appropriate care?
Q5. For those rehabs without inhouse detox, why did the NTA not mention organisations such as Addictions UK which can arrange detox in partnership?
Q6. The crucial definition of residential rehab – understood by the general public, if not the NTA – is that it offers the ability for residents to quit drugs/alcohol for the long term, that the rehab believes this can be achieved not least because of its track record plus the fact that a significant percentage of staff are in drug-free recovery. So why does the NTA/NDTMS definition of rehab include agencies which do not offer drug-free services?
Q7. Why is the definition not changed in the upcoming NDTMS dataset J, after ARF and the Concordat highlighted it to the NTA last year?
Q8. Does the NTA truly believe that including statistics for non-abstinent agencies under the heading of rehabs when advising ministers, officials and local commissioners will give an accurate picture of clinical effectiveness and cost effectiveness? That it will show government and taxpayers where their money is best spent?
S3. “Residential rehab currently accounts for 2% of people in adult drug treatment but 10% of central funding. On average a period in rehab costs £600 a week, making it much more expensive than non-residential treatment services.”
Q9. It is tragic that only 2% of people “in the system” are allowed to access rehab; will the NTA improve this? The Concordat has been campaigning to raise this to a more balanced 10%.
Q10. Cost per week is accurate only when multiplied by the number of weeks of treatment, to get a total sum. Why does the NTA omit such an important factor? After all, 52 weeks of methadone – and a significant number are on it for decades – can be equivalent to a month in rehab, which in some cases is all that is needed.
Q11. The drugs budget is about £900million but rehabs receive maximum £20-30million a year: 2-3%. So how does the NTA make it 10%?
Q12. Is the NTA including in the cost of rehab the cost of the non-rehab, non-abstinent community ‘treatment’ prior to rehab?
Q13. If so, surely that is a strong argument for people to get into rehab quicker than is currently the case?
Q14. A report on rehabs by the Concordat as to how NDTMS figures can be skewed showed that patients had been neglected so much before rehab that medical assessments saw them rushed immediately into the most expensive treatment possible: hospital emergency units. The NTA reports omit the far cheaper option of early rehab.
S4. “An audit of annual data returns shows that residential rehab is not an automatic exit door from the treatment system, but an integral part of a network of services. Three-quarters of residents come from community-based treatment services before accessing residential rehab, and the majority return for further structured support afterwards.”
Q15. This seems to support the theory that the NTA has included the cost of community-based treatment services in rehab, artifically lowering the first and raising the second – will it confirm this?
Q16. Is it not logical to reason that if patients’ rehab is delayed to such an extent that they might need A&E (see Q14) that they will need services over and above rehab?
Q17. And that this could be avoidable, with early and appropriate referrals?
S5. “For every ten people who go to rehab each year, three successfully overcome their dependency, one drops out, and six go on to further structured support in the community. Of those six, two overcome dependency with the help of a community provider, at least two are still in the system, and at least one drops out.”
Q18. Is this not a natural result of findings referred to in Q14 onward?
S6. “Almost two-thirds of those who drop out from residential rehab do so in the first few weeks, suggesting that referring services and receiving facilities need to ensure people are better prepared before entering residential programmes and better supported during their stay.”
Q19. A quarter of patients ‘decline’ treatment almost immediately after assessment in the rehab. One reason is the need to rush new patients to A&E, another is misdiagnosed patients such as streetworkers and young men with other issues. The NTA told us that ‘declineds’ were included in the NDTMS unsuccessful-outcome figures – even though they had not started treatment. Is it reasonable to include patients who have not even started rehab in unsuccessful outcome figures? Does it give a sound basis?
S7. “Outcomes vary across the residential sector. The best performers see more than 60% of their residents go on to overcome dependence, while the poorest struggle to enable 20% or fewer to overcome addiction. All services will have to demonstrate value for money in an increasingly outcomes-focused healthcare landscape.”
Q20. We agree that outcomes vary: one quasi-residential told a newpaper that he had only 30% success rates, which is half what would be expected in worldclass research. The question is how accurate will the measurements be? How independent will be those who measure?
S8. “The best-performing rehabs do well with complex users, who often do not benefit from cheaper community treatment. To justify the extra cost of residential placement, rehabs will in future have to focus on the complex cases, where they can add value to the treatment system.”
Q21. Does the NTA not know that rehabs already treat the most complex cases? As long ago as 2001 when the NTA was formed, the UK’s most comprehensive study on treatment, NTORS, found that “Clients in rehabilitation units included the more chronic, long-term users with the most severe problems. Rehab clients presented with the longest heroin careers, they were more likely to be regular users of stimulants (especially cocaine), and were more likely to have shared injecting equipment. There were also more heavy drinkers among the clients entering rehab. Rehab clients were more likely to have been actively involved in crime and had been arrested more often than the other clients.”
Q22. Why has the NTA not taken account of the above when stating costings?
S9. “Rehabs are more successful at retaining and treating residents with severe alcohol dependency than drug addicts – possibly because dependent drinkers have more personal and social capital to invest in recovery.”
Q23. We agree, from research we have seen! But how relevant is it when polydrug use abounds? And how will the NTA ensure that its statement does not stigmatise drug vs alcohol users?
S10.“In the light of the 2010 Drug Strategy, the NTA is collaborating with the Recovery Partnership and others to help residential rehab providers adapt to the shift to an outcome-focused local public health system in which they are paid by results. Some providers will need to improve their performance to meet future needs of commissioners and service user.”
Q24. Is it not against Civil Service ethics to give commercial advantage, as the NTA report does, to a private limited company? (Recovery Partnership, co reg no 8080136)
Q25. Why highlight, in a report about rehabs, a private company which cannot represent rehabs in the way the Concordat, for example, does with its greater numbers and specialist expertise? RP (directors Noreen Oliver and Martin Barnes, who is also CEO of DrugScope) is described as consisting of DrugScope, the NTA-initiated Skills Consortium and RGUK whose co-chairs are Barnes and Oliver. They should be congratulated on arranging meetings of a broad range of agencies to write reports to the Inter-Ministerial Group. But RGUK’s composition is similar to the NTA’s “expert group”, with the addition of a handful of rehabs, so must be mindful of its wideranging contributors’ interests, particularly where they could be regarded as competitive, so cannot prioritise rehabs.
Q26. Is the NTA denying information from ‘on the ground’ to ministers? ARF, the Concordat and EATA, which represented treatment providers until it closed last March, had contributed time, contacts and information to RGUK. But in January, NTA programme manager Jez Stannard wrote to me and EATA CEO Colin Wilkie-Jones, saying that its purpose was “not to offer a platform to the different organisations which come together under the umbrella of the Expert Group”. The reward for our help was a denial of our voices. This is inequitable for vulnerable clients.
“My impression is that the NTA is being forced to work with the rehab sector but is doing its best to denigrate it, while pumping up the appearance of effectiveness of community based services,” one provider representative wrote to us.
SUBSTITUTE MEDICATION REPORT:
CONFLICTS OF INTEREST
There was no space left in the journal to critique Medications in recovery, Re-orientating drug dependence treatment so we will return to it at a later date. In the meantime, ask yourself two questions. First, for balance, why did the NTA not commission a Full-recovery report and how to achieve it? Second, the report recommends using drugs such as naloxone and opiate substitutes – why is a statement of interests including those of the report chair paid by pharmaceutical manufacturers of those drugs not inclusive but must be sought elsewhere?