Specialist Detox Units are closed and patients end up in A&Es that are already at breaking point. When will it end?
The closure of City Roads after 30 years is yet another well established detox unit closing.
Just 10 years ago, there were numerous residential detox units across the country offering treatment to service users. Now, there is just a handful left and most of these are struggling to stay open amid budget cuts and decreasing referrals. The remaining five NHS in-patient units (which care for some of the most complex and vulnerable patients) estimate that, by 2020, they will also be in danger of closure if current funding arrangements remain as they are.
Arguably, as a sector, we had become too reliant on residential treatment and any service user deemed ‘problematic’ could be referred rather than having the option of local community based detox. Perhaps there needed to be a rebalancing and some units did need to close. Perhaps expanding the community provision was required to give service users more choice. Perhaps we have now gone too far and we are in danger of losing what few beds we have left.
With budgets being cut and the money for detox and rehab being increasingly given to the community providers to manage the referrals, the numbers accessing residential treatment have dropped. With this responsibility delegated to providers, local authorities are no longer directly responsible or accountable for any reduction in access as budgets are held by the providers. Providers can say that they have to balance the need of the many accessing their services against the few (and anyway we offer community detox so what’s the problem?). Therefore, accountability and scrutiny is fragmented and weakened.
The problem though, is that those clients that need more intense treatment haven’t gone away. Take London as an example. There is now only one residential detox unit in the capital. With a large drug using population across the city, we can only muster enough referrals to sustain one unit and no NHS units (the units that are equipped to treat the most complex patients) within the capital. Is this credible? If the clients haven’t gone away, where are they?
These clients are struggling to undertake community detox but continue to use and to have multiple needs. Instead of being supported, ever stretched, recovery-focused community services struggle to meet their needs and lack the capacity to engage. However, they do access other health services through A&E. Once in A&E, it is difficult for medical staff to deal with them; if they admit them into a ward then they are likely to have to start to detox them and if there is no safe place to discharge them they will then have to stay on a ward.
This type of detox is far from ideal: there is no structured psychosocial work undertaken and the medical staff supporting the patient aren't specialists in substance use. For context, in terms of cost, and this is a very limited assessment of the true cost, an A&E attendance episode costs £160 (NHS Improvement, 2018) and an ambulance costs £240 per see, treat and convey (NHS Improvement, 2018). This is prior to any additional costs associated with the hospital stay and higher than the day rate cost per patient of a stay in a highly specialised, well staffed, NHS Inpatient Unit.
So, maybe there is a solution. If the NHS is being forced to subsidise local drug and alcohol treatment systems by delivering detox in acute hospitals, then perhaps they should send a bill to the local commissioners for every patient they see?
Perhaps this would force a proper conversation about what the need for residential treatment is in each area. Perhaps it would enable the residential sector to stop shrinking. Perhaps it would force us to actually make services join up rather than just talk about doing it. Perhaps it would prompt decision makers nationally to properly consider how to maintain NHS inpatient units which see the most vulnerable and complex clients; meeting this challenge and striking a balance between national and local responsibility. Perhaps it would reduce some of the burden on the acute hospitals that are already struggling. Perhaps it would make national decision makers, local commissioners and providers identify real funding and build sustainable commissioning structures for proper residential detox, and perhaps, just maybe, it would offer service users more choice and help encourage those in most need to re-engage with community services. It might even help reduce the drug related death figures.
The other option is to continue to do nothing and the pressure and cost on other NHS services will just increase whilst funding for these types of services will continue to decline.