Rediscovering lost practice and skills couldn’t be more important.


‘Nostalgia isn’t what it is used to be’ goes the witty quote, but are drug and alcohol services what they used to be?

Well, no. Historically, before the formation of the National Treatment Agency, some areas saw more than two-year waiting lists for opiate substitution therapy and investment in alcohol services was severely lacking. However, at the start of the current cycle of tender and procurement, there had already been significant improvements in these areas.

The combination of commissioning by local authorities, the global financial crash and ongoing austerity has resulted in devastating disinvestment in our services. Recent disinvestment and retendering cycles have resulted in changes in the skill mix of services, with fewer nurses, doctors and psychologists (those registered with professional bodies) in teams. There is now an over-reliance on staff without professional registration or specialist training, and on volunteers.

There has been a significant loss of knowledge, practice and skills as provider organisations design services which try to manage the reduction in budgets whilst still meeting service users’ needs. The necessity for high-calibre clinical skills and expertise was recently highlighted by two eminent leaders in the field: Professors Colin Drummond and Sir John Strang in the Mental Health Times and BMJ respectively. Professor Drummond stated:

"Without proper care there are serious risks including epileptic fits and hallucinations, brain damage, suicide and risk of overdose. Yet many services do not have doctors or nurses with sufficient specialist training and competence to provide safe care."

This highlights that registered staff and Doctors have been in steady decline, but also that many of those recruited lack the relevant training, supervision and support to ensure high quality provision for the often very complex service users. These experts do exist but, more and more, they are in a lead role rather than ‘on the ground’. Due to their scarcity, this often means they are in a national-lead role which affects their contribution locally.

There are only so many hours in a week.

A reduction in budgets means cash-strapped services are so finely constructed that they are able only to work the purest interpretation of the service specification. This has resulted in a compounding effect: that of smaller budgets, and a loss in additional social capital from providers.

As a sector, we have been eager to seek solutions - usually through collaborative partnership arrangements across health and social care.  The significant decline in registered staff (such as Nurses, Social Workers, Clinical Psychologists and Doctors) within the sector means it is harder to achieve developments even when the willingness has been there. Being able to speak the language of those that you wish to collaborate with has its advantages and enables effective partnership to prosper far more easily. The loss of these posts and the assurance of the NHS badge have negatively affected partnerships, most notably with health colleagues.

The continued reduction in professionally-registered staff in treatment services is diluting the skills and professionalism required to address the needs of our service users. As an example, a recent CQC publication reports on serious concerns uncovered in many of the independent detoxification clinics across the country (CQC, 2017). The level to which registered staff and the number of NHS providers has reduced places the overall standard of care at risk in many areas. In short, the loss of these providers, practice and skills means some drug and alcohol services are relying on limited clinical expertise. This is to the detriment of care.

Public Health England recently commissioned three publications highlighting the importance of the roles of nurses, addiction specialist doctors and psychologists within the drug and alcohol sector. They are signifying to commissioners and providers that these skills and professionals are essential. The significant loss of these professions and their skills has, and is having, an impact on the overall provision of care. It is putting service users at risk.

NHS SMPA, as a group of NHS providers, is looking to make our contribution in changing this. The examples below illustrate what has been lost, but equally provide examples of how the sector can respond positively to this downward trend. These innovations by NHS services are where good practice has been implemented to improve the wellbeing of our service users, and illustrate why retaining an appropriately balanced and skilled workforce is essential: