3 Existing Services

3.1 This chapter provides a brief overview of the pattern of existing services for drug misusers and considers the ability of these services to respond to the demand they face.

The Advisory Council's Report on Treatment and Rehabilitation

3.2 The Advisory Council's report on Treatment and Rehabilitation was published in 1982. It highlighted the need for a comprehensive approach to drug misuse with the emphasis on a multi-disciplinary response, calling for active involvement of a wide range of both specialist and non-specialist agencies. It emphasised in particular, the need for the range of service provision to include:

a. Hospital-Based Treatment Services
Staffed by a multi-disciplinary team comprising at least a consultant psychiatrist, another doctor, a social worker, and a nurse. Able to undertake assessment and provide help from a full range of options which should include detoxification as an inpatient, outpatient or day patient, short or longer-term prescribing of controlled drugs or other medicines, referral where appropriate to a rehabilitation facility and counselling and treatment over a period of months or years. The need for active liaison with other specialist and non-specialist services was stressed.

b. Other Specialist Agencies
Three kinds of services were identified as important here. First, advice and counselling services which should aim to assist individuals to contain their drug misuse and, where necessary, to accept further help. Second, day care which was seen as a means of providing a more structured and therapeutic environment for drug misusers. Third, residental facilities for drug misusers including supported accommodation for those continuing to take drugs and drug-free accommodation for those needing a therapeutic residential unit to adjust to abstinence.

c. Non-Specialist Services
Primary medical services, social services departments, the probation service, housing departments and housing associations, employment services and non-specialist, non-statutory agencies were all identified as having a valuable role to play. The opportunities these services provide to intervene with drug problems at an early stage were highlighted.

3.3 The report recommended that this range of services should be supported by multi-disciplinary Drug Problem Teams established initially at Regional level, and in the longer term at District level. The establishment of Drug Advisory Committees at both Regional and District levels was also recommended, to monitor the prevalence of drug misuse and the effectiveness of services and to foster improvements.

Developments Since 1982

3.4 In response to the report, the Government funded a major expansion in services for drug misusers. In England, £17.5 million was committed to a Central Funding Initiative which provided `pump-priming' funds for 188 local projects. Forty-two per cent of the projects funded were in the voluntary sector and almost half the funding went to community-based services. This central funding was provided for a maximum of 3 years with the intention that statutory authorities should pick up the funding at the end of the period, providing the service remained relevant to local needs. First indications are that funding has been picked up locally in the vast majority of cases where central funding has expired, though the overall numbers of such cases are currently small. Since 1985-86 the DHSS has provided health authorities in England with £5 million a year to continue the development of local services and in 1987-88 a further £1 million was provided to help drug misuse services to play a growing role in tackling AIDS and HIV.

3.5 Central funding was also provided in Scotland and Wales. In Wales since 1985-86 £1.64m has been allocated to District Health Authorities and voluntary bodies for the development of services for drug misusers. Funding is on a recurrent basis for the duration of projects, subject to a review after 3 years that the services continue to be needed and are effective. Recently, the Welsh Office received bids from district health authorities for funds to support AIDS prevention activities, and funds (£33,500 pa) have been made available specifically for the counselling of drug misusers. In Scotland, funds have been set aside in the health programme since 1984-85 specifically for the support of drug misuse services. From 1987-88, over £1 million per annum is being made available for this purpose and Health Boards have assumed responsibility for the local projects previously funded by the Scottish Home and Health Department.

3.6 More details can be found in papers submitted to us by the Health Departments which are reproduced at Annex E.

The Present State of Services

3.7 Our enquiries, together with the evidence submitted to us, show that there has undoubtedly been a major expansion and development of services since the report on Treatment and Rehabilitation was published. We particularly welcome the very significant increase in community-based facilities. We also welcome the increased specialist psychiatric input which has occurred in many areas through, for example, more use of community psychiatric nurses as well as new consultant posts. The combination of community services and medical input in the Community Drug Teams which some districts have established, particularly in the North West, is an important development. There are, however, significant variations in the services available in different districts and regions. In some areas, the service provision is minimal and expansion is urgently needed.

3.8 Just as important as the scale of service provision is the range of services and help available. Here again, the picture varies considerably across the UK. In some areas positive and enthusiastic attitudes have led to a full range of co-ordinated services being provided. In others, entrenched attitudes have contributed to incomplete and ill-co-ordinated provision of services. Three points in particular cause us grave concern:

a. the refusal of many psychiatrists in Scotland to accept more than a very limited role in the treatment of drug misuse;

b. the failure of specialist services in some areas to provide help from the full range of options, including prescribing options, described in the Treatment and Rehabilitation report (and reproduced at para 3.2(a) above); and

c. the reluctance of many general practitioners, and other generic professionals, to accept the identification and treatment of drug misusers as part of their role.

We believe that these shortcomings must be rectified if services are to be fully effective in tackling the spread of HIV. We return to each of them later in this report.

3.9 We have not been able to conduct a comprehensive survey .of the demand on services but the evidence we have received suggests that most services are already working at, or beyond, their capacity. Several witnesses have explained that their services no longer actively seek new clients as they are already overburdened and there are some long waiting times for hospital-based specialist treatment.

3.10 In conclusion, we welcome the major expansion of services for drug misusers resulting from Government action and funding following the publication of the Treatment and Rehabilitation report. Those areas which have developed services in accordance with the Treatment and Rehabilitation report and subsequent Government guidance will be best placed to implement the further developments now needed to combat the spread of HIV. In other areas, where services are less well developed, urgent action is required to rectify shortcomings and provide a base for the new developments needed to tackle HIV. In all areas, substantial further expansion will be necessary if services are to reach more drug misusers and play an effective role in curbing the spread of HIV.