9 Management, Organisation, Resources and Training

Management and Organisation

9.1 The advent of HIV and AIDS has many implications for the management and organisation of services. Those which arise directly from the specific recommendations we make about services will be self-evident and are not repeated here. We do, however, wish to highlight three themes which are important for those responsible for the management of services.

9.2 First, the need for very proactive and imaginative approaches in making contact with drug misusers. It will not be adequate simply to cater for existing `demand'. A variety of ventures often using unproven techniques will be needed. A range of diverse approaches is likely to bring the maximum benefit.

9.3 Second, all services working with drug misusers need to recognise a hierarchy of goals (see Para 5.2), uppermost of which is that of combating the spread of HIV.

9.4 Third, the need to tackle HIV alongside drug misuse redoubles the importance of inter-agency working. This goes far beyond co-operation between those services primarily concerned with HIV/AIDS and those primarily concerned with drug misuse. Of key importance is the recognition that the services provided by a range of agencies working together is more likely to be effective in reaching many drug misusers and changing their behaviour than any single agency working in isolation. An increase in co-operative working between specialist and non-specialist agencies will be needed in many areas. Streamlined and effective referral procedures between agencies will be required. Many sections of the community will need to be informed and involved in the strategy to combat HIV amongst drug misusers.

9.5 We consider that Drug Advisory Committees provide the best forum for devising Regional and District strategies to tackle the spread of HIV through drug misuse. In some cases those committees will need to be strengthened to enable them play this role effectively. Cross-representation and close co-operation with AIDS Co-ordinating Committees (or their equivalent) will be essential. We recommend that responsibility for monitoring and co-ordinating service provision to combat the spread of the virus through drug misuse should be clearly assigned to the District Medical Officer, who should seek advice from, and report regularly to, the District Drug Advisory Committee.

Resources

9.6 Action to prevent the spread of HIV through drug misuse will inevitably cost money. Failure to take necessary preventive action will involve much greater future costs in both human and financial terms. The Introduction and Chapter 1 illustrated the speed with which the virus can spread through injecting drug misuse. We have also emphasised the potential importance of this route of transmission in introducing the virus to the general heterosexual population. There is no doubt that substantial investment in action to combat the spread of infection amongst drug misusers will prove to be many times cheaper than caring for the large number of cases of HIV infection and AIDS that will otherwise result.

9.7 Extra resources will be needed to implement our recommendations for two basic reasons. First, combating the spread of HIV requires that services reach and help more people. Second, the need to counsel about HIV and safer practices will require more time to be spent with each individual. No attempt has been made to quantify the extra resources needed but it will be clear that a substantial increase in the cash allocated to services for drug misusers will be required.

9.8 Central funding has been very effective in stimulating developments in both statutory and non-statutory services. It is encouraging that responsibility for a considerable number of such centrally funded projects has now been taken over by local funding authorities. But whether these projects will endure in the face of competition for resources remains to be seen. History would suggest that such funding in the drug misuse field will only last if there is both national and local support. It seems inescapable that when a special field of service is unpopular and may be near the bottom of any local priority list, serious consideration should be given to central funding or to funding devolved to health authorities which is separately earmarked and accounted for, We therefore welcome the Government's current policy of earmarking funds for drug misuse services. This policy should continue and extra cash made available for the implementation of our recommendations should also be earmarked. We are concerned that funding decisions for drug services have often been made for time-limited periods of 3 years or less. This can result in considerable stress for staff, impairing the efficiency of the service and creating difficulties in recruitment and retention. It can also result in staff effort being spent on seeking new sources of funds instead of providing a direct service to clients. Drug services will face tremendous demands over the coming years in tackling the HIV problem; they must not be handicapped by time-limited funding. Like any other service, they should be monitored and evaluated to assess their effectiveness and efficiency and to enable them to be further improved.

Training

9.9 HIV, and the recommendations we make on measures to combat its spread, have substantial implications for training of staff who come into contact with drug misusers. A number of opportunities exist for drug workers to receive training about AIDS. We have not attempted a comprehensive survey but the evidence suggests that such training is limited in scope and not universally available. Detailed recommendations about how training needs should be met will be addressed by a separate Working Group of the Advisory Council which is due to report shortly on training issues. We have however identified a number of training needs:

a. For Drug-Specialist Staff and Prison Probation Officers
—    basic training on AIDS and HIV and risk-reduction counselling (including, particularly, sexual counselling);
—    training on HIV antibody-test counselling;

b. For General Practitioners
—    as in (a) above, plus:
—    pre and post-qualification training on working with drug misusers;
—    continuing education for established GPs on a regular basis;
—    short-term attachments to specialist drug services (see para 4.11) (possibly including a short spell during vocational training for general practice);

c. For Generic Workers (including GUM staff)
—    as in (a) above, plus:
—    training on working with drug misusers;

d. For Pharmacists
—    basic training on drug misuse, AIDS/HIV and risk reduction;

e. For Prison Medical Officers
—    training on identifying and working with drug misusers.

We recommend that the relevant training bodies take steps to ensure that suitable arrangements for training are instituted as a matter of urgency. Health authorities should ensure that drug workers, including those from the voluntary sector, are not overlooked in arranging training on HIV/AIDS issues.

9.10 There will of course be many other training needs concerned with managing those drug users who become antibody positive. We will return to these in our second report.