Drug related deaths: getting some fundamentals right

August 15, 2019 in ADPH Updates, President's Blog

ADPH Vice-President Prof Jim McManus argues for the importance of getting the fundamentals right when it comes to tackling the complex issue of drug-related deaths

Today the Office for National Statistics published the latest figures on drug related deaths. And we have seen an increase. In particular, on top of the news about accidental poisoning a couple of weeks ago, we have cause for concern.

But as usual with this topic people will seize on it to provide easy solutions to what is a complex problem. So let’s bust some myths before we get down to the fundamentals we need to get right to stop people dying.

Myth 1: It’s all down to the changes in commissioning in England

This is simply not true. Scotland has had no changes in commissioning of drug treatment and has seen numbers of deaths rise far beyond England rates, and continue to rise, year on year. Similarly, the rise in England started in 2011, well before transfer of responsibility.

A major national review of drug related deaths concluded there were multiple factors including the age, immune system and respiratory health of some cohorts of opiate and opioid users, access to a range of treatment including NHS treatment and supply of drugs. We also know overdosing becomes more likely if your treatment is not properly calibrated and you use drugs on top of what is prescribed.

This is not about who commissions drug treatment. It is about how we ensure people get into the right services for their needs. And this means clear pathways for drug treatment needs, and for other needs like physical health, mental health and housing.

Myth 2: There is no residential rehabilitation left

Despite the efforts of one or two for-profit companies including UKAT (UK Addiction Treatment Centres) to convince us that this is all down to residential rehabilitation placements, this simply isn’t true.

First, the Scottish and English experience have both seen significant rises in drug-related deaths so the attempt to claim a move away from residential rehabilitation centres is the cause simply does not stack up.

Second, no amount of residential rehabilitation will treat people who need lung or chest treatment because of long term respiratory suppression from smoking and opiate use, plus multiple other conditions. In and of itself this is not the solution.

The examples of service innovation in the 2017 Collective Voice report demonstrate more appropriate approaches to preventing and managing overdoses than an approach based primarily on residential rehabilitation. One clearly effective intervention is ensuring Naloxone is available for appropriate use – this will save lives.

We know residential rehabilitation doesn’t work for everyone. For some it works well as part of a pathway of care. But it isn’t, never was, and never will be the main way we need to address this public health challenge.

Does that mean nothing can work?

No, there are things which can work. But in order to get to them we need to set aside the self-interested myths put about by people who stand to profit from them while the issues remain unaddressed. I mentioned above the Collective Voices approach, which collected a range of innovation from various places in reducing drug related deaths. Some of these are being adopted elsewhere. Some of these tools and methods are slow to roll out.

We can reduce drug-related deaths, but there are two vital ingredients we need. The first is proper funding – this is an area that has experienced severe cuts over the last 11 years (see Commissioning Impact on Drug Treatment report and Drug and Alcohol Services in Scotland publication). And the second is for public health commissioned services and NHS commissioned services to work together – integration is the way we will succeed.

So what should be done?

Here are my key steps:

  1. Identify the populations at highest risk – we do know mostly who they are, and we will typically find they have multiple needs , many are ageing, many have suppressed immune and respiratory systems and they are vulnerable for a number of reasons including housing and social support
  2. Ensure they all have good primary care which understands the complexity of their needs and ensures they can access services appropriately
  3. Ensure they get good quality drugs treatment
  4. Get every commissioner and provider together and build a pathway around this population, with a range of treatment. Specific lung and chest health, for example, needs to be included in this. So does housing
  5. Continue to make Naloxone more available and more usable
  6. Ensure clear joined up pathways from custody into the community. NHS England has often been conspicuous by its absence and people have often been discharged from prison without clear links into community services or given Naloxone. This is failing them.
  7. A national review of what works and roll out of evidence-based practice and innovation where we don’t know what works best
  8. A national strategy for drugs and one for alcohol which focus on saving lives and keeping people healthy.

This needs funding, and both the cuts in public health funding and the lack of anything about drugs in the NHS Long Term Plan should give us major cause for concern.

Drug treatment remains almost absent from the heath policy debate. While the NHS Long Term plan suggested a greater say in commissioning of sexual health, it was telling it didn’t mention drug treatment. It was telling that the Green Paper on prevention mentioned sexual health, but didn’t mention drugs. This is not policy which is focused on burden of disease to people and society. If it was, we’d have drugs higher up the agenda.

People who use drugs and who have complex needs as a result are still fellow-citizens whatever some may think of them. They have rights, and the NHS constitution applies every bit as much to them as it does to anyone else. Intervening effectively will save lives.

Spending Review needs to deliver for public health

August 9, 2019 in ADPH Updates

The Association of Directors of Public Health appreciates the clarity for spending and planning that the Government’s one-year ‘fast track’ Spending Round brings.

Responding to the announcement, ADPH President Dr Jeanelle de Gruchy said:

“With the launch of the Prevention Green Paper, the Government has signalled its commitment to prevention being better than cure. This one-year Spending Round, as well as the full Spending Review that follows, is the opportunity for the Government to walk the talk on prevention by investing in public health.

The public health grant needs at least £1 billion more a year to reverse decades of cuts to public health funding. The Spending Round must consider this, and 2020’s Spending Review needs to ensure a sustainable funding package for local public health.

Not doing so would mean a failure to tackle the root causes of ill health – such as poor housing, toxic air, inequalities in education and employment – which Directors of Public Health do, in our role as local public health leaders.

Only by investing in public health can the Government turn prevention rhetoric into reality, and genuinely enable people to live better, healthier lives.”

We need to rebuild our social fabric

August 5, 2019 in ADPH Updates, President's Blog

ADPH President Dr Jeanelle de Gruchy and Charlotte Augst, Chief Executive, National Voices look at what the recently published Green Paper means for patients and the VCSE.

We have got far too used to Brexit drowning out work on the key issues that really affect the wellbeing of our population. So much so, that it was a surprise for many when the Government managed to push out its consultation paper on prevention just before Theresa May left office.

The Green Paper contains many good proposals that are hard to argue with: making Britain smoke free by 2030 and halving childhood obesity by the same year, are goals that would have a significant impact on people’s lives if they were achieved. We also welcome the ambitious target of adding five healthy years to people’s life expectancy. This commitment offers the opportunity for bold action to make health and wellbeing a cross-government priority, like in Wales and New Zealand.

However, there is an overall lack of ambition and little to offer in terms of how these goals can be delivered. The paper gets carried away with its own rhetoric on ‘targeted’ and ‘intelligent’ prevention (as if public health hasn’t always been a data driven practice, using scarce resources where they matter). It suggests genetic testing, apps and ‘lifestyle’ advice will make the difference and will be the main driver for change.

But – as local government and voluntary and community sector (VCSE) organisations, which support people to have better, healthier lives – we strongly believe that this way of thinking will lead to a dead end. Although some diseases are due to genetics, these play a much smaller role in shaping a person’s health than where they are born, grow up, live, work and age. It is simply not the case that poorer people are genetically different from their better off neighbours. Rather it is the unequal social, economic and environmental circumstances throughout people’s lifetime that contribute to widening health inequalities. This imbalance has only been made worse by the years of austerity and sustained cuts to local authority and VCSE provided services and interventions – including youth clubs, children’s centres, social care and much more.

The consultation paper says nothing about funding for such social infrastructure and little about the role of places and communities. This shows a lack of understanding of the things that good, healthy lives are made of and what is needed to rebuild the social fabric that enables us to thrive: attractive places that help us to connect to each other, advice and support when we encounter difficulties, activities that create relationships, purpose and resilience. A healthy society is not one that waits for people to become ill, but one that sees how health is shaped by social, cultural, political, economic, commercial and environmental factors, and acts on these.

As we enter another turbulent chapter of national politics, we are disappointed that we haven’t succeeded in landing these insights with enough policy makers on the national stage yet. But now is the moment to redouble our efforts. Locally, we will continue doing what we do best – enhancing wellbeing and creating social value. Nationally, we will continue to make the argument for investment in social infrastructure and services that benefit those whose lives are blighted by inequality, economic decline and lack of connection. This work hasn’t stopped, and neither will we.

Charlotte Augst, Chief Executive, National Voices and Jeanelle de Gruchy, President, Association of Directors of Public Health

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About National Voices
National Voices is the umbrella body bringing together health and care charities large and small in England. National Voices stands for people being in control of their health and care, through person-centred care. Its aim is for people to have as much control and influence as possible over decisions that affect their own health and care and to be partners in the design of services, research, innovation and improvement.

National Voices helps people and organisations to gain the knowledge, understanding, skills and confidence they need to engage more effectively and to make their approaches more person-centred. It has expertise in what matters to people relating to health and care, how to involve people, and how to work with the Voluntary Community and Social Enterprise sector.

Prevention proposals are welcome but require funding public health to make an impact

July 23, 2019 in ADPH Updates

We welcome the publication of the Government’s green paper on prevention, including the recognition of the integral part local authorities play.

Only by putting prevention at the centre of all policy and funding decisions can we create the conditions for improvements in population health.

We will be working closely with Directors of Public Health to ensure their experience and recommendations feed into the forthcoming consultation.

ADPH President Jeanelle de Gruchy said:

“For too long ‘prevention is better than cure’ has been a commonly used mantra rarely matched with deeds. It is time for that to change.

We welcome ambitions to stub out smoking entirely by 2030 and ensure that people can enjoy at least 5 extra healthy, independent years of life by 2035.

But words are no substitute for actions. The scale of the prevention challenge will require investing once again in public health – with at least £1 billion more a year to reverse years of cuts – and strong, effective leadership across Whitehall to address the root causes of ill health, from poverty of money to poverty of opportunities.

We must remember, too, that it is the wider determinants of health – housing, employment, education, environment – that overwhelmingly shape our health and wellbeing, alongside health services, and Directors of Public Health play a critical role in addressing these.

This green paper must be at the top of the Secretary of State for Health and Social Care’s reading pile – and their to do list.”

ADPH Statement: Tackling violence as a public health duty

July 15, 2019 in ADPH Updates

The Government has announced plans to legislate for a new public health duty on local councils and other public bodies to tackle serious violence. This follows a consultation which the ADPH responded to.

Responding to the results of the Government’s consultation, ADPH Vice-President Jim McManus said:

“We welcome efforts by the Home Office to deepen its understanding of how a public health approach to violence can deliver safer communities.

Lessons from Scotland, London and across the UK, show the value of partnership working across local public services and there are some great examples of how this place-based, voluntary approach is preventing violent crime and replacing despair with hope.

Directors of Public Health are contributing their expertise and leadership to this collective action – and will continue to do so.

However, we have to be honest about the mismatch between the Government’s word and its actions. Whilst talking about a public health approach to violence, it continues to cut the public health grant to local government – amounting to £850 million since 2014/15. This funding is vital to deliver many of the services that transform prevention rhetoric into reality, such as drug treatment and early years services.

A duty without the funding to deliver it – and to tackle the causes of crime – risks being an empty gesture.”

Taking collective responsibility for a healthier society

July 4, 2019 in ADPH Updates, President's Blog

This is an adapted version of ADPH President Jeanelle de Gruchy’s speech in the conference plenary: ‘The future of care, health and wellbeing: opportunity, risk and ambition’ at the LGA Conference, July 2019.

As a junior doctor, I once saw a woman in my medical outpatient clinic with diabetes teetering on out of control. I spoke with her about the seriousness of the situation and about how she could better manage her diet to reduce her high blood sugar and avoid admission. After my clinic, I headed off to the local shop for lunch – where I met my patient, tucking into a large portion of fried chicken and chips.

It was vividly clear to me that it was unrealistic to expect people – even, or perhaps especially, at the point of imminent health crisis – to act differently on the basis of simple information and encouragement. Instead, what my patient probably needed over her lifetime was an environment – family, school, workplace, high street – that encouraged healthy eating and being physically active. And I could see this was true of so many more of the people I was seeing with major health problems.

This sense, that we needed to help people more effectively than the current system is set up to do, impelled me into public health as a discipline. Public health seeks to understand how we as a society create the conditions for people to develop diabetes in the first place – and then to help them manage their diabetes effectively to prevent it getting worse.

Public health in local government

Since moving from the NHS in 2013, public health teams are now firmly at home in local government – developing vital links across the council, the NHS and other local partners – with children’s and adults services, community safety, housing, planning and economic development, focused on addressing the social determinants of health.

This helps us work collectively with communities to create healthy, thriving places, to get people moving and connecting – for people to live a good life. This is the work that local government can and should be doing; it should be our ambition – and our strength.

Just as importantly, public health has maintained strong outcomes for the specific services we commission – drug and alcohol, sexual health, health visiting and school nursing, smoking cessation, physical activity and more. These are vital services and we’ve worked hard with the providers of these services to innovate and deliver improved outcomes despite government cuts to the public health grant of £850m in real terms.

The risk of further cuts to these preventative services is high – and the negative impact will be felt by other services, by our families and communities and will, of course, be expressed in our country’s health outcomes getting worse.

Challenging fatalistic thinking and championing prevention

We face some serious inequalities in health. Men and women living in deprived areas can expect to spend 19-20 fewer years in good health compared to those living in the least deprived areas.

By 2050, 1 in 4 of us will be over 65; between 1 in 2 or 1 in 3 will have a long-term limiting illness. This isn’t a good scenario for our society, or economy, or a sustainable public sector. But this is not inevitable. We don’t have to accept as fact an inexorable rise in poor health and ‘demand’. Because it’s not aging per se that’s driving demand, it’s unhealthy aging.

And we know that prevention works. Even dementia is not inevitable. The recent Lancet Commission on dementia identified nine modifiable risk factors across the life course which could prevent more than a third of dementia cases, including low educational level in childhood, obesity, smoking, social isolation, diabetes and physical activity. These all play to local government’s strengths, provided we’re effectively funded.

And we had great news this week about continuing drops in smoking prevalence, so we know we can do it. But the stats are not great for the other factors. Take physical activity – by the age of 75, only 1 in 10 men and 1 in 20 women are active enough for good health.

Taking responsibility for a healthier society

How are we organising ourselves as a society so that we end up with this grim statistic? This isn’t happening by accident. Our society is currently being socially and economically shaped to give us these poor results.

Our burgeoning epidemics of things like frailty, diabetes, heart diseases and cancers are not driven just by a lack of willpower – or ‘personal irresponsibility’, if you will – as if every succeeding generation since 1948 has worsened its diet because we’ve got progressively less good at self-discipline.

This is driven by a complex mix of social and environmental factors like poverty, access, advertising, food formulation, inactivity being the default option for many, and an assumption that the NHS will just fix whatever is wrong with us regardless of the cost.

Public health is about the art and science of improving our health and wellbeing through our organised efforts as a society – it’s not about blaming individuals for their so-called ‘lifestyle choices’.

It’s no good blaming and admonishing my patient with diabetes for going into the nearest chicken and chips shop if that’s their overwhelming, or cheapest, offer on the high street.

Everyone taking personal responsibility for their health has never worked as a population strategy. We know that policies which rely on people to know what’s required of them and do it, can lead to widening health inequalities.

The health and wellbeing problems we’re dealing with are complex societal issues, and they require approaches which work across systems. A simple single agency intervention is generally just not going to crack it. Whether it’s poverty, county lines and serious violence or domestic abuse, air quality, childhood obesity, unhealthy aging and increasing long term conditions… this is about people living and thriving in a place – it’s about good schooling, good homes and jobs, a decent income, it’s about community and connections, and sometimes health and care services.

Individualistic, silo thinking about services or ‘lifestyle’ takes the focus away from the socio-economic determinants of health, and detracts from the effective solutions we need to come up with.

We also need to shift to an approach that’s a positive one about people. Too often we refer to ‘system pressures’ or increasing demand or see our aging population or families with increasing needs as fundamentally the problem. Arguably, it’s we as public sector agencies who are creating the system pressures by not taking heed to do prevention effectively or develop a more fit for purpose system – or society in which people can thrive and grow old well.

The NHS Long Term Plan and Prevention Green Paper (which we hope to see in the next week or so) both herald the importance of prevention, and the latter, we hope, champions a focus on the wider determinants of health – and this is to be welcomed. This new dawning provides an exciting impetus and potential for a shift to a more sustainable population wellbeing focus.

Our ambition should be for a ‘Spending Review for Wellbeing’ which sets a test that every department puts wellbeing at the heart of its investment decisions (as is being done in New Zealand) and a sustainable funding package for local government and for public health. That’s why the ADPH supports the recent call by the Health Foundation and The King’s Fund for the Government to reverse £1bn of real-terms per head cuts to the public health grant.

We need to acknowledge that in 2019, your health and wellbeing is overwhelmingly dependent on who you are and where you live – this is unfair and drives inequalities. We need to challenge the way things are, maintaining a stubborn focus on prevention for the long term.

And I have an ask of local leaders – to recognise the role of the Director of Public Health with their knowledge of and responsibility for the health and wellbeing of their local population; their understanding of the evidence of what works for prevention, and their strong links across the council, the NHS, voluntary sector and many other partners in our local systems and places.

Our collective ambition should be a population wellbeing approach, with policies that create healthier places and fully funded, integrated and innovative services delivered in a place-based way.

A spending review for wellbeing? An idea whose time has come

May 31, 2019 in ADPH Updates, President's Blog

Guest blog by ADPH President Jeanelle de Gruchy for the Arthritis and Musculoskeletal Alliance

To its great credit, New Zealand has become the first country in the world to produce a “wellbeing budget” – a commitment to prioritise population wellbeing as the main mission of the government. A similar philosophy was adopted in Wales in 2015, with the Well-being of Future Generations Act requiring public bodies to think about the long-term impact of their policies on both people and places.

This is a bold and exciting approach for anyone living with a musculoskeletal condition or campaigning for change on their behalf – and for the wider public health community…

Click here to continue reading the rest of the blog on the Arthritis and Musculoskeletal Alliance website

It takes a village to raise a child

May 28, 2019 in ADPH Updates, President's Blog

Guest post by ADPH President Jeanelle de Gruchy for the NHS England blog

The National Medical Director for NHS England and Improvement and the President of the Association of Directors of Public Health discuss why prevention is key to the NHS Long Term Plan:

‘It takes a village to raise a child’ – this wonderful saying beautifully captures how an entire community of people must interact with children for them to experience and grow in a safe and healthy environment.

It encapsulates the interconnectedness of our society, across the generations and across all aspects of our lives.

If you think about it, it’s also true for us every stage of our lives….

Click here to continue reading the rest of the blog on the NHS England website