In Middlesbrough, citizens are statistically more likely to die from a Drug Related Death (DRD) than a car accident. As a case study area, you would struggle to find a more appropriate platform in which to test new models of treatment and care for people who use drugs (PWUD). If interventions to reduce the harms of drug use and structures which facilitate whole systems working can’t be implemented in areas such as Middlesbrough, it is likely the government’s vision of significantly cutting DRD in 10 years will be jeopardised, and underdelivered.
Not creating ‘more of the same’ was a key lesson from Dame Carol Black’s review into the current drug treatment system. New innovative ways to engage the most marginalised individuals that are not in treatment (estimated at approximately 45% of the overall population who use opioids) and those at most risk of mortality and morbidity are crucial to change the current outcomes. The search for new whole systems solutions to reduce the harms and costs of DRDs led local players in Middlesbrough to pilot an innovative yet often controversial treatment option for opioid dependency, Heroin Assisted Treatment (HAT), or Diamorphine Assisted Treatment (DAT), as it is locally known in Middlesbrough.
The DAT program in Middlesbrough provides synthetic medical grade heroin (as diacetylmorphine) for supervised self-injection twice daily, under medical supervision in a clinical environment. This was the first service implemented outside of a research trial in England. The service started in 2019, with an initial maximum capacity of 15 people who had used opioids long-term and for whom the existing treatment model (through methadone provision) has not been beneficial (estimated at around 5-10% of the current population of opioid users).
The development of DAT stands as a remarkable example of whole systems working, funded jointly by health and crime budgets to tackle shared priorities. Yet, during its operation, a number of external socio-structural challenges, such as the breakdown of commissioning structures, threw the service into an ongoing cycle of funding precarity and insecurity. Ultimately in September 2022, the clinic delivering the service was advised that no further funding was to be made available to allow HAT to continue.
So, what can we learn about ‘whole systems commissioning’ within drug treatment services from the decommissioning of the Middlesbrough DAT service?
1. Evidence of effectiveness and impact isn’t always enough for an intervention to be commissioned
The evidence supporting the impact and efficacy of DAT for people who do not respond to standard treatment is extensive. Not only is it regarded by World Health Organisation as gold standard treatment, it has been recommended in clinical guidance in the UK since 2017 (Department for Health, 2017). Over the past 25 years, there have been six Randomised Control Trials (considered the gold standard of evidence) conducted in Germany, Spain, Canada, Switzerland, the Netherlands and England.
Across all studies, participants’ consumption of street heroin was significantly reduced compared to groups given standard treatment (methadone management treatment), plus improvements in physical and mental health. Alongside these health outcomes are numerous social benefits, including large reductions in criminal behaviour. Crucially, economic evaluations conducted in the UK on DAT have proven that despite a relatively high running cost, these services create savings to the public purse that far outweigh their operating costs.
In Middlesbrough, we found similar positive results which were echoed in the first-year evaluation of those engaging with the service, including:
- Increased engagement with psychosocial interventions
- 80% of tests for street heroin were negative
- Reduction of risky injecting practices
- Substantial improvements in physical and psychological health
- Improvements in secure housing and reduction of street homelessness
- Total offences were reduced by 60%, generating associated cost savings to the Ministry of Justice of £97,800
Despite this wealth of evidence, DAT has struggled to gain long term funding to support its delivery. Critically, these services for PWUD, which are often seen as ‘low hanging fruit’ in the context of stretched health budgets. Having evidence of the effectiveness of the intervention (even when it is regarded as gold standard care) is not enough to guarantee its survival.
2. Many ‘whole systems’ contracts can exist in a locality, and yet projects meeting the aims and intentions of these commissioning structures can still struggle to access funding from all parts of the system.
The funding insecurity experienced by DAT is not due to the lack of money for whole systems innovative solutions to tackle the harms of drug use in Middlesbrough. Middlesbrough was selected as one of a number of ‘pilot’ areas for ‘Project ADDER’ (Addiction, Diversion, Disruption, Enforcement and Recovery), the government’s pathfinder programme pilot which combats drugs “misuse”. As such, it could fund harm reduction interventions such as DAT. The aims of ADDER were to:
- Reduce drug-related deaths
- Reduce drug-related offending
- Reduce the prevalence of drug use
- Disrupt in a sustained manner high-harm criminals and networks involved in middle market drug/firearms supply and importation
On paper, DAT meets each of ADDER’s aims. However, the service was given substantially less than what was required to operate it for another year, resulting in the September 2022 announcement of the service’s decommission.
Overlaying Project ADDER are the government’s plans to implement localised Joint Combatting Drugs Units (JCDU) structures to deliver their 10-year drug strategy. The JCDU aims to support innovative whole systems approaches to tackle the prevalence and harms of drug use between health and crime services. Again, DAT clearly fits this brief.
Here we see DAT, a ‘whole systems’ intervention that predates both ADDER and JCDU falling through the cracks of these two strategic contracts specifically implemented to deal with interventions of this very nature.
3. Localised approaches are helpful, but if interventions are left solely to local decision-makers then you risk of commissioning services on other criteria, rather than on what works.
Without ringfencing funding, some effective yet controversial solutions to drug treatment such as DAT may not be implemented. This in effect creates a postcode lottery in care for PWUD. We must recognise that the most effective interventions may not always be the most popular or the most well received by the general population; implementing these at a whole systems level and with fair funding can only be achieved by strong, confident, and effective drug treatment policy-making.
Realistically, this is unlikely to occur for DAT as the 10-year strategy was criticised for not even mentioning some of the most evidence based interventions to reduce the harms of drugs, such as DAT or overdose prevention sites.
4. A false economy: funding based on short term bottom-line vs long term impact
DAT is not a cheap intervention, but it is one that overall saves money to the public purse. It targets a small but very important population, impacting and reducing what are costly outcomes within the health and criminal justice sector. DAT is a high cost but high yield intervention. Although the government has advocated for a change, commissioning priorities can still be fixated on short term cost, as opposed to long term quality and impact.
Where do we go from here and what can we learn?
If whole systems working cannot be facilitated within the context of a single intervention, then the capacity and capability for delivering whole systems of interventions across multiple budgets, localities and priorities is difficult to envisage. Reverting to more siloed approaches to commissioning within a health system that is trying to work together is a huge barrier impeding the transformation of the drug treatment system. There are ways we can make DAT more cost-effective, but that would require government intervention. For example, generating a national supply of diamorphine so that services would not have to import medications from outside the UK, which increases operating costs. We need to learn both from how this intervention was successfully implemented, as well as how delivery has broken down.
DAT in Middlesbrough is a rich example of a whole systems approach within a local area to address multiple health and justice concerns, predating the work of ADDER and JCDU. Crucially, DAT as a case study highlights that what is most effective and innovative may not always be what is most politically palatable. Policy driven by the government based on evidence and long-term impact is vitally needed if we are serious about changing the direction of travel regarding DRDs in England.
*Hannah Poulter is an academic and researcher who’s work reduces harm and improves the health and quality of life for people who use drugs. She led the first evaluation of DAT is currently part way through her PhD on DAT.