The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, I thank the noble Lord, Lord Patel, for raising this issue. It is clearly hugely important. He said that this rise in deaths was a direct result of government policy. We should take that very seriously coming from someone who knows so much about the issue. I also thank him for warning me earlier about the likely thrust of his comments.
This debate is particularly timely as we are currently finalising our new drug strategy and thinking about what it needs to say in relation to this important issue. It will take a very close look at the impact of the current strategy. It is due to be published later in the year. The noble Lord’s comments today will certainly be taken into account.
We are especially concerned about the increase in drug-related deaths. Separately, Public Health England is now convening an inquiry into the reasons for the rise. I encourage noble Lords to give their views to PHE. A key part of its inquiry will be an in-depth analysis of the drug-death data. A national expert group will rapidly review the data, including the ONS data, and local experiences to better understand the causes of these deaths and how they can be prevented. That report is expected in a few months. This is not a Chilcot inquiry; it will be out in a few months, and it will include looking at dual diagnosis.
Although my comments today will largely cover England, since health is now a devolved matter, the PHE inquiry will look at experience in Wales and Scotland. Interestingly, both countries have widely differing results, so if there are lessons that we can learn from them, clearly we will do so. I will come back to the specific question about payment by results, if I can, towards the end.
As the noble Lord said, the ONS reports of 2013 and 2014 showed that registered drug-misuse deaths increased in England very significantly from about 1,500 in 2012 to 2,120 in 2014. They are a matter of huge concern and highlight the need for further national and local action. A small part of the increase might be explained by changes in the speed of registration of death. That is probably not significant, but it will be looked at in the PHE review. We are assuming that it will not be material.
Overall, fewer people are using drugs such as heroin. Those that do form an ageing cohort, which means that the health harms from the use of heroin are increasingly concentrated among older, more vulnerable users, particularly men aged between 40 and 49—the “Trainspotting” era, in a sense—and those who have not had recent contact with the treatment system. We may need to accept that because of their long-term drug use, the health problems associated with that and the recent availability of purer heroin, all of which can contribute to a much greater risk of death, deaths may still rise in future years, despite our best efforts to reduce them. Again, that is something that PHE will be looking at very carefully. This means that although overall drug use has declined in recent years and the treatment system has helped many more people to recover—some 70,000 in 2014-15—we need an enhanced effort to help these entrenched users and thus reduce the number of deaths.
Local authorities are best placed to be responsible for drug prevention and treatment because of their knowledge of the local population and its needs. They can approach a system on a place and local population basis, bringing together their experience of local employment, education, housing, social services and the like. That is the reason why this has been devolved to local authorities. Much improvement has been achieved, and the Government are determined to continue that improvement. We have therefore added a condition to the central public health grant which requires local authorities to further improve the take-up of the drug treatment services they provide and to achieve improved outcomes. I will turn to funding later on, if I can.
About half of the deaths involved opiate users. PHE analysis found that most of those who died from opiate overdose were not in treatment and, in most cases, had not been receiving treatment for some time. This emphasises the need to encourage drug users to engage with treatment services, because treatment has a protective effect, as the noble Lord referred to in his speech, and can help prevent deaths. It also emphasises the need for local authorities to ensure that vulnerable drug users outside the treatment system are given advice on how to reduce the risks from drug misuse and are encouraged into treatment—all the more so as heroin is becoming purer.
As mentioned earlier, Public Health England is convening an inquiry into the recent rise in drug-related deaths. The national expert group will rapidly review data and local experiences to better understand the causes of those deaths, how they interplay with other health issues such as mental health, and how those deaths can be prevented. We know that some parts of the country have much higher death rates than others, and PHE’s local centres are working with those areas to understand the factors contributing to those higher figures and what can be done to reduce them: for example, by spreading best practice.
We have also asked PHE to work with local authorities to make sure that services are available to anyone who needs them. So PHE is working with local commissioners and providing them with expert advice, evidence and management information, including outcomes and value for money data. This helps to ensure that services are evidence-based, effective, available, integrated with local health services and supported by local housing and employment policies.
In October 2015, we changed medicines regulations to widen the availability of naloxone. Naloxone is a medicine that almost instantaneously reverses the effects of opiates, and we have made it easier for drug services to supply naloxone to more people who might witness overdoses and could use it to prevent overdose deaths.
Turning to prisons, the thematic report by Her Majesty’s Inspectorate of Prisons, Changing Patterns of Substance Misuse in Adult Prisons and Service Responses, published in December 2015, acknowledges that substance misuse treatment provision in prisons has improved very significantly over the past 10 years. I am told that there is strong evidence that evidence-based commissioning by the NHS has had a positive impact on prison health more generally, as well as in this area.
PHE, NOMS and NHS England are working together under the auspices of the National Partnership Agreement to tackle the new challenges presented by new psychoactive substances and the misuse of prescribed medication. PHE recently published a toolkit for custody and healthcare staff to support their response to NPS and is currently delivering a national training programme across the prison estate.
PHE is working closely with the National Offender Management Service and NHS England to improve “through-the-gate” arrangements between prison and community services, including improved commissioning of services. It is also using new post-release supervision arrangements and licence conditions to make sure that prisoners are more effectively engaged in drug treatment after release. As the noble Baroness, Lady Walmsley, said, when people have been off drugs and then come out and go back on to drugs, that can have very severe consequences.
As I mentioned earlier, engagement with good-quality drug treatment has a protective effect. It stabilises people and helps to improve their physical health and well-being. For example, people in treatment for their opiate use are less likely to inject drugs, experience overdose or transmit blood-borne viruses such as HIV and hepatitis C. People in treatment are also more likely to be tested and treated or vaccinated for blood-borne viruses. There were nearly 300,000 adults in contact with treatment services in 2014-15. Over half of the 130,000 patients who left treatment in 2014-15 had successfully completed their treatment free of dependency. This is an improvement on past performance and is helping people to achieve their potential and live a fuller, more rewarding life.
We have commissioned and received advice from the Advisory Council on the Misuse of Drugs about the contribution that opioid substitution treatment such as methadone can make to helping people recover. This is not in the least at odds with long-term prescribing of methadone to protect the health of those who are not able, or not yet able, to achieve full recovery. A question was raised as to whether at the time the policy was implemented—in 2010, I think—an assessment was done of the potential perverse consequences of that policy. I am not aware of whether such an assessment was done, but I can revert to the noble Lord about that afterwards.
Over the last decade, treatment outcomes have steadily improved, but have slowed in the past couple of years, most likely because the people remaining in treatment are those with more entrenched drug use and long-standing and complex problems. This is why recovery remains at the heart of our approach, with the key aim to support people to free themselves from drug dependency for good. We have moved our focus beyond the treatment system, to look more holistically and to include factors that help people recover from drug dependency and fully integrate back into the community.
We know that mental health can be a particular issue for many drug users. Some may use drugs as a form of self-medication for a mental health problem. Some will find that drugs exacerbate or cause mental health problems. PHE is encouraging substance misuse and mental health commissioners to work together at a local level to ensure that the services they commission are responsive to the needs of this client group, and there are clear specifications and transfer arrangements that describe how they will be effectively co-ordinated and delivered. I do not have time to talk about prevention; I thought I would have more time but I have only two minutes left.
The issue of funding is an important area. The noble Lord, Lord Patel, mentioned that the number of specialist mental health care nurses was down 10%. This reflects a more fundamental problem that over the past five to 20 years so much of the budget has gone into acute care. Community and mental health care has unquestionably suffered over that time. It illustrates a much broader problem. It is clear from the mandate of NHS England that parity of esteem is a key part of our policy over the next five years. Each clinical commissioning group’s spending on mental health will increase in real terms. There will be more money available for mental health care.
However, it will still be tough. There is not a lot of money in the system, but we are prioritising mental health care, and I think that, together with the public health grant, which is ring-fenced in local authorities, there will be resources available to tackle what I accept is a hugely difficult, complex and, as we have seen from the figures today, tragic area in which society, not just healthcare, has so dismally failed.
Briefly on the PBR point, the DH has done an evaluation on the payment by results pilots for drug and alcohol recovery, which will be published later this year. The preliminary evaluation, which is already published, suggests that the pilots did not lead to inappropriate pressure to discharge people from drug treatment—but it is preliminary and the full results will be published later in the year. I was going to say a little more about prevention but we can discuss that at another time.