Sibling Rivalry or Just Poor Parenting?

I don’t know whether the title to this blog will make sense to you or whether my sometimes-abstract style of communication will just produce a confused look?
The title alludes to a conversation that I have regularly with people in the drug & alcohol treatment field about Recovery.  I have been told, and I sometimes see it for myself, that the biggest threat to the development of Recovery in the UK is in-fighting about which ‘brand’ of Recovery is either the best or most effective.
Is it AA, NA, one of the other ‘A’s.  Or is it Smart Recovery, often pointed to as a sort of secular alternative to the ‘A’s (although I think its quite different really).  What about Recovery Communities, often manifest in specific geographic locations e.g. where there is a longstanding rehab or groups of rehabs.  What about faith based communities, predominantly (but not exclusively) Christian in nature – does any of this really matter?
Anyway, I thought I was being quite clever with the title, “Sibling Rivalry.”  Portraying the various Recovery groups as siblings, members of the same family, fighting for primacy, elbowing their brothers and sisters out of the way to get noticed and avoid being the runt of the litter.
In reality, this is not the case, Recovery groups tend to try to get along, they collaborate and try to do something useful, good even (mostly).  While I believe we must try to guard against faction the “sibling rivalry” conversation is often more complex than two Recovery groups squabbling with each other as there is good evidence to suggest Recovery groups can live and let live

In my experience the context for a conversation about Recovery orientated sibling rivalry is often a a partial smoke screen by those that have a vested interest in capturing the Recovery zeitgeist in a particular area, usually as part of a commissioned service, struggling to remain relevant or seeking to expand influence in the context of an evolving commissioning landscape which demands a more Recovery orientated approach.
Or it’s a commissioning led dash for some signs of visible recovery to satisfy a need by the commissioner not to get left behind in the rush for Recovery.  There also seems to be little coherent organisation behind the development of Recovery in the UK currently, this partly reflects the age of the Recovery movement in the UK and partly its peripheral location in-terms of the existing treatment infrastructure, for now at least (although people like Mark Gilman and others are changing this.  Lets also not forget those that have campaigned for some time, even when it was very unpopular and unfashionable to do so e.g. Kathy Gyngell et al).  
If, as in most trends, we follow where America leads, then we might glean some lessons from our cousins over the pond.  They seem to have thriving Recovery communities that are growing and no sooner does a person find recovery, they in turn are found a role in helping others.  They seem to have a strong rehab sector, residential and community based.  A good Recovery infrastructure that puts people back into productive, worthwhile activity – (maybe more on this another time)
We on the other hand have residential rehabilitation sector which is in decline as it has fallen foul of the commissioned treatment system or should I say national treatment policy, which after all, are the rails on which the local commissioning trainruns so to speak.  While millions of pounds are still spent on community based prescribing and harm reduction services there is precious little left over to spot purchase residential rehab places and even less being spent on the development of Recovery communities, again with some notable exceptions acknowledged.
With this backdrop we now see the spectre of legal highs on the horizon, rushing at the treatment system and threatening to derail national policy and the local commissioning system.  Faced with a ‘legal highs’ onslaught our target-focused, admin orientated, clinically led, still quite opiate based treatment system with its coercive style of engagement is ill equipped to respond.  Gone (or in short supply) are the ex-addict drug workers from the formal treatment system, driven out by the need for degrees and enhanced DBS/CRBs and a flawless CV required for the now corporate, and largely risk averse treatment system.  
Our compliance testing regimes for those coming into treatment through the criminal justice system are useless, unable to detect some of the illegal, never mind so called ‘legal’ drugs.  Safeguarding vulnerable adults and children that often rely on a testing regime to trigger action are rendered obsolete and worse may see a lack of a negative test as a sign of progress rather a deepening of addictive & problematic behaviours that put dependents at further risk because the social workers and drugs professionals are just not sighted on the latest developments relating to ‘legal highs’, sadly something I see all too often, and don’t even get me started on the police, seriously! (Maybe another time we’ll explore the police response to so-called ‘legal highs’)
So in one direction we have a treatment system that still costs millions and yet is struggling to re-balance itself so it can get people better, because the main vehicle for doing this historically (resi-rehab) continues to waste away like an unused muscle, and the slack cannot yet be taken up by the developing Recovery communities as they are largely unfunded and are often being developed by those in recovery, service user groups and concerned professionals in their spare time and on a shoestring.
In the other direction we have an assault on the same treatment system by the emergence of legal highs users which won’t go any where near existing drug & alcohol treatment services as they don’t see themselves as addicts in need of help and the treatment system has lost (save for one or two amazing exceptions) its ability to reach out and connect with this new cohort because their primary skill is not service user engagement but administration of a large, well funded and complex system of targets, linked to ever larger and more costly contracts which commissioners and providers are seeking to consolidate to save money in the most efficient way possible, usually the reduction of overhead through merger (of contracts and in some cases of service provider organisations too)
I’m not saying get rid of harm reduction, lets not throw the baby out with the bath water, most of the money currently goes into community prescribing anyway, so this is where most of the rebalancing needs to occur.  It’s also not just a question of getting rid of prescribing either; what we need is a quality clinical component as part of a well functioning national response to addiction that helps people get and remain stable for varying lengths of time but that is less dominant than it currently is.  All of the above needs to tee-up Recovery, the ultimate harm reduction measure.
In short, it seems that if we want a more functional, balanced treatment system, and less sibling rivalry, then we need better, more visible and responsible “parenting”

Best regards

Huseyin
PS – now for a bit of shameless Recovery orientated promotion!!
So here’s the advert:
As part of a local Recovery initiative in Henley-on-Thames a group of us in (or affected by) Recovery started a Recovery café in December 2012.  We have opened monthly since then and seen the beginnings of a Recovery community start to grow in and around this area.   We are now intending to put on a Recovery conference in November of this year (23.11.13 to be exact).
You can get details of the conference, which is free by the way, at: www.towardsrecovery.co.ukwhere you will also find dates for the monthly Recovery café that is also free to attend as are the coffee and cake.
We are dedicating the conference to the following aims:
 The continuing development of a Recovery community for Henley and the surrounding areas, to highlight the need for more funded residential rehab places for those dependent on drugs and alcohol, and to raise money for 2 local charities that have been providing treatment that leads to long term recovery for decades

www.leycommunity.co.uk
www.yeldall.org.uk

Advertisements

Treatment & Recovery or Taxi Rides & Train Journeys?

I heard some time ago, from Mark Gilman at the NTA (now Public Health England) that if Recovery were a train ride from Manchester to London, then the treatment element of that journey would be the taxi ride to the station.  A good analogy I thought at the time, and still do
I’ve used his analogy several times (and always give him credit for it – see link)
On one occasion I was consulting with the clients at a community based substance misuse service and they developed the analogy further.  What they said was that they had had many taxi rides to the station but had never managed to make it onto the train for that elusive onward destination (Recovery).
They said that having got in the taxi, sometimes under duress, they started their journey.  The skill of the taxi driver (let’s say drug worker) often lifted their mood, improved their motivation, and helped them to start believing that the journey ahead would be a good one and hope started to rise in them.
In the taxi they were given all they needed (as far as the taxi driver was concerned anyhow) for the onward journey.  They left the taxi confident and ready to move on.  Reaching the platform however, often for the umpteenth time, was confusing.  No one was there to help them navigate the hustle and bustle.  Trains were coming and going but their tickets weren’t valid.  No one to show them the way!!
Eventually, after surviving on the platform for a while, visiting the public loos for a wash and eating at the overpriced coffee shop where the tiniest of snacks seem to cost a fortune, they decided to leave and go back to where the taxi had picked them up from.  They turned up their collar, faced the night and the long, often lonely walk back into the place and the life they knew before the latest taxi ride fiasco
Often, they felt so hurt and let down that it would ages before they ventured into a taxi again, but eventually, circumstances would expose their need for help, and even though they knew it was useless going back to station, they got into the taxi, once more under duress.  Once in, the cheeky cabbie would win them over…….. And on and on it would go
It seems we have replaced one revolving door with another.  Or rather we’ve added an expensive treatment merry-go-round to the existing revolving door of drugs, crime and other personal, familial, and societal problems linked to that life by paying for a series of expensive taxi rides that end up being fruitless 
We are paying for services to find people (the drug and alcohol clients) whom we then force into taxis (other services) and then we take them to the station again.  We measure the numbers found and forced into taxis, we measure the number of taxi rides to the station and we measure how long someone stays on the platform and in some cases we pay for taxi rides that never seem to get a station and that stay parked down a side road with the meter still running.  We justify this by saying that as long they are in the taxi, we know where they are, we are reducing the trouble or harm they can cause to themselves or others, while conveniently forgetting that their lives are effectively on hold while in the taxi.
We never buy any train tickets and we never employ any platform helpers.  We have no information about the many possible destinations and everyone in the system gets paid for the status quo – do you think the taxi drivers want the system to change………
Treatment and Recovery are often used as interchangeable terms in certain circles and I hear so much about treatment as if were Recovery and so much about Recovery trying to be treatment, credible, evidenced based etceterarara
The world has changed and in the face of that change lets not stay the same Discuss……
All the best
Huseyin
ps this is my first blog in ages and it felt really good, lets hope I can stop dodging taxis long enough to put finger to keyboard again soon

Recovery or Rhetoric

The Recovery rhetoric is reaching epidemic proportions!  Service User representatives are adding Recovery Coordinator to their titles, Drug Workers are becoming Recovery Workers or Recovery Initiators and the definition of what constitutes Recovery is getting ever wider, including those still in treatment and on substitute opiate medication.

Soon, maybe active addicts, on illicit street drugs will be defined as being in a Recovery of sorts, maybe if they attend an assessment, who knows what will happen next.

What then is a viable definition for Recovery.  Typing “Recovery” it into MSWord and engaging the dictionary function came up with the following:

  • A return to health
  • A return to a normal state, and 
  • The gaining back of something lost, or
  • In the process of recovering from an addiction or other destructive habit
These are just dictionary definitions and I’m not one of the new wave of clever academic types running or developing the UK or Global Recovery Movement(s), I’m just someone that has been in Recovery since 1986 when I entered rehab and stopped taking drugs and am still trying to hustle a living by being in the drugs field but not taking or selling drugs
Personally I try not to buy into the polarized arguments that try and make Recovery exclusive.  For instance I dont buy into the view that recovering addicts need to recover near their home location and show others the way into Recovery, we can do that where ever we are and its not location dependent.  I can see why commissioners want to ensure that they keep those in Recovery nearby, so that they can use them within a specific geographic location, because usually those that go to rehab (often out-of-area) that do well, re-settle near the out-of-area rehab and the only ones that go home are the ones that maybe didn’t do so well and I have heard some commissioners coining the phrase, “we dont want to export success and import failure” (not my words)
This, like the pseudo-academics and payment-by-results advocates, that are adopting a Recovery rhetoric, it is still about treating the addict as a commodity and not a unique individual with choice.  Choice to define their own Recovery, in their own way. 
With this in mind, I dont care if your recovery is opiate free, nicotine free and/or alcohol free or whether its a process that is moving toward this or is stopped at a particular point along the way.  I dont care if your recovery is near or in your home town or miles away from it – my own journey meant I had leave where I grew up and start again somewhere new
Its none of my business and yet, the current Recovery Rhetoric being adopted by many professionals is more about engaging the addict as a commodity and exploiting them for personal or professional gain (get them on my committee, get them to start a recovery community or mutual aid group for tuppence, get me a payment by result etc).  We used to have a drug and alcohol sector that operated as a cottage industry; small, diverse, fiercely independent and successful (if a little dysfunctional from time to time – I must admit)
However, the success generated by the cottage industry was highjacked and led to promises of greater social benefit if only investment could be forthcoming to scale up drug treatment, not least a reduction in crime.  Drug users were marshaled into treatment and the corporates gradually moved in.  Professional standards were developed and we saw minor league charities become major league players, some moving from a turnover of tens of thousands to tens of millions, literally over a few years
Drug treatment was something you used as a platform for getting better (Recovery) and it became an end in itself (a script for as long as you required it).  Drug users tip-toed between the dealer on the one hand and the state or state representative (NHS or Charity treatment provider) on the other.  As I said in my 2008 piece (inside out)  “both wanting control and neither offering freedom” (sorry for quoting myself!!!).
And here we are today, another twist and turn down the road and the new mantra from above is Recovery.  Something I and many others advocated for, at a time when advocating it meant getting shot down by the harm reductionists, and being labelled ‘the new (and slightly mad) abstentionists’.
As Jimmy Greaves used to say, “its a funny old game” and its “also a game of two halves” so I wont try and call the score at what feels like half time but low and behold, the harm reductionists have highjacked Recovery and bent it to fit their definitions or should I say bent it to fit their existing contracts – I know, I’m being cynical so try and screen that out if you can and look for the hidden nugget of truth, its there somewhere
The truth is, we all move toward all sorts of addictions for all sorts of reasons.  In my experience it was an answer to problems and it was a while before I noticed that my solution to my problems became my biggest problem and I was fortunate enough to get help.  The system we had back then (1986) was based on residential rehabilitative care, accessed via the Dept. for Health & Social Security (DHSS) and I was welcome for as long as I needed to be there (the programme was 11-months but this wasn’t seen as a maximum).  Detoxing was the main reason for using methadone but I, like many others back then, came off heroin without the use of opiate substitutes, (we”clucked”, went cold turkey) and most of the people on substitutes were blagging scripts to get by and self medicating on-top with whatever they could get
Going cold turkey seems really inhumane by todays frivolous prescribing standards but was the norm back then.  I’m not advocating going back to those days but I do believe we need to get some perspective because we have gone too far the other way, otherwise lets not pretend that the rhetoric is reality but often a convenient staging post to delay the onset of recovery by continuing with our addiction
All the best
Huseyin

Sentencing guidelines or a perverse incentive to take or sell drugs!

On the 24th January, while the rest of us were still trying to shift the January blues, the courts in England and Wales were issued with new guidance for sentencing drug offenders – click here to see the press release


The stated aim being to, bring sentencing guidance together for the first time to help to ensure consistent and proportionate sentencing for all drug offences that come before courts in England and Wales” – if only everything in the criminal justice system was so uniform.


The publication of the guideline follows a public consultation on the Council’s draft proposals, which heard from nearly 700 members of the public, criminal justice professionals and other interested parties”  


So it seems that 700 people and a few special interest groups can change sentencing policy and yet 100,000+ people recently asked for a referendum on Europe but were refused


This is a policy that is designed to keep Tristram and Porsche out of jail for being in possession of so called small amounts of all sorts of drugs and sharing it with their friends in the student dorm or in mum and dads holiday home.  Its for the city trader and the North London set that need a whiff of danger but want to remove the risk of going to jail as it just wouldn’t do – dont you know!!I feigned a Noel Coward accent for the underlined bit of that sentence


Do the sentencing geeks really think that the dealer that sells to Tristram and Porsche, the North London set or the city trader is somehow disconnected from the major or mid level importer or dealer?  Do they think that these are somehow, responsible dealers, that don’t get involved in other crime, like transforming replica guns into real guns that fuel gang and other violence in our towns and cities – I wonder, are they “green or ethical” dealers, do they eat Tofu?


If the guideline allows a defence that there was no intent to sell, make a profit etc and if the amounts allowed are as described in the Guardian newspaper e.g. 100 grams of cannabis (nearly 4 ounces), 20 tablets of ecstasy or 5 grams of heroin or crack, then its quite worrying,  5 grams of a class A drug is quite a lot (as is 4 ounces of cannabis and 20 tabs of ‘E’).  


5 grams of heroin or crack/cocaine, bought wholesale at £50 per gram would be the same as buying £500’s worth retail (i.e. in individual £10 bags) as 1 gram yields at least 10 x £10 bags.  


Drug users will probably pool resources and buy wholesale and split the savings.  They will in effect be able to get £500 worth of drugs for £250.  This may increase individual use?  If users pool resources they may use more in company with others, as occasional use becomes addiction they may move from smoking to injecting, and on and on we go.  


Is this about keeping Porsche and Tristram out of court, or is it sanctioned drug use, protecting the middle the class – whats the real story here


Any half serious criminal would look at this policy shift as a business opportunity and decide to get into drug supply – within the parameters of the policy guide – of course
They would organise supply to stay within the allowed limits, give it away or sell at a loss to create dependency (thereby staying within the guideline) and to ensure control of the newly created addict for all sorts of other possibilities, criminal of course
Organise the runners to have just enough to have the ‘gear’ taken off them but not to go to prison – not having to do long sentences takes away a vital intelligence gathering tool when low level dealers get arrested

These people, the MP’s, the Judges, the so called Advisers are meant to be clever people and yet they come up with the most stupid ideas.
The current health response to class A drug use is substitute prescribing.  Recovery from addiction is a recent feature of state policy.  Methadone prescribing has got so intense that it is now a contributory factor in drug related deaths!  The cure, in some cases, is killing the patient.  Lets get proper treatment for drug users – I had proper treatment (rehab) and 28 years later I am still well, not using any drugs, Im working, contributing to society (working in the drugs field in fact).  I want people to get help but I also want a credible deterrent

Rehab is dying on the vine while we spend millions on handing out methadone, and all sorts of other ‘treatments’ that do not result in the user stopping their use.  I caught a short clip of Richard Branson on TV and he said we should have a policy that helps people rather than imprisoning them.  We should treat people as we would treat our own family.  I cant disagree with that.  If my family or friends needed help with addiction I would do all I could to help them.  I would not use the current system mind you, I would pay for them to go to rehab somewhere, I’d mortgage my house, take a loan, whatever it took. 

Richard Branson needs to know that the health system as it is currently configured is found wanting and these new guidelines wont help as all they will do is undermine the Restricting Supply strand of the current drug strategy.  Treatment in prison is more available than ever but it also mirrors the community substitute prescribing system.  Addicts used to use jail as a break, a breather, somewhere to get clean, get healthy, go to the gym, put on some weight; it was like a break from addiction and a chance to start afresh, but prison is like the community now, and too many prisoners are on methadone.  

We need a fair and balanced drug policy, which includes enforcement as well as treatment.  

This sentencing guideline, I fear,  will create perverse incentives to take and sell drugs

Meeting Doreen Lawrence

Two of the people involved in the murder of Stephen Lawrence have been convicted and sentenced and as they start their sentences we hope that any others with blood on their hands will be identified, arrested and sentenced as well
The recent news coverage jogged a memory I have of meeting Doreen Lawrence in person.  It was March 2004 and I had been working for the Prison Service at their London Area Office since April or May 2003.  My line manager had informed me that I was to attend the Stephen Lawrence 10th Anniversary Dinner at the South African Embassy along with other HMPS Staff – my first official function in my new role as Area Drug Strategy Coordinator for the London prisons.
It was a formal occasion so I had to rent a dinner suit and I think it was a Friday night so I stayed on after work, got changed and started making my way from John Islip Street (where HMPS HQ was at the time), to the South African Embassy at Trafalgar Square
There was no public transport and no taxis that night as, unfortunately for me, it was the night there was a major protest against the Iraq war and I felt so self-conscious in my ‘tux’ walking against the tide of thousands of people protesting that night.  I must have said sorry a thousand times as I bumped and jostled my way through the crowd
Finally I got to the venue and the crowds thronged as it started to drizzle.  I couldn’t get in the front door so went round to what I can only describe as the tradesmen’s entrance where I showed my invitation and was met by a rather tall and quite glamorous lady in a fantastic African headdress.  She took me into the embassy and everyone we met stopped and addressed her, respectfully and reverently, and at each meeting she introduced me as Huseyin, from the Her Majesty’s Prison Service.  Unbeknown to me, I was being accompanied by the host, the South African High Commissioner!!
It was in this context that I met Doreen Lawrence; we exchanged pleasantries and business cards (I still have hers) and I must say, for a small woman she was mega.  She had a quiet forcefulness, tempered with a motherly grace that was very evident and very humbling amongst the cut and thrust of career types and all the protesting going on outside.  I’ve never forgotten the meeting and never forgotten her and it is good to see the Lawrence family finally getting a measure of justice, its long overdue
The other highlight from the night was seeing Rio Ferdinand but for completely different reasons.  My son, Harry was quite young and supported Man Utd at the time (I’m from north London and an Arsenal fan).  Anyway, I went up to Rio, (who was serving a ban for failing to turn up for a drugs test) took a deep breath, and with pen and invite in hand said, “much as it breaks my heart, as an Arsenal fan, to ask you this, can you sign my invite for my son, Harry”.  He was very gracious and duly signed, although he did give me a funny look for the Arsenal fan comment
Sadly we have misplaced Rio’s autograph but I still have Doreen Lawrence’s business card from The Stephen Lawrence Charitable Trust and still treasure the memory of that very inspirational evening when I walked through the protesting crowds, to get to a post-Apartheid South African embassy, being introduced to everyone by the High Commissioner, getting Rio’s autograph, and the highlight of the evening, meeting Doreen Lawrence
All the best
Huseyin Djemil 

Drugs in Prison

I’ve just had a piece on drugs in prison published by the think tank, The Centre for Policy Studies

Its always nerve racking doing a piece that points out a flaw or offers criticism, particularly when attempting to speak truth to power.

Have a look at the blog on the CPS website and make your own mind up.

I’ll be doing a follow up piece here in a few days

All the best

Huseyin

It’s a weird world out there!!

I never mean to stay away for as long as I do, but life often takes over and at the moment it seems to be all work and no time for me!
I’m at that place where I am busy with existing contracts and work (my new addiction – sort of), trying to branch out and network potential clients, and catching up with old friends and as a result I seem to be either running about or staying up late to write a report, meet a deadline or plan my diary.

No sympathy please, its all self inflicted.
However, some interesting things happen along the way and it’s worth taking a moment to write some of it down and share it with you
For instance, I’ve come into contact with former colleagues; particularly civil servants and they are in all kinds of turmoil because of the looming cuts to funding (as I am sure others are too). For some the turmoil is making them stressed, making them work harder, be tougher, be indispensable as they want to assure their place in the ‘new world’ (more of which later)
Others are opting to take some of the many ‘golden goodbye’ deals on offer e.g. leave now and get a generous payoff.
I know several former colleagues that have agreed to leave the civil service and are getting 2-years money (over £100k), the pension will kick in a few years down the road (with another six figure lump sum then above average wage e.g. over £25k for the rest of their lives) and in the meantime they are going to walk into other publicly funded posts all at a minimum of £40-50K per year.
This is happening with alarming regularity and the newspapers only pick up on the high profile, ‘heads of service’ moves, but for each top exec there are many more middle and senior managers taking the payoffs, getting pension top ups or early retirement and a significant proportion of those walk straight into new, often publicly funded posts – some of the stunts being pulled in the public sector are shocking and staff are getting well over the statutory minimum for redundancy and the taxpayer foots the bill. More scrutiny of publicly funded redundancy deals is definitely required (oh, and as they walk into the new post the first thing they do is sign up for the pension as nearly all are less than 55-years of age thus preparing for the next pension and financial turbo boost in old age)
The same publicly funded organisations are also squeezing front line services to do more with less. It’s a weird time out there.
I’ve also come across quite a big strategic deficit. Organisations trying to muddle through because of a lack of strategic direction. Take prison drug services for instance, something I am heavily involved in at the moment. There are so many different approaches to the same task i.e. transferring responsibility of prison based substance misuse services from MoJ/NOMs to DoH/PCTs/DAATs – its a bit of a minefield just learning the language, acronyms and abbreviations.
The transfer was announced in March 2011 to take effect as of 1.4.11. The initial central advice on completing handover of services and having new services in place has moved from, ‘needs to be done by April 2012, to summer 2012, to Oct 2012 at the latest to April 2013 – what!!!!!
The rush to impress ministers, to make a splash (as mentioned above, so as not be replaced, to look tough, dynamic etc) has led to more speed and less haste. While localities are moving forward as steadily as possible the central govt. depts. seem to be at odds with each and singing from different hymn sheets – all very confusing for those attempting to identify need, write new service specifications and deliver something approaching recovery based services that meet prisoner’s needs
In the end, my experience is that there are too many staff that were recruited against specific project funding streams, and are now surplus to requirements but cannot be downsized without great expense
There are particularly huge numbers of central and regional staff (some good value but many working as ‘clip board holders’) and there is a shortage of good, experienced and skilled frontline and delivery staff. If well managed, central (national/regional) staff could be re-deployed into the front line, at minimal cost if there was the will, and a plan to do it – something which is sadly lacking in my view – no one is taking a whole system view (maybe the cabinet office needs to put its foot down)
Doing this simple task could reduce the stress workers and managers feel, increase productivity at the frontline, and reduce the cost burden of these ridiculous (un-scrutinised) taxpayer funded pay off deals
I’ll try not to stay away so long next time
All the best
Huseyin
ps – this post is also available on my ‘wired in’ blog, click link as there are other posts there that dont appear here

Commissioner, Prime Provider or The New Gang Masters?

I haven’t written a blog on these pages since mid September and I’m getting withdrawals, I haven’t written on ‘Wired In’ for a while either, so double withdrawals!!

There are several reasons for this (I’m not just lazy!).  Firstly work is hectic, which for a self-employed consultant is a good thing.  I have 3 contracts at present and deadlines galore.  When it gets this bad I start having to pull all nighters because there are literally not enough hours in the day to cram in work and family life.
Also, I have a number of projects on the go: 
  • I’ve been asked to write an article
  • I’ve been asked to include my story in a book of Recovery Stories, which is a huge privilege.
  • Finally, I have a couple of pro-bono jobs which are also busy at the moment
  • Oh, and finally finally I’m prepping for a conference, filling in as a favour for a friend and I’ve committed the cardinal sin (for a consultant that is), I didn’t agreed a fee upfront!! So will probably end up doing it for expenses, boo hoo, woe is me!!

Anyway, all that to one side, I was going to sit tight, meet my deadlines, go to my little committees, and conferences, write my stories and wait till November before musing any more musings.
Sometimes however events just conspire against you (I mean me) and I felt I had to put e-pen to e-paper.  I’ve been seeing quite a lot about service re-design on various DAAT websites, driven as ever by PbR (whether as a full on pilot site or a wannabe early adopter)
I’m all for knocking some walls down and moving the furniture around but some of the stuff being mooted seems a bit beyond the pale and I’m not sure that commissioners and the policy types have really thought things through.  With this in mind and in light of some of the proposed changes I thought I would explore a modality close to my heart, residential rehabilitation aka resi rehab
Getting into rehab can be a complex journey if you don’t have the money and need the state to pay.  There are several starting points on the journey to rehab and several ‘levels’ to negotiate.  If you are already “in treatment” you can see your drug worker and ask for a referral, e.g. at a ‘care plan review meeting’ and if you have a good drug worker they will brief you on how things work where you are (I’m going to be positive and assume there is none of the usual game playing, hoop jumping and gate-keeping that normally goes on and that you get the referral).  
Following referral you’ll need an assessment.  Now different areas do this in different ways, even though they all work to the same set of rules, they just interpret them differently.  Under the NHS and Community Care Act 1990, we all have a right to an assessment of our needs, leading to a care plan and if eligible, access to appropriate care in a residential setting – e.g. resi rehab
After assessment, care planning, etc, a decision about funding comes next and an individual commissioner, or a panel of social care professionals can then make the decision.  Sometimes the panels include local statutory or non-stat service providers e.g. The Probation Service, NHS Trusts, Police, Voluntary Sector Groups and other stakeholders – but always chaired, organized and administered by a statutory body because we are dealing with a member of the publics statutory rights and deciding on the use of public money
Increasingly however DAATs, via PbR, or service re-design, as mentioned above end up, in their innovative zeal, going a bit too far.  For instance, in some areas, it almost seems that the NHS and Community Care Act 1990 doesn’t apply anymore.  Some DAATs are shifting the responsibility for most or all aspects of the resi rehab process to Prime Providers or a series of voluntary sector providers, under a framework agreement.  They are in effect turning a service provider into a type of ‘gang master’ and asking them on the one hand to be a proxy commissioner and the other to be a service (or outcome) provider – surely this poor governance. 
We are in Nick Leeson territory, performing the back office and trading floor functions without proper oversight.  It’s like authorizing your own expenses; it just isn’t done because to do so would open you up to allegations of a conflict of interest, a bit like a news article I saw on the BBC today.  The BBC said that a GP practice in York wrote to its own patients to inform them they had to go private for certain minor ops etc, only to find out that they owned one of the private providers they were referring their patients to. 
Some of these prime providers and proxy commissioners are also resi rehab owners / providers and in effect could be referring clients to their own services, assessing them and judging they are suitable, funding them and then paying themselves for the clients stay and then claiming the money back from the DAAT!!
   
Don’t splutter into your coffee, you heard me right.  They are asking service providers to effectively commission (no that’s the wrong word) be responsible for finding, assessing, placing and paying the invoices for, resi rehab clients.  In some ways this seems a brilliant strategy, and it means the commissioners’ don’t have to solve the much more difficult and confusing statutory situation surrounding how we get people into rehab (via the community care act and via the paid commissioners whose role it really is).
It’s also brilliant because not only do they shove the problem onto someone else, it sets provider against provider (I know that’s not their aim but its inevitable, and its already started).  The selected providers will decide who gets referred, who gets assessed, who goes to which rehab and who gets paid.  These providers suddenly become very powerful because they suddenly hold the DAAT budget for resi-rehab
What if these service providers (that also have services across the country and which turnover millions of public £s per annum) use this privileged position to further their own ends?  I’m not sure about that.  What if they want to stifle a competitor that is threatening their income stream or their preferred status?  What’s to stop them? And what of the commissioners that have given them this power and responsibility; what of them, will we see a reduction in the number of commissioners due to a reduced workload?
The logic is very much like the rationale behind PbR.  I’ve been told on several occasions by civil servants, in a sometimes boastful manner, that Oliver Letwins Cabinet Office is plastered with flip charts and post it notes as he charts the growth of PbR in every area of government and because of this PbR (or a modified version of it) is here to stay
I’ve been in Oliver Letwins cabinet office (I know, I’ve dined out on this story before, but please be patient and allow me one more crumb).  I witnessed an early version of this rationale, PbR-v1.0, when I met him in September 2010, and where he declared that the government will pay only for what works.  If a particular approach doesn’t work, then we won’t pay and the public purse is protected, if something does work then we will be more than happy to pay because the public benefits, brutal, but brilliant logic, undeniable and impressive, as was he  
However, whilst brutally brilliant, the PbR rationale is critically flawed, and even the more recent versions 2.0 and 2.1 etc are also critically flawed.  First off, somewhere in the discussion about PbR we have forgotten that we are talking about the care of often very vulnerable people and we are treating them as a commodity, slapping a tariff on them and trading them – the promise of payment for a good outcome.  I wonder how long before a provider is enticed to split the winnings with the clients if they pretend to be better.  They are people and not widgets.
Anyone that has been in this field any length of time will tell you, everything and nothing works.  There are so many variables that if we could have solved this problem we would have done it years ago – the truth is we almost did, it was called resi rehab.  
It’s the one people with money and means choose.  No celebrity ever went to a prescribing service for help – they go to rehab. They get stable, they get detoxed, they get hope and they try and put their lives back together. Sometimes it takes a few goes and if you have the means you persevere, if you don’t have the means, you get methadone or Buprenorphine for years and years and the irony is it costs more than rehab ever would.  The costs eventually run into the hundreds of millions, and the legacy is that it hurts for generations and it keeps costing.  You cannot prescribe your way out of addiction in the same way that you cannot borrow your way out of debt.  At some point we have to confront addiction, and yet what do we spend most of our treatment budget on?  Well, 18-months after the new coalition came to power and nearly a year since the new coalition drug strategy and we are still spending most of the budget on prescribing.  A bit like spending all your money on interest payments, eventually you have to pay back the capital, something the loan shark failed to mention!
And yet, lets assume for a moment that the brutal logic is sound, ok then, if it is lets apply across the board, not just to the most fragile part of the system, the bit that only 2% of addicts get a crack at.  Use the logic and apply it to prescribing services that take up 80% of the resources and contribute the least to the Recovery journey of an addict.  In fact these services, over inflated as they currently are, seem to rob the client of the very cognitive skills required to build motivation and hope.  They trap the individual and make it almost impossible to escape, if we are going to apply the brutal logic of PbR lets do it to the whole system and lets have a free for all
I am amazed at how so many genuinely clever people, like Mr. Letwin, top cabinet ministers and the civil servants that advise him (many with an education to die for) can be so clever and so stupid at one and the same time – government strategy, is that what they call a paradox or an oxymoron?
Maybe its like the story about the emperors new clothes, it was fabled that only the clever courtiers could see the fine new cloth, and so because no one wanted to be seen as ‘not clever’ they went along with the deception.  In the end, the emperor was humiliated because a little child pointed out the bleeding obvious, in public, and everyone laughed at the naked King.
Nuff said, rant over
All the best
Huseyin

Residential Rehab 01 – setting the scene

Access to residential (or even the cheaper quasi residential) rehab is at an all time low.  The stark facts are that for a variety of reasons, very few people get into rehab anymore, and yet it remains one of the most effective treatments for recovery from drug and alcohol addiction out there

Now by asserting that rehab is effective, please don’t read into that that I am saying other forms of treatment are not effective, I am advocating a mixed economy of treatment options.  Please DO read into the above that at present we do not have a proper mix of treatment options.
In 2010 the coalition government published its new drug strategy, which now promotes Recovery rather than being predominantly about Harm Reduction.  The new strategy focuses on “supporting people to live a drug free life”.  
Already less than a year old and we see some unhelpful semantics attempting to hijack the new strategy by re-defining the simple term “drug free life” to mean, “free of drugs of dependency”, or “free of illicit drugs” etc – anything except what it says on the tin
We are in danger of rebranding harm reduction and calling it recovery – not good. There seems to be a disconnect between policy and practice as very few substance misuse partnerships seem to be “re-balancing” their treatment systems to adopt a recovery focus.
There are a number of reasons for this but one of the reasons seems to be a lack of leadership from the very top of government.  To change the focus of an almost £1billion pound treatment economy needs more than the publication of a new strategy.  It needs more than a few PbR Pilots and it needs more than the current, confusing and stalled / paused NHS Reforms
My experience is that there are substance misuse partnerships out there (whether as DAATs or as part of Community Safety Partnerships) that are in limbo.  Some are taking the initiative and moving forward as best they can, and others are standing still, effectively ‘holding the fort’ until news of next steps arrives or is clarified.
The last government were characterized by an over use of targets, micro-management and medaling and this government is characterized by not wanting to be like the last government.  Therefore, rather than showing real leadership and getting behind their published strategy they are adopting a, we’ll let the market decide what works approach, predominantly through PbR.  Unfortunately there are 8 PbR pilots, some of which are already floundering (but putting on a brave face) and 140+ other DAATs wondering, “ok, we’ve had the new strategy, what next”
There is no real practical guidance, drive, or workforce development to help coax HMS Drug Strategy along.  There is no target date to achieve re-balancing by; there is no requirement to commit any % of resources to recovery.  Many partnerships are even confused about what Recovery actually is.  The coalition are hiding behind the localism and big society agenda, which is itself unclear at this stage
You may not believe me but I take no pleasure in writing in such harsh terms about a field which I love, which I am totally committed to and which has not only helped me by offering me rehabilitation when I needed it but continues to sustain me in employment.  I advised the conservatives, directly and indirectly when they were in opposition.  I gave evidence, as a civil servant, to the centre for social justice policy review (the addictions report) and I praised the breakdown and breakthrough Britain reports as some of the best evidence I had ever read. 
I guess, given the coalition that the 2010 election produced all bets were off .  Maybe this is coalition government, paralysis.
It’s a long way from the potential of the Breakthrough Britain Report, (Volume 4 Addictions, Towards Recovery) where the opening statement was…..
If we concentrate on restoring people’s lives, most of the public health and crime issues will take care of themselves.
Looking at the current treatment landscape, in the light of these excellent reports and best intentions, shows us just how far we have regressed.  These reports were based on a solid evidence base and were the result of a lot of hard work and good consultation and being so far out of step and is an indicator that at present the tail must be wagging the dog i.e. civil servants, not ministers are again driving policy
In trying not to become like the previous government the current coalition will have the same regrets as Tony Blair said he had in that he never went far enough, fast enough.  Well, the current coalition are going fast but it seems they have left the roadmap (the reports referred to above) behind
I’d urge them, to re-read the addictions reports they authored in opposition, to pick them up and drive them forward.  Any strategy is dependant upon implementation.  Implementation doesn’t arrive on its own, it needs visible and dynamic leadership, something the wait and see approach is not delivering

Huseyin Djemil
ps – later in the week I will start proper the series on how to access residential rehab, what your (and your commissioners) rights and responsibilities are; using a variety of case studies and other examples to hopefully illustrate this

A week in life of the good consultant….

I originally started this blog, several years ago, to track my progress as a new consultant.

To recap I had worked in the field of addictions / substance misuse for many years and was presented with a unique opportunity (crisis) to do something new.  Stumbling blocks really can become stepping stones to new opportunities, as I know from my own journey of recovery from addiction, so I started freelance consulting in July 2007.

Several years on, and now as the Director of my very own company (Green Apple Consulting Ltd), I have not forgotten those early days and want to capture and communicate some of what being a consultant is all about in this and future blogs.

I could look at any week since July 2007 as most weeks have been busy, interesting, manic, diverse etc etc.  Even though I’ve been busy all the time I’ve also been worried about all sorts of things, mainly, delivering my current contract(s) and where the next contract is coming from, and nothings really changed in that regard, except I can maybe pick and choose the roles a bit more now than I could then

I’m not complacent though as the cliche really is true, you’re only as good as your last project

This week has been an interesting week:

  • Monday and Tuesday I worked from home on two separate contracts, for two county partnerships on developing and changing prison based substance misuse services within those counties
  • Wednesday I was invited to HMP Bronzefield (a privately run prison) to be part of a delegation to meet with HRH Princess Anne in her role as Patron of The Butler Trust.  Later that evening I was invited to speak at an upcoming recovery conference 
  • Thursday I was at the South East DAAT Commissioners Meeting, representing one of my clients as an ‘honorary commissioner’
  • Friday I was working from home again, taking calls, answering emails etc
And next week looks just as busy and diverse
  • Monday, prison meeting at 11am, working lunch at 1.30pm, 3pm meeting with Care, before going on to meet with Care and David Burrowes MP at Portcullis House
  • Tuesday, Surrey DAAT (meet with the Manager in the morning and with the executive group in the afternoon)
  • Wednesday, work from home in the morning and from 4pm House of Commons for the launch of the Concordat
  • Thursday and Friday are again, admin and working from home days and on Sunday I am invited to attend (and very much looking forward to) The Ley Community, to celebrate with them 40th Anniversary for delivering transforming, rehabilitative care to men and women with drug and alcohol addictions
The above is not about name dropping or showing off about how interesting my job is.  Its about demonstrating that people in recovery can aim high, that we can have a good life beyond treatment.  Its about having and keeping a hopeful outlook on life, despite our usual worries about money or relapse or what we think others think about us, or what we think about ourselves or (to get properly into some rehab speak – what we think others think of us!!!
I got into consulting because I felt I had to leave the civil service because I landed a great job but it made me miserable.  I also went into to treatment many years ago because I wanted to give up drugs and start my life again as a criminal without the major impediment of a drug habit around my neck
Along the way, in life as in work, my motivation changed and I learnt a lot, made new friends, redefined my goals and suddenly was living again.  Relating my personal story back to the treatment field of today we have to do so much more than we are doing.
Treatment and recovery services (as they are beginning to be defined) need to provide hope and opportunity for those that access them.  In my experience, those accessing drug and alcohol treatment services (like me) predominantly want to give up drugs, move away from dependancy and live again
In the coming weeks and months I want to chart what I do as a consultant but will also try and give my recovery insight as well as bring insight from friends, colleagues and clients in recovery
Hope you enjoy it
All the best
Huseyin