SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Clinical & Policy Updates:
SMMGP Policy Update November 2008

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No One Written Off: Reforming Welfare to Reward Responsibility 2008

November's Policy Update is dedicated to the Department for Work and Pensions (DWP) Green Paper 'No one written off: reforming welfare to reward responsibility' and your response to it. The paper attempts to set out plans for improving support and work incentives to create a system that rewards responsibility and delivers greater choice and control over the support that is provided.

In chapter 2 'An Obligation to Work' the DWP estimate that 240,000 people in England are in receipt of out-of-work benefits and are dependent on opiates or crack cocaine (problem drug users). This is around three-quarters of the estimated total number of people who are dependent on these drugs. The proposed plans could have a significant impact, potentially both positive and negative, on people who are 'out-of-work' and claiming benefit, but for drug users it means a new regime.

A new regime for problem drug users

'No one written off' sits neatly alongside the 2008 Drug Strategy (Home Office, 2008, Drugs: protecting families and communities - The 2008 drug strategy), which states that ...'we will explore the case for introducing a new regime for drug misusers which provides more tailored and personalised support than is currently provided by the existing Incapacity Benefit or Jobseekers Allowance regimes. In return for benefit payments, claimants will have a responsibility to move successfully through treatment and into employment.' The Drug Strategy commits the government to ensuring that the benefit system supports this new focus on reintegration. However, up to 100,000 problem drug users on benefits are not in drug treatment; the first priority set out in the consultation paper, therefore, is to ensure that problem drug users in the benefits system are identified. The DWP intend to develop a new approach to identifying drug users based on interventions in the Employment and Support Allowance (ESA) and Jobseeker's Allowance (JSA) alongside information shared with the criminal justice system.

How will problem drug users be identified?

The consultation paper suggests systematically building the identification of problem drug users into the new claim process for ESA. For JSA they intend to strengthen guidance for advisers to help them to identify claimants who may be dependent on heroin or crack cocaine and once identified problem drug users will then be required to see a drug treatment provider.

They also propose to legislate to enable information to be shared between Jobcentre Plus and the police, probation services and prisons. However, they acknowledge that this will need to be in line with the Data Protection Act - and on respecting individuals' right to privacy - under the European Convention on Human Rights.

They propose to do this in 3 ways:

The DWP are also seeking views on the merits of changing the benefit rules to require all applicants for benefit to declare whether they are addicted to heroin or crack cocaine. This could include bringing in sanctions such as recovering overpayments and investigations for fraud against those who mislead the benefits agency.

Drug users on benefits

Once drug users have been identified, those who are not in drug treatment will be required to see a drug treatment provider and failure to so could result in benefit sanctions. The DWP also propose that drug users on benefit should be required, where appropriate, to see a specialist employment adviser to draw up a rehabilitation plan. The approach will build on the Progress2work programme which provides specialist support for recovering drug users.

In return for drug treatment and specialist employment support, there will be an obligation on individuals to take it up. Failure to do so without good cause would result in a referral back to Jobcentre Plus and a potential benefit sanction. This approach will take into account the range of barriers that many drug-dependent claimants face (often including chronic health conditions).

Treatment Allowance

The DWP are seeking views on making changes to the benefit system in order to introduce a 'Treatment Allowance' this would replace normal benefit payments while problem drug users stabilise in treatment.

Testing and Evaluating Approaches

The DWP acknowledge that the above proposals will require careful development and propose testing and evaluating approaches. They will roll-out the programme based on the results of the evaluation. They intend to link up treatment provision with employment support by appointing DH funded drug coordinators in Jobcentre Plus by 2009.

SMMGP Response

Department for Work and Pensions Consultation
No one written off: reforming welfare to reward responsibility

We, SMMGP asked our members to respond to the Department for Work and Pensions (DWP) consultation on 'No one written off: reforming welfare to reward responsibility.' They were asked to consider and respond to the two questions (questions 6 and 7) posed in the Green Paper that relate directly to their clients and their work with them.

The responses from 35 members are summarised below along with a position statement from SMMGP.

Do you agree with the proposed approach for identifying problem drug use? How should the approach be implemented?

Yes: 9 (26%)
No: 26 74%

Members gave a range of opinions on how the proposed approach for identifying problem drug users could be implemented, though the majority expressed concerns. Some respondents tentatively welcomed the principle of encouraging hard-to-reach groups into treatment, but had concerns about the potentially punitive aspects of the Green Paper, particularly the imposition of penalties for non-engagement.

Many commented that the proposed approach should not be implemented because it would create a lack of trust and break-down of relationship between treatment providers and patients, resulting in worse and not better outcomes. There were also concerns that this approach would drive problem drug users "underground" by leading them to drop out of treatment and stop claiming benefits altogether - and possibly returning to crime.

One respondent raised concerns about the lack of training for staff working in benefits agencies particularly around substance misuse issues and questioned how they would cope with disclosures of substance use.

Several also questioned how the proposed changes would fit in with existing confidentiality procedures. A number of respondents asked why this approach was restricted to drug users and did not include alcohol users.

Some felt that the Paper was by its very nature stigmatising drug users by treating them as different from the rest of society.

A small number of respondents suggested ways to implement the system including: to trial it in the criminal justice system and needle exchanges, GPs playing a part in implementing the approach, urine testing as a way of identifying drug users in the system, and QOF targets to encourage GPs to participate.

SMMGP Position Statement

SMMGP welcomes the DWP's attempt to encourage social integration but is deeply concerned that this paper fails to understand the fundamental nature of addiction. We do not agree with the proposed approach of labelling and the resulting discrimination of drug users in the benefits system. SMMGP is committed to engaging hard-to-reach groups, however we believe that benefit sanctions for those who are using drugs but failing to engage with treatment will have the effect of driving many drug users away from the treatment and benefits system and into a life that is characterised by poverty, high risk drug taking behaviours and crime. This group will be at a significantly higher risk of death and ill health than their age-matched peers.

We are also deeply concerned that there is no understanding of dual diagnosis, although we know from one large UK study (Weaver et al 2002) reported, that 44% of people in adult mental health services had a coexisting drug or alcohol problem and 75% to 85% of people in drug and alcohol services had coexisting mental health problems.

SMMGP believes that if responsibility is placed upon treatment providers to inform the benefits agency of patients' engagement, or otherwise, in treatment that this will significantly affect the relationship between the clinician and the patient, leading to a worsening in treatment outcomes. SMMGP believes that targeting drug users in this way is adding to the stigma that they already experience in society, and which contributes to difficulties they already face in addressing their problems, including finding employment. SMMGP is concerned that drug users have been singled out as a group who can be excluded from benefits due to their wish not to engage in treatment. Many people chose not to engage with treatments that may improve their capacity to work, and yet are not denied benefits. SMMGP is not in favour of using urine testing in the benefits system to identify drug users, or for rolling out the proposed approach in primary care.

Loss of confidentiality and sharing of information between the criminal justice system and DWP is also a concern, though SMMGP supports the idea of encouraging employers to take on people with a history of problematic drug use as this is an enormous barrier to return to work. Also we have real concerns about the introduction of a 'Treatment Allowance' replacing normal benefit payments while problem drug users stabilise in treatment, as drug users would be treated as different to other claimants.

Do you think that everyone claiming a working-age benefit should be required to make a declaration of whether or not they use certain specified (opiates and cocaine) drugs?

Yes: 8 (23%)
No: 26 (74%)

Many questioned why the proposed approach suggests that all people who are claiming working- age benefits should be asked whether they used drugs, rather than an approach that focused on the people who identified drug use as the cause of their inability to work.

Some questioned why drug use is targeted as an issue when there are other health problems such as alcohol use, anxiety and depression that can cause greater difficulties regarding incapacity for work.

Several respondents expressed the opinion that drug users would conceal their drug use if asked, and that it would, therefore, be a worthless exercise. A number of respondents suggested that the approach stigmatises drug users, pointing to the fact that people are not being asked to disclose their alcohol use.

A number of respondents expressed the opinion that this approach may encourage some drug users who do not want to enter treatment, not to claim for benefits, and turn to criminal behaviour instead as a way of providing for themselves, and also that some drug users on benefits would avoid coming into treatment for fear of having their benefits stopped if they were seen to be failing in treatment.

Several respondents expressed concern about the potentially coercive nature of this approach being stigmatising and ineffective, suggesting it is only people who are motivated who will respond well to treatment.

SMMGP Position Statement

SMMGP believes that claimants who are not ready to access treatment are unlikely to declare or admit drug use when questioned if benefit sanctions are likely to follow if they refuse to attend a service for treatment. SMMGP also believes that if people who have declared use of opiates and/or cocaine are to be referred to treatment then consideration should be given to ensuring that this takes place in a non-stigmatising way.

SMMGP believes that if this approach were introduced, a number of drug users who are not ready for treatment would stop claiming benefits or will chose to continue to claim benefits, but not enter treatment for fear of their benefits being cut if they are seen to drop out or get discharged from treatment. Moreover threats of criminal investigation and drug testing are yet another threat to drug users' civil liberties.

This will have a serious effect on the mortality and morbidity of this vulnerable group who already experience social exclusion, ill health and higher death rates than their age matched peers. SMMGP believes that the introduction of a responsibility on drug treatment staff to provide information regarding patients to benefits staff will have a serious negative impact upon their relationship with their patients and, therefore, upon their patients' treatment outcomes. Job Centres already provide support for claimants on a range of issues, including drug use and help to get them back into work. SMMGP questions why additional and coercive measures need to be put in place, particularly at a time of rising unemployment when targets to get people back into work will be challenging.

What elements should an integrated system of drug treatment and employment support include?

The overwhelming view of SMMGP members is that support with employment should be a central and integrated part of drug treatment, together with medical interventions, support with housing and psychosocial support. Clear communication, care pathways and joint working between agencies are also important.

Many highlighted the fact that in order to achieve good outcomes, patients needed to be offered treatment in a supportive, needs-led system and not a coercive environment, as proposed by the Green Paper, and that the process of moving back into work may take time and should not be forced.

Many highlighted the importance of a non-judgemental attitude to engaging and supporting individuals through this process, and suggested that the singling out of drug users within the benefits system would in fact have a stigmatising effect.

Some respondents reported concerns about any integration with employment services at all, in light of the potentially coercive nature of the Green Paper, and the negative effect this could have on patients of their service, and of clinicians' relationship with their patients.

SMMGP Position Statement

SMMG believes that support for employment should be a central part of drug treatment, but that enforced and punitive approaches will not have the desired outcomes of encouraging more drug users into treatment and work, but are likely to lead to people disengaging with both drug treatment and employment services. SMMGP highlights the good work that is currently going on between drug treatment providers and the benefits agency, such as Progress2Work, and suggests that this model of joint work can be effective without the coercive and potentially stigmatising measures of the Green Paper.

Do you agree that a rehabilitation plan would help recovering drug users to manage their condition and move towards employment?

Yes: 29 (82%)
No: 2 (6%)

Many highlighted the fact that this was already happening in drug treatment as part of the care planning process, and some highlighted the fact that this was already available in some Job Centres, in particular with Progress2Work.

Several respondents emphasised that in order to work, a plan should be supportive and centred on patients' needs and should not to be coercive, as the measures of the Green Paper have the potential to be.

A small number of members, however, welcomed the increased emphasis on drug users having some coercion back into work.

SMMGP Position Statement

SMMGP is committed to the principle of ongoing planning to support drug users in treatment toward their goals, which may include finding employment. Like the majority of its members SMMGP believes that this will be best achieved by ongoing support of the individual based upon needs-led planning, rather than by coercion of individuals either into treatment or back into work without adequate planning and support. SMMGP feels that this process is already happening in many areas and would encourage the increased involvement of benefits agencies with a patient's consent, but not as a requirement of drug treatment.

SMMGP's position seems to be in line with other agencies working with drug users. Many agencies have described the proposals set out in the green paper as 'unworkable' 'punitive' and 'discriminatory', which we also echo. Others share our concerns about the potential increase in discrimination and the effects these changes will have on an already vulnerable population.

In this age of evidence-based practice we agree with the statement by UK Drug Policy Commission: 'We find no convincing evidence that making benefits conditioned upon engagement with treatment will be effective in improving outcomes' ...and ...'Many problem drug users have multiple, long-standing problems which will require long-term, multi-component solutions as part of a rehabilitation package.'

During the writing of this Policy Update a campaign was launched by PCS and Compass to challenge the proposed welfare reforms. To find out more about this campaign and to sign up to support their welfare statement visit www.pcs.org.uk/welfare.