Norman Fowler calls for Prevention Strategy

FowlerAs part of a wider set of interviews carried out to reflect on the 65th anniversary of the NHS Sir Norman Fowler makes some points that may resonate with readers of this blog.

He says:

far, far too little time and money is devoted to preventing ill health. It is still simply not taken remotely seriously enough. Much of my experience is with HIV at the moment and with the recent select committee we did point out that the Government was spending £760 million a year on drugs to treat people with HIV. I’ve got no complaint about that, but they spent £2.9 million a year on government publicity to prevent HIV. Actually they’ve now reduced even that. It does show something of the kind of priorities that we have.

And I think that prevention needs to be given priority. I mean it’s all very well having a separate budget, and I’m all in favour of that, but what it really needs is to be given a lead, a strategy, a belief, because without that people are still not going to take it very seriously.

And that goes way beyond HIV. It goes to all the things that people talk about – sugar, obesity, smoking, alcohol. You are going to be shot at if you go into that area. People are going to talk about the nanny state and all that. But that just has to be taken on. If you do these things one by one, it is highly dubious whether you really have an impact. I’d be all in favour of a separate prevention budget. But what it really needs is a strategy and a belief and someone with that belief to push it forward.

What does a public health response to drug prevention look like?

The debate on what a public health approach to drug policy looks like is not only happening here in the UK but is something that Americans are also looking at following the publication of the Obama Administration’s latest drug strategy.

This piece at the ever interesting Alcohol and Drugs History Society’s Points blog asks whether there’s any appetite in the public health community to ‘own’ the issue alongside the many other issues that they have traditionally addressed.  And it points out that public health measures can also mean:

fear-mongering and produce risk, blame and shame in their efforts, identifying “risky” lifestyles and behaviors. At its best, public health projects can address the complex etiology and interactions between individuals and their environments as well as focusing on the “upstream” societal factors—poverty and inequality, to name a couple—that are such important forces in determining one’s life chances.

This concern that drug policy could get lost is (broadly) the same point that Marcus Roberts from DrugScope makes here about the emergence of Public Health England and the local government’s budget decisions when it comes to determining local need.

The article on Points does however link to an attempt to map out what a public health approach may look like.  Developed by the New York Academy of Medicine and the Drug Policy Alliance the Blueprint for a Public Health and Safety Approach to Drug Policy sets out one way that New York might try to tackle issues around illegal drug use.

As you would expect the paper has sections that deal with prevention, treatment and the role of law enforcement.  Readers will I hope understand if I focus on the recommendations for prevention.

They are clear about what they see as prevention:

Effective prevention strategies enable people to make healthy choices and improve health outcomes for themselves and their families. Prevention can delay the initiation of drug use, avert the escalation of use, and diminish engagement in drug related activities that can lead to violence and/or criminal justice involvement. Prevention, here, is conceptualized both in its traditional sense of programs that provide education and skills to avoid or address drug use and, more broadly, to encompass community development strategies that address the root causes of drug use and offer individuals meaningful alternatives to drug use and drug dealing.

chart_1 (21)The first of their findings is that there is a desire to see more funding allocated to effective prevention initiatives.  The paper estimates that only 5.5% of the federal budget for drugs was spent on prevention work.  (It is worth noting that when the UK Focal Point estimated central government spending on drug policy here in the UK they were barely able to identify any spending at all.)

The paper argues:

Research shows that prevention programs can also be cost effective; for each dollar spent on prevention, communities can save up to $10 in drug treatment and counseling costs.  Too often, however, drug prevention programs are underfunded, narrowly defined, and operate in isolation, especially from other health promotion and community development efforts.

They are, however, keen to point out that what they are not calling for is solely investing in education and messaging (though they remain part of the mix) but to extend prevention to tackling the risk factors and building protective communities and environments in which young people can grow and which foster resilience.

The conception of a community prevention strategy is focused on the social determinants of health, particularly by reducing unemployment – which, for the authors, is also linked with providing alternative economic routes for those who may otherwise engage in drug dealing.

Youth Development

It is clear that the consultations that the authors did in drafting the report suggests that drug use by young people, and trying to prevent those harms was a significant issue for communities and professionals.

Prevention programming that facilitates positive youth development not only decreases drug use, but also reduces delinquency, violence, drop-outs, and teen pregnancy. Community members and academics highlight several risk factors for young people that needed to be better addressed in New York communities, including normalization of drug use and other problem behaviors by the media, peers, and, in some cases, parents; academic failure; family conflict; community disorganization; and lack of opportunities for positive involvement with family and community members.

The authors highlight the difficulty of providing positive out of school activities that focus on developing young people as a significant barrier to a good prevention strategy.

Drug education

The paper echoes our experience – see for example the youth led research we did for the London Youth Involvement project – that school drug education isn’t currently meeting the needs of young people.

Several participants, including young people, felt that current education strategies were nonexistent, under-resourced, or ineffective.

They are however able to report that nearly half (47%) of those who received prevention services got an evidence based programme; something we couldn’t claim.

The paper is clear that a a wide health education curriculum is part of what is needed:

According to research, a broad health based curriculum including drug education, along with life skills and decision-making training, can impact the choices young people make on a range of issues (drug use, gang involvement, violence, delinquency, teen pregnancy, etc.).

But the curriculum isn’t enough:

Schools were identified by community members as an important—but missed—opportunity to increase youth engagement, raise achievement expectations and outcomes, and more comprehensively address students’ needs in ways that can prevent drug use and drug dealing. Participants wanted schools to go beyond health education and do more to bolster positive youth development and academic achievement.

And what schools do should be allied to providing parents with the information and skills they need to be able to support school based drug education.

This draft strategy of building skills, supporting positive health behaviours and the protective factors that make risky behaviour less likely allied to a wider prevention push on the social determinants of health is very attractive to me and fits neatly with the UN’s recent prevention standards.  But it requires significant political will to make it happen, and that will be difficult to achieve in a period where resources are tighter than ever.


Substance misuse and early intervention; a role for schools

Above are the slides I used at a conference on substance misuse and the role that schools play.

The argument I was trying to make was that the protective role that schools can play isn’t just down to the quality of their drug and alcohol education, or even the broader PSHE agenda (important though that is).

Rather we need school rules that are clear, applied consistently and help to identify and support students when they may be getting into trouble.  The curriculum needs to help young people develop relevant skills and values, rather more than focusing on facts about drugs or alcohol.  A positive school ethos that builds attachment has also been shown to be a powerful protective factor in young people’s lives.  And being able to make sure that vulnerable young people have early access to appropriate services means that problems can be dealt with before they lead to more intractable problems.

The presentation lead to two sets of interesting and important questions.

Firstly about the role of ex-users in drug education.  We heard from the audience about three distinct ways that schools and other organisations work with those in recovery from addiction:

  • As motivational speakers – through whole school or class assemblies
  • Following a programme delivered over a number of weeks – where students can then ask questions based on information acquired through the programme
  • As mentors to young people who are receiving treatment themselves

My sense was that broadly the audience would find it very helpful if there were some proper research done into the outcomes that might result from these sort of interventions.

The second issue that was raised was about identifying those at most risk, particularly those who are already using substances.  There was feedback that the changing patterns of use, and in particular the use of ‘legal highs’, may be changing the speed at which risk was becoming apparent.  One participant talked about the speed at which some young people were now moving from first use to turning up at A&E being a matter of weeks rather than months or years.

The question this raises for me is whether we have sufficiently good local data and screening tools to react to what might be quite localised problems.

Evidence-based programmes in schools: are they a realistic solution for drug and alcohol prevention?

On 26 March, Mentor will be hosting a seminar: ‘What works’ in supporting young people’s development – making evidence useful for schools and practitioners. Mentor is very supportive of the use of evidence-based programmes, but to say that their use in the UK for drug and alcohol prevention has been limited is an understatement.

There are different types of evidence (see the presentation below) but some of the strongest comes from randomised controlled trials (RCTs). Allocating randomly between the intervention and control groups makes it more likely that any improvement is due to the intervention and not some other factor. Continue reading

Government response to Drugs: Breaking the Cycle

The government have responded to the Home Affairs Select Committee’s report on drugs.  The select committee’s recommendations covered a range of issues and as such so does the government’s response, but I’m going to focus on what it has to say about two recommendations.

  • Recommendation 13
    The evidence suggests that early intervention should be an integral part of any policy 
    which is to be effective in breaking the cycle of drug dependency. We recommend that the next version of the Drugs Strategy contain a clear commitment to an effective drugs education and prevention programme, including behaviour-based interventions. (Paragraph 75)
  • Recommendation 14
    We recommend that Public Health England commit centralised funding for 
    preventative interventions when pilots are proven to be effective. (Paragraph 76) 

Continue reading

Marking the government’s drug strategy from a children’s rights perspective

crae - 2012The Children’s Rights Alliance for England in their review of government action on the meeting the Convention on the Rights of the Child mark the government as having overseen a “significant deterioration in law or policy in the past year” in two of the three sections on drugs and alcohol.

They say that there has been a worsening of the position in relation to:

  • providing accurate and objective information on drugs and alcohol to young people; and
  • ensuring support is given to those attempting to end dependency on toxic substances

They also say there has been no significant no significant change in law or policy in the past year when it comes to studying the causes of substance misuse in order to provide targeted preventative measures.

Of particular concern to the authors is the impact of the increasing number of academies on health education.  They say:

The deregulation of education means that increasing numbers of academies and free schools are not under an obligation to, for example, teach key aspects of the curriculum in relation to sex and relationships, drugs and alcohol and citizenship. It also means that schools are subject to weaker accountability and oversight mechanisms.

The report quotes the evidence that we gave to the Home Affairs Select Committee on drug education and prevention.

If drug education is central to the government’s prevention strategy why don’t they know more about it?

The government’s annual report to the European Monitoring Centre on Drugs and Drug Abuse (EMCDDA) has been published and as always it has a chapter on Prevention.

The government say:

School-based drug education forms a central part of the United Kingdom’s approach to universal drug prevention.

And argues that drug education is part of the national curriculum and that most schools have a drug education policy. The report also points out that the DfE carried out a review of PSHE education (including drug education) in 2011.

Unfortunately it doesn’t record that Ministers have yet to make recommendations as to how government will support better drug education some 14 months after the consultation on the review closed.  The report also points out that the revised non-statutory guidance for schools issued in 2012 “does not cover drug education.”

Continue reading

BMA – Delaying initiation and minimising the use of illicit drugs

The British Medical Association have produced a large report looking to:

open and refocus the debate on drug treatment and drug policy through the eyes of the medical profession.

Chapter 7 of the report sets out their reading of the evidence for drug prevention and their take on the policy landscape.

What I notice is that the authors take a pretty pessimistic view of the state of evidence, pointing to the limited amount of research that has been carried out, how most of that has been carried out in the US, and the difficulty of showing long-term outcomes.

In many ways this is very similar to much of what we at Mentor point out when we talk about prevention, but our tone is much more positive about the potential for achieving better outcomes.  The slide I use in my presentations [below] describes the same research landscape as the BMA paint.

olive of prevention

What I try to emphasis is that the challenge is to grow the red ‘pepper’ and white ‘garlic’ parts of the olive while reducing the brown ‘bruise’.

I also note that when the American National Academy of Sciences looked at these issues in 2009 they seem to have come to a very different view of the evidence, arguing that:

Several decades of research have shown that the promise and potential lifetime benefits of preventing mental, emotional, and behavioral (MEB) disorders are greatest by focusing on young people and that early interventions can be effective in delaying or preventing the onset of such disorders.

The BMA paper concludes by arguing that it may be time to explore policy alternatives to universal school-based prevention predicated on drug education lessons.  Tentatively suggesting as an alternative approach that:

Taking action on preventing the underlying causes of drug use may be as effective as, or more effective than, preventing drug use directly.

It would be tempting to be irritated by this iteration of the challenge of Marmot but, while I don’t believe in throwing the baby out with the bath water (particularly just at a point when the evidence is stacking up which finds that “certain generic psychosocial and developmental prevention programs can be effective and could be considered as policy and practice options“) I’m attracted by extending our conception of what makes for a prevention programme.

It’s why we’ve been championing the Good Behaviour Game and Preventure, both are school based  programmes that don’t talk about drugs or alcohol, but which have shown longer term outcomes reducing substance misuse harms.

It’s also why we have produced a toolkit to help schools review and improve their drug policy, because we know that the rules that schools have and the ethos they engender have the potential to protect young people.  And it is why we are positive about environmental prevention interventions like Minimum Unit Pricing for alcohol.

But the relationships between early substance misuse and other outcomes suggests this isn’t a simple trade off.  Nor can we be confident that we’ve developed sophisticated screening tools or interventions that will help us identify all of those at risk of developing problems and reduce their numbers.

life course

It is why I think a life course approach, or sunblock as Professor Tom McLellan put it, offers more hope as a strategy, than trying a single track approach, but all of what is tried should try to follow the evidence for what has been shown to be most effective, and where that evidence doesn’t exist we need to develop it and then find ways of bringing it to scale.