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UK National Health Service and Criminal Justice Approaches

Introduction

Drug use has increased in the UK in recent times and there are an estimated five million regular users of illegal substances in the region (Emmett and Nice., 2006). Of these, about one million people are found to be addicted to cocaine, whose use has multiplied four times within the past ten years (Emmett and Nice, 2006). However, it is heartening to note that the central government has taken important measures via the NHS and the Criminal Justice systems to reduce drug related mortality and crimes and also to provide treatment options for those who wish to escape the net of substance misuse. This article explores the various measures taken by the government in the realms of NHS and Criminal Justice to combat substance misuse and focuses on comparing and contrasting the approaches of the two agencies in the treatment and prevention of substance misuse using journal articles, magazine articles, books and authentic internet sources.

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History of NHS versus CJ approaches to SM (substance misuse)

The NHS approach to substance misuse is a combination of psychosocial and pharmacological interventions (Taylor et al., 2007). Substance misusers in the UK are provided a wide range of services from the NHS (National Health Service) (drug dependence unit, community substance misuse team, etc), the social services and the Probation Service (hostels or halfway houses) to voluntary help by community service agencies (Rassool, 1998). Alcohol abuse was the first to be tackled by NHS in the late 1950s, when the first specialized NHS alcohol treatment unit (ATU) was formed. Later on, a number of community alcohol teams (CATs) were created to assist healthcare professionals at NHS in the treatment of problem drinkers (Rassool, 1998). In 1965, the Brain Committee presented its report in which it recommended that there must be treatment units provided for treating problem drug users and addicts and to maintain opiate addicts on heroin (Ministry of Health and Scottish Home and Health Department, 1965). Consequently, drug dependency units (DDUs) were established all over UK in 1968 with the objecting of treating people hooked on opiates and heroin (Rassool, 1998). In the 1980s, with increasing misuse of psychoactive substances community drug teams (CDTs) was set up to include the opinion of generic workers into clinical work. More recently, a number of CDTs and CATs have been integrated together to form community substance misuse teams. Moreover since the early 1980s, the central government policy in the UK has been to include general practitioners (GPs) in the management of substance misusers. This is because a large percentage of the population is registered with a GP and sees them regularly. Primary care in the UK is readily accessible for the general population and is provided in a community setting with general practitioners and primary care nurses playing a crucial role in the delivery of health services. Initially, drug abusers were referred to specialists for treatment. But more recently there has been a shift towards the belief that, given the right support and training, the GP can play an effective role in caring for drug misusers. According to the joint policy statement of RCGP and GPC – two national Primary Care Bodies- issued in April 2000, “The RCGP and GPC believe that General Practitioners should offer appropriate care to all patients on their lists. Where patients have problems with substance abuse, appropriate care will include aspects of primary care normally provided by the practice health care team, shared care with other services and referral to other appropriate services. Certain GPs may develop particular expertise in the care of substance abusers, and the number and location of these doctors should, ideally, be sufficient to avoid substantial workload falling onto a few GPs” (RCGP/GPC Policy Statement on Care of Substance Abusers, 2000). The U.K. government’s 1998 White Paper titled “Tackling drugs to build a better Britain” outlined a ten year strategy for tackling substance misuse and revolved around four concepts: prevention, treatment, reducing availability and fighting drug related crime (Strang and Gossop, 2005). While the first two options fall within the purview of the NHS, the remaining two come under the criminal justice department where the public health approach ranges on the continuum from personal care to punishment. Within the premises of NHS, there is a debate whether pharmacological treatment is necessary or not. Methadone and buprenorphine are the best known pharmacological treatments in opiate dependence, but there are other drugs used in different cases as well: naltrexone for relapse prevention in opiate dependence; clonidine and lofexidine in opiate withdrawal; disulfiram and acamprosate in alcohol abuse; disulfiram in cocaine abuse; octreotide for preventing diarrhoea in opiate withdrawal. Within the community treating substance abuse, there are large sections opposed to pharmacological treatment as they believe that drugs cannot cure a drug problem (Bean and Nemitz, 2004). However, Paul Hayes, Chief Executive of the National Treatment Agency says to make treatment for substance misuse effective NTA plans to work towards improving the skills of general practitioners, allot more funds for needed resources, improve the quality of drug treatment in prison through the implementation of the Integrated Drug Treatment System in prison, and focus on outcomes. According to Paul Hayes, the main challenge is to move users who are in treatment to the recovery phase and reintegrate them in society and this is possible only by using several treatment paths (Hayes, 2009).

According to the British criminal justice system, the drug policy focuses on reducing demand for drugs, treatment and law enforcement. Karen Duke, in her review of prison drug policy since 1980, says that the CJ approach to substance misuse is a mixture of control, order and punishment along with a policy of strengthening supply side programs which means restricting the availability of drugs within the prison (Duke, 2000). The 1995 White Paper, Tackling Drugs Together created drug action teams (DATs) to act locally against substance misuse. DAT’s used multi-agency approaches to counter drug related crime (McBride and Peterson, 2002). Later, a ten-year strategy was outlined in a white paper issued in April 1998, entitled Tackling Drugs to Build a Better Britain. This paper recommended incorporating all sectors of society in the fight against substance misuse as it believes that drug misuse is linked to other social problems. The criminal justice strategy to counter substance misuse has four objectives: to help young people be aware of the evils of drugs; to reduce drug related crime in society; to support drug users to become free of drugs and live healthy lives; and to stop the flow of drugs to the streets (Cherry et al., 2002). In accordance with these objectives, a new community sentence termed “drug treatment and testing order” has been passed and this requires that drug offenders must be under compulsory treatment and drug testing enables courts to require drug offenders to undergo treatment and to submit to mandatory and random drug testing to ensure that they remain clean.

The ten year strategy included additional funding of about £217 million over the next three years to counter the problem of drug abuse in UK (Joyce, 2006). The money was t be used for treatment and support services, treatment programs in prisons, education and prevention programs and function for arrest referral schemes (Joyce, 2006). The multi-agency approach was further strengthened in 2001 by the establishment of the National Treatment Agency for Substance Misuse in 2001 in a joint fashion by the Home Office and the Department of health. It was the responsibility of this new agency to set standards for treatment and rehabilitation on various local agencies involved in countering the issue of substance misuse. This preventive approach was balanced by a more punitive proposal put forth in 2000 Criminal Justice and Court Services Act. According to this law, courts could order a convicted user of Class A drug to stay clean and be regularly tested and if in case he is not able to adhere to the conditions, he will be penalized. The Act also allowed the courts to order the drug testing of defendants charged with property crime, robbery and Class A drug offences and the results were considered during bail decisions (Joyce, 2006). Thus, since 1997, the Labor government has pursued a range of social and economic policies to address substance misuse that was seen as both a cause and also an outcome of social exclusion (Young and Matthews, 2003).

Contemporary NHS versus CJ prevention and treatment approaches that clash (e.g. harm reduction) and others (e.g. public health) that are more complimentary:

The criminal justice system targets areas such as treatment, prevention, enforcement and interdiction, the latter referring to the practice of preventing drugs from entering the country (Bean and Nemitz, 2004). Despite these varied objectives the law does not always integrated with enforcement and treatment. An arrest referral scheme cannot be effective when there is no provision for treatment. Both the NHS and CJ approaches aim at harm reduction. But harm reduction in the health context may not always mean harm reduction in the CJ context. Enforcement and treatment sometimes conflict with each other. For example, an increase in the effectiveness of law enforcement can possibly increase the number of people seeking treatment for substance misuse, thereby overloading the treatment services at NHS. Similarly, increasing the effectiveness of treatment at the NHS can cause negative role models in substance abuse to disappear, increasing the number of people entering drug abuse. There can be internal conflict within the criminal justice system approach as well. For example, an increase in certain methods of law enforcement can push existing drug users to do higher levels of crime to get more money for their drugs. This shows that though these strategies are all good ones, “harm reduction” through one strategy can “cause harm” from another angle and cannot be truly effective when they are used in isolation (Bean and Nemitz, 2004)

The government strategy with regard to the NHS is based on the conviction that treatment is effective and will lead to less crime. However, it cannot be said with certainty that drug is directly related with crime. Some studies show that there is a connection between drugs and crime whereas some others show that drugs and crime were both outcomes of the offender’s deviant lifestyle (Hough 1996).

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There are times when both the NHS and CJ approaches complement each other. No one can be certain about how many drug users would benefit from the treatment or what the effectiveness of different treatment modalities is, but treating more people with substance misuse results in increased public health in society. This is complemented by the CJ system where treatment is coerced on the drug offenders. Coerced treatment for drug-using offenders is based on three assumptions: that the reduction in drug use among offenders will lead to reduced crime rate; that even when coerced, treatment can be effective and finally, that treatment can be most effective with persons who feel that they have very little negative consequences of drug abuse. All these three assumptions have been supported by empirical literature indicating that in the instance of coerced treatment for drug offenders, the NHS compliments the approach of the CJ. Criminal activity of drug users is proportionate to their drug use (Anglin and Perrochet 1998; McBride and McCoy 1993; White and Gorman 2000). Moreover, coerced treatment reduces both drug use and criminal recidivism (Farabee et al. 1998; Marlowe et al. 2001). Finally, drug users who are not aware of their problems can also benefit from the treatment (Nurco et al. 1995; Sia et al. 2000).

The complementary effect of the NHS and CJ approaches is further validated by the tentative results of a study by Bean and Nemitz (2004) that show conditional treatment offered compulsorily along with probation has slightly better outcomes than other sentences. Treatment offered to drug offenders within the prison is similar to those given outside it and the general finding is that offenders in treatment tend to commit fewer crimes than those who are not given treatment. Street heroin users, who tend to be the most criminal, are impacted the most by treatment, showing reduction in criminality by 70% (Chaiken and Chaiken, 1990). This shows the treatment provided by NHS is complementary to the efforts taken by CJ in the realm of reducing criminality and increasing public health. Thus to what extent the NHS approach compliments or conflicts with the CJ approaches depends on the specific conditions and situations of each case. Discuss how contemporary NHS and CJ approaches to treatment and prevention for drug misuse differ from those for alcohol.

The misuse of alcohol in the UK is a major cause of health and social problems and the affected people are mostly disadvantaged groups in society (Parliament of Great Britain, 2008). The establishment of the National Health Service Alcohol Treatment Unit (ATU) in Great Britain in 1955 was the first step towards providing specialized treatment for alcoholics in the country. Historically both alcohol and drug treatment services in the NHS came under general psychiatric services. Community oriented approaches developed in the late 1980s (Rassool and Gaffoor, 1997). Within the NHS, the approach to counter the issue of alcohol misuse includes prevention, treatment and social services with wide variations by area. Treatment interventions include counseling/psychotherapy, “12-step” programs, detoxification and pharmacological treatments as well treatment or other help. The most effective prevention is through central policies regarding pricing and control (Stevens, 2004). Alcohol related problems are increasingly plaguing society due to globalization of alcohol industries, deregulation of markets and abandonment of alcohol-control policies as a result of economic and political unions (Kraner et al, 2002).

Alcohol is a bit difficult to tackle than drugs as many people associate consumption of alcohol with good health and moreover, many countries include alcohol consumption as part of their culture. To counter alcohol misuse, it is necessary for NHS to adopt systematic community-based and cross-national approaches (Monteiro and Gomel, 1998; Saunders et al., 1998). Studies show that much of the harm in alcohol comes from risky alcohol use by nondependent drinkers rather than by the smaller proportion of alcohol-dependent people (Kreitman, 1986). Hence the regular approaches of the NHS and CJ will not work in the case of alcohol misuse. It has been found that among the nondependent subgroup of drinkers, brief intervention involving screening to identify alcohol misusers and brief advice on how to reduce consumption has been shown to be effective interventions to reduce alcohol consumption and alcohol-related problems. Contrary to substance misuser programs, brief intervention programs appear to be equally effective for both men and women to combat alcoholism (Ballesteros et al., 2004). Brief interventions have been shown to save one in three lives among alcoholics (Cuijpers et al., 2004). Statistics reveal that in order to prevent one death in a year, on an average 282 patients need to be counseled (Moyer et al., 2002). WHO reports that just 510 minutes of structured advice regarding alcohol, from primary care professionals can effectively reduce alcoholism among the general population (WHO, 1996). The government has based its alcohol misuse strategy on the 2004 Public Health White Paper, “Choosing Health: Making Healthy choices Easier” and according to this paper, the four main themes of cross government Alcohol Harm Reduction Strategy are: improving health and treatment; education and communication; tackling crime and disorder and working with the drinks industry. Contrary to the NHS approach for substance misuse where the focus is on treatment using pharmacological and psychosocial interventions, a holistic approach is adopted in the case of alcoholism.

A study conducted by the Cabinet Office has found a link between alcohol and crime and concluded that certain forms of crime can be directly attributed to alcohol consumption. The government alcohol policy in the context of criminal justice includes restricting the sale of alcohol and its consumption on licensed premises to people aged 18 and over. Moreover, the government as introduced several measures to limit the consumption of alcohol by young people. A bylaw passed in Coventry in 1989 banned public drinking and this measure is said to have resulted in appreciable decline in alcohol related disorder in the lower level (Ramsay, 1990). The government also studied alcohol free zones in various parts of the country such as Bath, Chester, Scarborough, Stockton-on-Tees, Aldershot and in Newquay/St. Austell. More recently the Criminal Justice and Police Act of 2001 has empowered local authorities to ban public drinking (NewBurn, 2007). These measures are unique and very different from the approaches used in the case of drug abuse.

Discuss directions for future evidence based policy that will minimize the clash between the CJ and NHS approaches.

Most public statements by politicians on the subject of crime and its control include references to drugs and over the past two decades, there has been a number of criminal justice based interventions aimed at drug users (Newburn, 2007). Most of the interventions have been focused on criminal justice and enforcement. Hence coerced treatment and punishment have often been the methods of tackling drug abuse in the context of criminal justice. To avoid conflict with the efforts of the NHS, it is important that treatment for substance misuse leads to overall reduction in substance misuse as well. Hence, in the future, it is important that focus is made on recovery and rehabilitation after treatment – both in the NHS approach and criminal justice approach. It is also essential that the treatment must be made effective through integration of psychosocial methods along with pharmacological methods. Moreover, it is important to bring all general practitioners and nurses to an accredited level in treating people with substance misuse problems. It has been suggested that potential candidates for nurse consultant posts develop additional knowledge and skills to tackle substance misuse at primary health centers. Currently law does not permit nurses to prescribe substitute opiates for addiction treatments. Nurses must be encouraged to participate in prescribing for substance misuse patients by giving them generous pay enhancements to purchase expanded professional indemnity. Moreover, when GP and nurse practitioners work together it would be possible to enhance treatment services (Winyard, 2005). With a futuristic view, the IDTS (Integrated Drug Treatment System) has been introduced by the UK government. The objective of IDTS is to expand the quantity and quality of drug treatment within prisons by increasing range of treatment options, integrating clinical and psychological treatment in prison and integrating prison and community treatment to ensure safe recovery and rehabilitation in home. Such measures where the crime rate is reduced by providing effective treatment will reduce the conflicts between the NHS and CJ approaches to substance misuse. The key elements of the IDTS are: better treatment for drug offenders in prison, improved clinical management with greater number of maintenance prescriptions for those who need it, intensive CARATs support during the first 28 days of clinical management for all patients, greater integration of drug treatment to create multi disciplinary teams, better customization of interventions and forming networks with community services such as Primary Care Trusts, Criminal Justice Integrated Teams, Drug Treatment providers, etc. Thus the IDTS is aimed at not only providing effective treatment for substance misuse but also focuses on early custody and improved integration between clinical and CARAT services and reinforce continuity of care from the community into prison, between prisons and on release into the community (Bradshaw, 2008).

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Conclusion

The NHS and CJ approach to treatment and prevention in the substance misuse sector have been compared and contrasted using authentic print sources. It has been found that there are some conflicts between the NHS and CJ approaches though their objectives are primarily the same. By improving treatment effectiveness in such a way that it can reduce crime and by assuring that recovery and rehabilitation are part of any substance misuse program, it is possible for the NHS and CJ to work together in a complimentary manner.

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