Aug. 11, 2022
Professor Dame Carol Black: An Independent Review of Drugs, Stigma, Treatment & Recovery
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In Episode 9 Matt talks to Professor Dame Carol Black. In 2019 Dame Carol was commissioned by the Home Office and the Department of Health and Social Care to undertake a 2-part independent review of drugs, to inform the government’s thinking on what more can be done to tackle the harm that drugs cause. Part one was published on 27 February 2020 and provides a detailed analysis of the challenges posed by drug supply and demand, including the ways in which drugs fuel serious violence. Part tw...
In Episode 9 Matt talks to Professor Dame Carol Black.
In 2019 Dame Carol was commissioned by the Home Office and the Department of Health and Social Care to undertake a 2-part independent review of drugs, to inform the government’s thinking on what more can be done to tackle the harm that drugs cause.
Part one was published on 27 February 2020 and provides a detailed analysis of the challenges posed by drug supply and demand, including the ways in which drugs fuel serious violence. Part two was published on the 8 July 2021 and focuses on drug treatment, recovery and prevention.
The report’s aim is to make sure that vulnerable people with substance misuse problems get the support they need to recover and turn their lives around, in the community and in prison. It contains 32 recommendations for change across various government departments and other organisations, to improve the effectiveness of drug prevention and treatment and to help more people recover from dependence.
In 2018 Black was appointed Chair of the British Library and she was made a CBE in 2002 in recognition of her research work on Scleroderma. She was also appointed DBE in 2005 while President of the Royal College of Physicians and she was awarded an honorary doctorate of science by the University of Bristol in 2003 and an honorary Fellow of the Academy of Medical Educators in 2010.
You can read Professor Dame Carol's review here:
https://www.gov.uk/government/collections/independent-review-of-drugs-by-professor-dame-carol-black
Click here to text our host, Matt, directly!
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WEBVTT
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This is a Renew Original Recording.
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Hello and welcome to the Believe in People podcast.
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My name is Matthew Butler and I am your host, or as I like to say, your facilitator.
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Today we are here in the lovely Cambridge where we have been personally invited to the home of Professor Dame Carol Black to talk about drug addiction, stigma and of course her recent work in the drug and alcohol treatment field.
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So my name is Carol Black and I've been an independent reviewer for the government on a two part review on illicit drugs.
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And since the publication of the second part, the government's made me, for the time being, their independent advisor on the misuse of drugs.
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I want to ask if you can give us a bit of a summary.
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You mentioned the two-part report, and I was hoping to give us a bit of a summary of the report, including the process, the findings, and what some of your recommendations are, if you can condense that.
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It's a big piece of work, I understand.
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It is a big piece of work.
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Well, just to tell you what it's like to do a review.
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So the government decides this is a question it wants to ask or it's a difficult problem.
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They decide who they want to be the reviewer.
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They will then ring you up.
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So Sajid Javid, who was then the Home Secretary, rang me up.
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and said, would I do it?
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He envisaged a report in two parts.
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Part one was going to be on supply and demand.
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Part two would be on prevention, treatment and recovery.
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When you say yes to a report, you're given a team of civil servants to work with.
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And for the period of the review, That team is yours.
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So they don't report into their own director in their department.
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They report to you.
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And depending on the topic, the team will be pulled from different departments.
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So in my case, I had some people from the Home Office.
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I had someone from what was then, well, several people from Public Health England, the Department of Work and Pensions.
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You know, people would come into the team who were necessary.
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And for those months, they worked for you.
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They got you all the information you needed.
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You need somebody in the team who is a very good analyst, needs someone who can write well, someone who'll make all the arrangements for you to visit centres, prisons, wherever you want to go.
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So it's usually a team of about six or seven, if you're lucky, a few more people, and you work together.
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to produce the report and you test it as you go along with the different departments because it's no use producing a report the government isn't going to act on.
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So you must take everybody you need to support you with you and that's probably one of the most difficult things because you often have to keep going back to say, is this okay?
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This is really what I think should be done.
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that's the process so part one was really a market review so if you think about it the selling and buying of drugs is like any market it depends on money we wouldn't have drug dealers if they weren't making a lot of money out of this so what we did we took the drugs wherever they were produced or grown, so heroin from Afghanistan, cocaine from South America, the synthetic drugs that are often made in China or Europe.
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Of course, cannabis is grown and produced in this country.
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And we followed their journey to the person who was going to take them.
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We looked at who controlled those pathways, how much money they made at each step, and who was engaged as they moved down towards the person who was going to buy them and take them.
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We looked at how much money there was in this market, who made the most money, the damage it did, and really started to think about what was some of the solutions.
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So really, in part one, what I found was it cost the country 19.2 billion a year.
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everything to do with managing drugs and the drug trade and prisons and the benefit system.
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Drug dealers earn about 9 billion a year.
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So it's a worthwhile market.
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And we were able to see who was doing it.
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For example, Albanian gangs control the cocaine market.
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So you could see exactly where the money was, where it was taken out.
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and how the drugs were being sold, whether they were being sold directly on the street, whether it was through the post, ordered on social media, etc.
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And we really saw a very violent and unpleasant trade.
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And of course, county lines have been developed, which is really a delivery system out from the big cities, often to our seaside resorts, but all over the place, with the runners being young vulnerable children.
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So young vulnerable adults, teenagers usually, often children expelled from school, coming from disadvantaged backgrounds, pulled into the drug trade, and then very badly misused.
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And of course they might die because there's quite a lot of fighting between drug dealers and those who carry their drugs.
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And I also found a perfect storm because there'd be more and more drugs imported because the weather was good in Afghanistan and South America to produce the drugs.
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There was no barriers to them being exported from those countries.
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So, in fact, what was being sold on our streets was purer, therefore more dangerous.
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And at the same time, we'd had 10 years of austerity, which started politically in about 2013.
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perhaps a bit before um money taken out of the drug treatment budget the police budget the national crime agency budget um each year and therefore less money to really deal with the problem so it was like a perfect storm and i described a pretty awful picture i didn't think the government would find it easy reading and I didn't think they would give me part two because you know I didn't tell them anything that was good at all and it was nothing good um there were a lot of people trying hard to make the best of it but Everything was going in the wrong way.
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Drug deaths were going up.
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Murders were increasing due to the drug problem.
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Serious acquisitive crime driven by drugs was going up.
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Number of prison places needed for people with an addiction problem was going up.
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So I thought, well, you know, maybe the government was hoping for a slightly better story.
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But to their credit, They took it on the chin and said, it's the evidence, you found the evidence.
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There was a very, very good evidence pack with the review.
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You couldn't really dispute it.
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So in part two, what I did was to really look at the state of treatment and recovery in the country.
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And to put it very simply, I said to government, it's broken.
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And if you don't do something about it, We're going to continue to pay the cost of that, i.e., there will be more deaths on the streets, there will be more deaths in treatment, there will be more murders, there will be more serious crime, and you'll need more prison places.
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I think, you know, you're absolutely right.
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What you described, obviously you said it isn't a pleasant story, it isn't a pleasant read for them to hear, but you painted the picture of something that is the reality.
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And I think that's one thing that a lot of people, especially the public, don't necessarily realise when they see someone with substance abuse issues.
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They just see, I suppose, the symptoms of the addiction, not necessarily the signs and everything else that they're going through.
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To backtrack a little bit, when you said about basically you was given a team, was you able to choose the team or is that a team that's provided to you?
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Because I imagine that makes it a little bit more difficult being told, here's the staff that you're going to be working with as opposed to you finding the right people for the job.
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Well, you see, you don't really know how to find them.
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I mean, you have to...
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What you have to do is see who they want to give you and then you talk to those people and you try to make an assessment about whether the skills they have will be okay for what you think you've got to do.
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So, you know, for example, if you're looking for someone who knows how to write, because you need somebody all the time to be recording, to be writing.
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And somebody's going to write the first draft because the team likes to produce this.
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So if they offer you somebody who's never written anything more than, you know, four pages long, well, I think you would go back.
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And I have gone back to them and said, I don't think this is really perhaps somebody with enough experience.
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Yes, very bright.
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Very good.
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But is this going to be enough, you know?
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For me, I have, as I've done the review, asked for extra help.
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You know, as you do it, you see things you didn't know you needed.
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Until you
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realize you need
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them.
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You didn't realize you needed them until you were into the
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review.
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Usually, you get a very good response.
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It's usually not a problem because, after all, they need a good review.
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So you had a call directly from Sergei Gervais.
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You've done work with the Prime Minister before.
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Was it David Calman?
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Tell us a little bit about, I suppose, the process of that.
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The head of the department that's going to commission it.
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So it would be
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like Matt Hancock for part two, Sajid Javid for part one.
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But then I was lucky enough to be able to discuss the findings in a meeting with the prime minister.
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So I had the pleasure of meeting many of the ministers.
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I think the easiest way when you're dealing with people who are very busy, as politicians are, you really need to have really decided what are the essential things you need to tell them and what is it you're asking them.
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Because they can always get their team to give them the extra facts.
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So you don't go burdening them with everything you did to ever get there.
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You give them...
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the really hard core information that tells them where the country is on this particular problem.
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And then say, and these, I think, are the solutions.
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This is what I think we should do.
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But you need to keep it very simple.
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Because, you know, they have to take in so much stuff.
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Yeah, I can understand that.
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And what's it like in terms of, I mean, is there a negotiation part there on your part in terms of the work you do?
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Or do they just sort of say, here's the work I need you to do and come back to it?
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They suggest terms of reference and you can push back on them.
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So, for example, there were two specific things they decided to exclude from my review.
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One, I was quite comfortable with.
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The second...
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In retrospect, I wished I'd pushed back on, but I didn't know when I started that it was important.
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So they told me I couldn't do anything or recommend anything that required a change in the law.
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So decriminalization, legalization.
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I was very relieved about that because that is a topic that divides people.
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And
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I really wanted to do a review that got us to a point where we could persuade the government to give us resources to improve life, treatment, recovery for people who are drug dependent.
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If I'd gone into all the bother of trying to study decriminalisation and legalisation, it would have swamped it.
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The second one I didn't understand how important it was.
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They said I didn't need to study the health care and drug care for prisoners in prison.
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They wanted me to look at how you prevented so many people going to prison, and they wanted me to look at the aftercare for people coming out of prison after being in there with a drug offense.
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As I finished the review and slightly before that, it really is all a continuum.
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And in fact, if you think about it, a drug-dependent person who may have to go and serve some time inside is still the same person that is outside.
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So that was a mistake.
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I think I should have pushed back on that.
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It would have made it more complete.
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One thing that I don't understand, you know, I've worked in drug and alcohol treatment for seven years now, and one thing I just can't understand, and you might be able to explain it to me, is when people with a drug dependency go into prison and prison have methadone programs and they run, you know, sex social groups and so forth, but then people come out still five years later still on a methadone prescription, and I think surely that is the best time to...
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to tackle that problem in prison.
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Do you know why we do that?
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Well, I don't think it's an intention to do it.
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I think the real problem is they reduced the number of special wings in prison that were equipped and staffed to help someone become drug-free.
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But recently, with the money that has come through my review and the new drug strategy and the Ministry of Justice announced last week that they're going to put many more special units in prison because it isn't a quick and easy job and you need to provide the right environment and you need to be in prison for one or two years you can't do this in three months and you need an environment in which you're going to be able to help people train or find something meaningful to do or hopefully do some work.
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So I think it was lack of resources that the only thing they could do was give them a methadone script, which I absolutely agree with you is totally fine.
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not what you want to see.
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So I visited Wormwood Scrubs about six weeks ago.
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That is a remand prison, so a lot of people churning through, very difficult for them.
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But in fact, the drug service there is short of about nine key workers.
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Mm-hmm.
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That means they're stretched to their absolute limits.
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They know that.
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They can't recruit.
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And what I discovered, which I never knew, was if you're a drug worker in prison, you earn about£5,000 less per year than somebody working outside.
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Now,
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there's a lot about...
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supporting people in prison that needs to be changed and and it would have been nice to have taken a better look at
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them and to be fair there's a lot more money coming into the system because of you and your research and your family what what's that like you know how much of an impact you're making in the community because of the work that you've done
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well we i mean i'm delighted um that they have given it resource and they've given it resource for three years um and um I hope that that's going to make a difference.
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But money alone, you know, doesn't make a difference.
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So if that money is distributed and we just do more of the same and it's not used wisely by local authorities and all the other agencies who might benefit from it, then it won't have been worth it.
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So my greatest concern now is Is this money really going to start to turn the tank around?
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And are we going to see real holistic care?
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Are we going to find that providers don't do more of the same, but they really do develop a recovery program?
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Because one of the things I found in doing the research whatever people tried to tell me, and they all tried to convince me how good their service was, but I knew the service wasn't good because of the stats in front of me.
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I mean, everything was going in the wrong direction.
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So are we going to really be able to get people treated initially with whatever pharmacological agent, if you like, the medical part of it, but then...
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are we really going to develop proper recovery programs?
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Because recovery can take a long time.
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And if all you get is the medical bit plus a script, which is actually what's been happening, and if there are no psychologists to support you and all the other things that need to wrap around you, and if there's not safe housing, and if there's not the opportunity to work, and if the providers do not bring that stuff back, together
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and
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mental health support, it won't be any better than it is
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now.
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I can't do that.
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I
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can only provide, I've provided the route map, but I can't, you know, deliver it.
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My concern was originally when we were told that X amount of money was coming to it, that we'd just hire X amount of new key workers.
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You spoke about service having nine less key workers than it should do.
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Case loads now, when I started seven years ago, there was around between around 50, I'd say, which was considered high then.
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And now we're talking caseloads of around 80.
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How do you deliver a real psychosocial intervention to somebody when you've got such limited time to see them?
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You can't.
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You can't.
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It's impossible, isn't it?
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So I understand the need to invest in more key workers, but you're absolutely right.
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If we haven't got the base stuff right, if people haven't got stable housing and accommodation, we can't.
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If you look at the Maslow hierarchy of needs model, you can't.
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get to that point of enlightenment, can you?
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If we don't have this basic stuff.
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You can't go to work every day if you don't have somewhere to live.
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And you're not going to stay off drugs.
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If you're being housed in a home or a house with somebody who's shooting heroin, you will shoot heroin.
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We're none of us that strong.
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You know, it would be...
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It's simply not giving somebody a fair chance.
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So I...
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I'm going to, I will visit as many places as I can and I will ask as many difficult questions as I can.
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But I can't change alone, I can't change motivation or determination to really deliver a high-class service.
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How do you stay focused and ensure that your key messages stay at the forefront of the public's attention?
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Well, first of all, you need to stay evidence focused.
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I don't really want to talk about anything that I don't feel I've got evidence to back me up.
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So if you stay sort of focused on the facts.
00:21:15.232 --> 00:21:26.865
And if you then think on any interview, unless it's a long one, so for example, if you're doing the Today programme, you can only get over, if you're lucky, three messages,
00:21:26.885 --> 00:21:27.507
and
00:21:27.527 --> 00:21:37.577
you may only get over two, but you've really got to not let them deflect you from what you know you want that audience to hear.
00:21:38.210 --> 00:21:52.221
and therefore you have got to work pretty hard to strip out all the unnecessary stuff because you've got very little time on either television or on the radio.
00:21:52.702 --> 00:21:57.205
I often find that people with addiction are vilified in some forms of the media.
00:21:58.567 --> 00:22:04.653
People talk about the benefits system and how to sort of drain the benefits system just to spend money on drugs with a real lack of understanding.
00:22:04.732 --> 00:22:18.909
I think one of the things that I want to ask you is why was important to you to spend so much of your time and effort and you know to do all this research to I suppose improve the lives of people that do have such a I suppose a bad reputation amongst people
00:22:20.510 --> 00:22:51.210
I guess the simple answer to that is I've spent my life my professional life that is trying to improve the lives for people in various different situations so the largest part of my professional life has been in medicine and I I specialised in an uncommon condition, which you won't have heard of, called scleroderma, which kills people, particularly women, which had very little research in this country or anywhere in the world when I got interested.
00:22:51.289 --> 00:22:57.415
And I set up the National Service and started the research programme in this country.
00:22:58.196 --> 00:23:16.087
I then went on with my job as National Director for Health and Work to really tackle the difficult problem of how do you enable people to stay healthy in work and enable more disabled people to be in work.
00:23:16.167 --> 00:23:19.411
And that I include people with mental ill health.
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I like challenges.
00:23:21.993 --> 00:23:25.356
I'm not so good in the steady state.
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So this really is a fantastic challenge.
00:23:30.201 --> 00:23:42.795
I also felt passionately, strongly, that drug addiction is a health condition, a chronic condition, just like you might have diabetes or rheumatoid arthritis.
00:23:43.497 --> 00:23:48.403
If you've got drug addiction, you may have relapses and remissions.
00:23:49.665 --> 00:23:59.500
The important thing is not to think somebody goes into treatment, tick box, we have done the treatment, which is what has been happening in this country.
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They're then sent out with no follow-up.
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often with not a programme of recovery.
00:24:06.194 --> 00:24:11.162
And I felt very strongly that we stigmatised people.
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The NHS, when they met the NHS, did not give them the same service that they would give you or I if we had a medical condition.
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And I really wanted to see if I could change it.
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I think services can score.
00:24:25.963 --> 00:24:28.586
CQC ratings are outstanding, good, good, good.
00:24:29.509 --> 00:24:36.411
Whatever it is, But the reality to me, when I read that report, I just see that all their paperwork is in check.
00:24:37.252 --> 00:24:51.695
And also the CQC examination or investigation is simply not good enough because what they can only do is score the service you deliver.
00:24:51.736 --> 00:25:00.712
So if all your delivery is a methadone service, as long as you're doing that correctly, you'll tick all their boxes.
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What they're not able to do is say, where is your mental health service, your trauma-informed service?
00:25:08.260 --> 00:25:10.083
What's your housing project like?
00:25:11.084 --> 00:25:13.446
How many people are you getting into work?
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Do you have a service for families?
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Show me your recovery program.
00:25:18.792 --> 00:25:22.797
All the things that really are important, they don't score.
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It was one of the things I have said absolutely needed change, because to change it, I think, to change it radically, you need to change the law.
00:25:35.633 --> 00:25:49.246
But I mean, everybody knows that this is an incomplete assessment of a service, and I really would never look at the CQC scoring to tell me whether a service was good.
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I talk to the people who have the service.
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When I was doing the review, all the providers told me how good their service was.
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When I talked to the people who were in the service, I didn't get many good reports.
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So, I mean, it was like chalk and cheese.
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And actually, you need to listen to the person in the service.
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What is your favourite thing about your career today, or perhaps the thing you're most proud of?
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It's very hard because I've had a long career.
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