Paul* was “devastated” when he found out the NHS clinic he has relied on for 26 years is set to close next month. He is terrified that when a new service provider takes over they will stop his prescription for methadone – a medication used to treat heroin dependence, which some doctors are reluctant to prescribe. “Come 1 April, it’s going to be chaos,” he told Novara Media.
In February, the NHS lost the contract to run all drug and alcohol services in two north London boroughs. Paul’s clinic at the Margarete Centre in Camden – which has been NHS-run since 1967 – will shut down as a result.
The decision to shutter the “excellent-rated” service has triggered an outpouring of sadness and anger. “The council is more interested in ticking boxes and saving money than caring about people,” wrote one service user in a letter to the Camden New Journal. “This change of contracts affects the most vulnerable and those who do not have a voice.”
In recent years, NHS contracts have been put up to tender across the country, meaning external organisations can bid to run the services – and be paid public money to do so. A map created by EveryDoctor, a doctor-led campaign for “a better NHS”, shows thousands of privatised and outsourced NHS services in England alone.
“These services often have the NHS logo outside,” said chief executive doctor Julia Patterson, “so members of the public might not realise that a service they’re interacting with is actually being run either by a private company or by a different organisation, like a nonprofit.”
Since 2012, the Health and Care Act has made it “mandatory for commissioning organisations to put contracts out for tender,” explained Keep Our NHS Public co-chair John Puntis. While this rule “was intended to drive up competition and increase the quality of care,” Puntis said, it “doesn’t really work in a healthcare context.” It is often the case that third-sector companies will win contracts after bidding to run services at the lowest cost. “In terms of the quality of the service [that] usually means reducing staff, or having staff with a kind of downgraded skill mix.”
Doctors treating people with addiction and other complex mental health issues often rely on the trusting relationships they have built up over time. “There’s a huge amount of embedded knowledge in the NHS from the staff members who’ve been working in a service for a long, long time,” said Patterson. When a service closes or a new organisation takes over, it inevitably disrupts the continuity of care, as new staff scramble to “ build up that knowledge of the local population in a new way.”
Nick, in Leeds, struggled to get an appointment with a doctor when the NHS-run drugs and alcohol clinic he had used for 25 years was taken over by a charity in 2015. The new provider, Humankind (then operating under the name Developing Initiatives for Support in the Community), told him it didn’t like to work with service users for more than three years.
Humankind denied it had ever had a policy of automatically ceasing support after three years. “It is important to us that people with drug or alcohol problems can access the support they need,” it told Novara Media. “The support we provide is of the highest quality. We are very proud to say that the Care Quality Commission rated every [one of] Humankind’s services it inspected as ‘outstanding’ or ‘good’.”
But Nick said the charity made him feel like an inconvenience. “They told me that I had to go and find somewhere else,” he said. “I’d been using for so long I didn’t fit into their treatment paradigm.”
When Humankind initially refused to renew Nick’s prescription for oral morphine tablets (used to treat opioid dependence), he claims he threatened legal action. Eventually, Humankind agreed to give him a bridge prescription, which Nick was able to use until he found a service out of his area that would provide the prescription.
“I became more erratic. My sleep suffered,” he recalled. “They put me in a position where I was so stressed, I actually started using more drugs.
“I survived [that period] because I knew about harm reduction after attending the service there for a long time […] but my friends and co-clients – I’m damn sure some of them are in the ground now because of it. Every time this [re-tendering] happens, even if it’s handled well, it’s deadly.”
In north London, Change Grow Live (CGL), a charity that works on substance misuse and criminal justice intervention projects, is set to take over all drug clinics in Camden and Islington from next month. Reflecting on his experience of outsourcing, Nick said he is frightened of what might happen next: “People will die as a result of this change.”
In 2016, CGL came under fire over the number of deaths among drug users and alcoholics in the Wirral. Public Health England was forced to intervene. CGL whistleblowers alleged there had been a push for users to quit drugs entirely, even when this was not in their best interests. CGL denied this claim.
Neil has been both a patient at Camden’s Margarete Centre and a volunteer with CGL. He describes the care he received at the clinic as “amazing […] you just feel like you’re in really safe hands.” Staff went out of their way to help him during relapses, he said, even when he was no longer technically their patient.
His experience with CGL, however, has made him deeply concerned for the future of the service. Rather than well-trained staff, CGL has always relied heavily on volunteers, he said.
“I do not feel they look after their peer mentors,” Neil told Novara Media. “I remember when I first started at CGL, another volunteer came up to me and said: ‘Watch yourself, they’ll burn you out’. And it’s true, that definitely did happen.” Neil said he struggled to stay on top of a huge caseload. “It’s very fragmented; there’s a very high turnover of staff.”
Paul has worked with CGL volunteers in the past as a service user. “I felt I knew more than they did, in terms of the working drugs system,” he said.
Vicki Markiewicz, Executive Director of CGL, defended the charity’s use of volunteers. “Many of our volunteers have the unique experience of using services themselves and they are an integral part of why we are able to provide a safe, accessible, and welcoming space for people to access treatment,” she told Novara Media. “Everyone in the team is provided with the relevant training and support to be able to offer the highest level of service.”
She added: “All staff from the Camden and Islington Foundation NHS Trust will be offered the opportunity to work in the new CGL service.
“Treatment will not be disrupted by the transfer of services and, importantly, individuals currently accessing services will continue to receive their repeat prescriptions.”
Magdalene Harris, a sociologist specialising in the social science of drug use, health and harm reduction, cautioned against “demonising” a particular provider. “I think it’s a systemic problem – it’s not about CGL, per se,” she said, criticising short-term contracts that make it impossible to plan 10 or even five years ahead. “All providers have been put under this incredible pressure by the government with this process of re-tendering.”
Patterson said that charity providers often have “excellent intentions” – but ultimately she sees the “structural integrity” of the NHS as being eroded by outsourcing. “One of the greatest strengths of the NHS is that it’s a system where information is shared, and progress is shared,” she said. “As the NHS becomes more fragmented, we’ve got concerns about what that means in terms of the strength of the service as a whole.”
*Names have been changed.