The tortuous routes to rehab
I’ve been reading a bit recently about the challenges of healthcare funding in the United States – an ‘international scandal’ according to Noam Chomsky. And although the problems are not the same, those issues have become linked with my thinking on the difficulties of accessing funding for residential rehabilitation in Scotland.
The Lord Advocate’s recent statement allows more discretion to police officers when dealing with class A drug possession. In effect this creates a facility to issue a warning for simple possession. While not all those in possession of drugs will have a problem, it does feel as if we could have moved a little closer to treating substance use disorders as a health, rather than a criminal justice issue.
Where drug problems do develop – particularly for those associated with high mortality like opioids and alcohol, treatment is generally available via the National Health Service (or a partnership of health and social care) – free at the point of delivery. Further support comes from the third sector. There can be delays to access this treatment, particularly for opioids, but these are being addressed through the MAT standards implementation. Sadly, as I’ve written before, alcohol does not seem to have the same urgency or resource applied, despite killing as many people.
There’s a caveat here. An anomaly. When I say treatment is available via the NHS, for the moment, for the most part, we must exclude residential rehabilitation treatment. It’s much more available to you or your loved one if you have insurance, or money, or you live in the right place, or you have powerful advocates, or perhaps if you are very, very persistent. In some places you can access rehab via the NHS, but it’s generally not an easy process. Where it is available, it is often not available on NHS principles.
While there are hundreds of rehab beds across Scotland, relatively few are funded by the public purse and even where they are, funding can be tortuous to obtain. Although pathways to rehab are being addressed by the Scottish Government, it saddens me to say that I am still regularly hearing stories of access being blocked, opportunities missed and negative consequences accruing.
A few years ago, on a visit to a large, well respected, residential rehabilitation facility in the United States I was given a tour of the site by the director. It was striking – nice buildings, lovely location, and access to an impressive range of professionals in a multidisciplinary team. I was struck by some differences to Scotland though. The residents were predominately middle class. Most had opioid use disorder, but the route in had been through prescribing or via diverted prescription medication rather than heroin. The biggest difference was the cost – around £25,000 for 28 days. That’s a short treatment dose at a premium price.
That wasn’t the greatest shock though. As I was shown around the facility, I’d seen various offices, been in patient spaces and met teams of therapists, psychologists, and a couple of doctors. However, the busiest room was choc-a-bloc with admin staff. They were engrossed on phones, animated in conversation. Naively, I asked the director why on earth the facility needed so many admin staff. The answer was simple – they deal with the insurance companies who fund the patients.
In this industrious place we listened briefly. One of the staff was pleading (yes pleading) with someone on the other end of the phone for two more days funding for a patient. I was stunned, and to be honest, upset.
In a team meeting later, therapists presented on their clients’ progress. Again and again, the issue of pursuing further funding came up – treatment planning seemed to be largely dependent on whether more time could be negotiated from the insurance company, and not so much on what was best for the patient.
NHS or not?
In 2005, the Scottish Government elected to fund five pilot projects aimed at introducing choice into the treatment system. These were to support individuals whose goal was abstinent recovery. There was a fair bit of resistance to this.
With the support of what was at the time the equivalent of the Alcohol and Drug Partnership I submitted a proposal for the service which became LEAP. Early on in development, there was discussion around where best to site the service. Should it be delivered via the third sector, in social care or in the NHS? The decision was easy. I felt access to residential treatment for addiction should be on the same basis as access to treatment for heart disease, diabetes, or cancer.
This meant embedding the principles that access to the service should be based on clinical need, there should be clear and simple referral routes and equity of access. Treatment should be free at the point of delivery and treatment standards should aim to be excellent.
Furthermore, we should be accountable – and we should be fully integrated into other parts of the NHS, allowing patients access to the full range of healthcare available. This approach was an easy sell, and the treatment part of LEAP was set up within the NHS where it operates to this day. Of course, we work in close collaboration with essential partners in the statutory and third sector to deliver the complete service.
As I say, this is not the norm for residential rehab in Scotland, where residential treatment services can sometimes feel like silos, disconnected from NHS and other services. This can cause barriers to referral, poor connections to detox and a lack of buy-in generally.
Now I don’t believe for a minute that rehab needs to be delivered via the NHS across Scotland (though it’s clear this can be done effectively and economically) – there are plenty of advantages in the third sector doing this – but surely the same principles ought to apply. Whether we call rehab ‘healthcare’ or ‘social care’, we need to be moving towards a system where funding is simple, equitable and based on need. We need a system where there is real choice and where there are straightforward and obvious routes to get there.
In the past this has not necessarily been easy to do and there are good reasons why. Leaving aside the poor perception some professionals have of rehab and the historically poor resources, in some places those charged with making funding decisions found themselves in difficult positions. Working with a small budget, they were expected to have the wisdom of Solomon in deciding who could go to rehab and who could not. Those tasked with this may not have had any training about rehab, could have had no experience of working in that setting, or indeed had any evidence-based guidance to support the decision making. That needs to change.
Later this year, we will hear more about the reality of the state of play in residential rehab in Scotland which will help inform actions to make matters better. However, things are already changing. Work is afoot to increase capacity, to develop and improve pathways to rehab, to prepare people for it, and to support them better and for longer afterwards. Significant financial resource from the Scottish Government is behind this and there will be more accountability on how effectively it is utilised. Funding models are likely to change for the better.
Thankfully, in Scotland we don’t have to navigate the for-profit difficulties of a system like that of healthcare in the US. I hope we will never see banks of staff begging for funding, but at the moment we have our own unique challenges, not least of which is getting the funding process right. Why should funding for a treatable condition be accessible on a completely different (and more difficult) basis than that for other health issues? It feels discriminatory – stigmatising. Those seeking rehab ought not have to sit in front of panels judging their readiness, or have delays based purely on funding difficulties.
We need to iron out anomalies and inequities and it is likely we will have to take a national approach to do this. As we develop and improve rehab, I’d like to think that a few threads of NHS principles woven into the system would go a long way to making things better.