10 Dec 2010
Submission by Trevor King (DPMP Deputy Director) (UNSW: Drug Policy Modelling Program)
Introduction and Mission
Compared to earlier drafts of the strategy document and the previous strategy, this is a clearer, much improved version. It is sufficiently broad to sustain Australia until 2015 and builds on the solid foundations provided by the earlier strategies.
The emphasis on safe and healthy communities in the mission statement is welcome. Specific reference to the range of drugs covered by the strategy sets the scene for a more integrated NDS and contributes to shared, cross-substance policy responses.
The explanation of terms used in this strategy (p 5) could be more comprehensive. The glossary in the previous strategy was much better.
The section on harms from drug misuse (p 6) should use a more consistent format and language across different drug types. Health and social harms can be attributed to each of the drugs or drug categories mentioned and could be addressed in that order for each. In terms of language, illegal drugs are described as having “dangerous health impacts” and inhalants “can cause brain damage and death” whereas for legal substances the language is less emotive.
The term ‘balance’ as it applies to the 3 pillars is contentious given the obvious funding imbalance between pillars. It requires definition or at least a brief statement acknowledging the complexities associated with the concept (p7).
The diagram of the NDS on p 7 does not enhance the clarity of the NDS text description on p 8. Inclusion in its current format should be reconsidered.
The NDS sub-strategies are briefly mentioned on p 8 but there is no detail about how they currently relate to the NDS Strategy document or what if anything may change in the future.
The emphasis on “age and stage of life”, “disadvantaged populations” and “settings” is a welcome addition to the strategy. Some evidence/rationale justifying focus on the chosen settings (p 10) is necessary. The use of the term “communities” in this section also requires some explanation.
Extending the NDS partnerships beyond health, law enforcement and education (p 10)is welcome. Specific details on what departments/sectors will be involved and how this will be achieved need to be included in the governance section.
The Pillars: Supply Reduction
The strategy outlines a range of supply reduction actions relating to illegal drugs that have been in place over previous strategies (Objective one, p 16). Given the substantial cost of these activities and the proportion of resources allocated to this pillar of the NDS, far greater emphasis needs to be placed on evaluating the effectiveness of the strategies. Therefore the actions relating to research in this area detailed on p 17 are welcome.
Paragraph 4 in this section (p 15) refers to the role of government and non-government authorities in regulating access to certain drugs based on “community norms and standards and health and other harms arising from inappropriate access”. It is equally important that government provides leadership designed to influence these norms, when the evidence suggests that a shift is required.
The Pillars: Demand Reduction
Objective two on page 20 & 21 focuses on reducing drug misuse largely through treatment. The first paragraph on page 21 should be strengthened by the inclusion of a statement to the effect that treatment should be evidence based or innovative/promising where the evidence base is weak. These words could also be incorporated in the first action regarding the development of nationally agreed principles for treatment services (p 23).
A key consideration is the delivery of treatment by competent specialist and generalist workforces (an issue considered in the workforce section of the strategy). The actions listed on page 23 will all contribute to improved treatment, however of fundamental concern is the issue of difficulty recruiting and retaining skilled staff due to inadequate service funding. This needs to be acknowledged in the strategy.
The lack of specific reference to substitution therapies in the strategy is very concerning. Efficacy as an intervention for opioid dependence has been well established and we know that potential unmet demand for treatment may be as high as 50% in the opioid-dependent injecting drug using population. There are many actions that require Commonwealth leadership to address issues such as national program consistency, client affordability and accessibility.
In previous NDS strategies there was a commitment to develop and implement a national prevention agenda. This is an important issue that requires a comprehensive strategy and significant investment. Actions listed on p 20 are welcome, but need to be located within a comprehensive strategy.
The section on social inclusion and resiliency (p 24) requires an action about the need for research to explore, understand and evaluate better ways of achieving community resiliency and social inclusion.
The Pillars: Harm reduction
The statement that ‘harm reduction is as important for the NDS as supply and demand reduction’ is welcome and its application across drug types is important. We also welcome the focus on families in this section.
In the past Australia was recognised for providing leadership in the harm reduction area. This is no longer the case. The action on p 26 to “sustain existing harm reduction efforts including needle and syringe programs….” and the last two actions listed on p 28 (“sustain efforts to prevent drug overdose” and “continue support for needle and syringe programs”) fall short of what is now required.
This strategy should signal Australia’s willingness to explore or implement strategies such as heroin prescription, injecting rooms, peer administered naloxone, pill testing kits and so on. An action should be included to this effect in this section. For example, the action could read – “to continue to advance internationally recognised harm reduction interventions plus explore and develop new harm reduction opportunities as appropriate”.
The ‘medically supervised injecting centre’ should no longer be referred to as an experiment (p 25).
We agree with the statement on p 29 that ‘an appropriately skilled and qualified workforce is critical.”
We know from the work of Roche and colleagues (2010) that a significant proportion of the ‘specialist’ sector has no professional qualifications or bare minimum qualifications. This creates a challenge in the context of rising expectations that AOD workers will address the increasing complexity of AOD work.
Many of the workforce challenges listed on page 30 are a reflection of the long-standing underinvestment in the AOD workforce. This is particularly the case in the NGO sector. Many of the priorities outlined such as responding to emerging issues, strengthening treatment outcomes and enhancing research literacy are all commendable but largely dependent on recruiting qualified/registered health professionals and retaining them through adequate remuneration, on-going professional development and provision of career opportunities (Siggins Miller 2009 p ix). Attention to this fundamental, long-standing issue will be the most effective way to improve quality treatment and better treatment outcomes. This will require Commonwealth leadership and commitment from states and territories.
The establishment of an IGCD workforce development working group (including workforce experts) to develop a national workforce strategy is an important step.
Evidence base and Performance measures
The commitment to evidence is important but it is equally important that the rhetoric is accompanied by effective measurable strategies.
The development of the National Drug Research and Data Strategy by a working group of experts is a good starting point for identifying research priorities. As outlined in the previous DPMP Expert Group NDS submission (2010), the end product needs to be ‘a directions document rather than an undifferentiated list of research topics’ (p 7). It will be necessary to draw on broad and multidisciplinary expertise to ensure good advice on research, testing and validation of new interventions, dissemination and translation into policies and programs.
The title of the strategy implies consideration of data systems. This was only briefly mentioned on page 33. It is critically important and was raised in the NDS Evaluation (Siggins Miller 2009). One of the dot points on page 32 should make specific reference to enhancing data collection systems.
The section on performance measures (p 33) notes that they are intended “to provide a broad indication of progress against the 3 pillars” of the NDS. Inclusion of these headline performance measures is a welcome improvement on the previous strategy. This is consistent with a high-level, broad, consensus document.
To strengthen the performance measurement section, the task of finalising indicators and measures should be the responsibility of the expert group developing the National Drug Research and Data Strategy.
The inclusion of objectives and actions in the strategy document serve to signal areas of focus for the NDS. But this level of detail also raises questions about the relationship between the NDS strategy document and the sub-strategies. The NDS strategy document needs to be supported by flexible sub-strategies or action plans written by experts and other stakeholders. It is at this level that specific goals, actions, resource allocations and performance measures (outputs and outcomes) could be outlined. This would complement the NDS strategy and increase the level of accountability.
The strategy document notes that ‘the IGCD will seek to engage sectors beyond health, law enforcement and education.’ On critical issues such as the relationship between drug use and social disadvantage/inclusion there is a compelling argument for expanding the IGCD to formally include representation from relevant sectors/departments.
The strategy document states that stakeholders will be invited to the IGCD to ‘discuss particular issues’ or working groups established to provide input (p 36). This approach will go some way to address disconnection from the policy process expressed by key stakeholders (eg. DPMP Expert Group NDS submission, 2010, p 3). The strategy document still falls short in outlining mechanisms for meaningful, ongoing engagement in the policy process for groups including consumers, Indigenous people, researchers etc. This also applies to the non-government sector where confusion still exists about representation – how? And by whom (ANCD, ADCA, other)? The challenge will be to demonstrate commitment and establish and document the structures and processes necessary to ensure meaningful input.
We would also expect the IGCD to provide or advocate for AOD representation in other critical forums. This is needed to address the sense that AOD ‘is not even at the table’ when many key health and welfare reforms are discussed (DPMP Expert Group NDS submission, 2010, p 3). We welcome reference to this issue and strategies to address it on p 37.
Unlike other sections of the strategy document, actions to improve areas of governance and performance measures are not included. This needs to be addressed given the concern expressed previously about this issue (Siggins Miller, 2009 p 63).
Strategies to engage with the public are absent from the document. As mentioned in a previous submission ‘the future of effective AOD policy in Australia will rest with an engaged and committed public driving better processes and outcomes’ (DPMP: Expert Group NDS submission 2010, p 4). Increasing a sense of public ownership of the strategy is important. Improved public evidence literacy will serve to reduce marginalisation and stigma experienced by drug users and create the environment for evidence informed policy change.
Although drug user/consumer involvement in treatment service planning and operations is mentioned on p 22, involvement in policy processes/governance structures is not mentioned. This oversight needs to be addressed.
This and future strategies should focus on incrementally rectifying the misallocation of funding by placing greater emphasis on interventions of known effectiveness than is currently the case.
Although prison and post-release settings were identified as areas of focus for the strategy (p 10), this is not followed up with specific actions across the 3 pillars. Further commitment in this area is necessary.
Aboriginal and Torres Straight Islander communities are mentioned in the disadvantaged populations (p 9) and partnership sections (p 11). Given that the Complimentary Action Plan covered the period 2003-2009 a further statement of commitment is required. This area should also be listed as a challenge (p 12–14). This comment is also relevant to one earlier about the relationship between the NDS strategy and the sub-strategies. How do they relate? Will this change? How will performance of these sub-strategies be evaluated?
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