© National Audit Office 2023

Reducing the harm from illegal drugs

Home Office

Session 2022-23

20 October 2023
HC 1864

The National Audit Office (NAO) scrutinises public spending for Parliament and is independent of government and the civil service. We help Parliament hold government to account and we use our insights to help people who manage and govern public bodies improve public services.

The Comptroller and Auditor General (C&AG), Gareth Davies, is an Officer of the House of Commons and leads the NAO. We audit the financial accounts of departments and other public bodies. We also examine and report on the value for money of how public money has been spent.

In 2022, the NAO’s work led to a positive financial impact through reduced costs, improved service delivery, or other benefits to citizens, of £572 million.

We are the UK’s independent public spending watchdog.

We support Parliament in holding government to account and we help improve public services through our high-quality audits.

Report by the Comptroller and Auditor General

Ordered by the House of Commons
to be printed on 18 October 2023

This report has been prepared under Section 6 of the National Audit Act 1983 for presentation to the House of Commons in accordance with Section 9 of the Act

Gareth Davies
Comptroller and Auditor General
National Audit Office

16 October 2023

Value for money reports

Our value for money reports examine government expenditure in order to form a judgement on whether value for money has been achieved. We also make recommendations to public bodies on how to improve public services.

The material featured in this document is subject to National Audit Office (NAO) copyright. The material may be copied or reproduced for non-commercial purposes only, namely reproduction for research, private study or for limited internal circulation within an organisation for the purpose of review.

Copying for non-commercial purposes is subject to the material being accompanied by a sufficient acknowledgement, reproduced accurately, and not being used in a misleading context. To reproduce NAO copyright material for any other use, you must contact copyright@nao.org.uk. Please tell us who you are, the organisation you represent (if any) and how and why you wish to use our material. Please include your full contact details: name, address, telephone number and email.

Please note that the material featured in this document may not be reproduced for commercial gain without the NAO’s express and direct permission and that the NAO reserves its right to pursue copyright infringement proceedings against individuals or companies who reproduce material for commercial gain without our permission.

Links to external websites were valid at the time of publication of this report. The National Audit Office is not responsible for the future validity of the links.

012238 10/23 NAO

This report can be found on the National Audit Office website at www.nao.org.uk

If you need a version of this report in an alternative format for accessibility reasons, or any of the figures in a different format, contact the NAO at enquiries@nao.org.uk

The National Audit Office study team consisted of:

Richard Baynham, Alice Hamilton and Greg Hannah, under the direction of Oliver Lodge.

For further information about the National Audit Office please contact:

National Audit Office
Press Office
157–197 Buckingham Palace Road
Victoria
London
SW1W 9SP

020 7798 7400

www.nao.org.uk

@NAOorguk

Key facts

Summary

1 The distribution, sale and consumption of illegal drugs causes significant harm to individuals, families and communities. In 2021, almost 3,000 people in England died because of drug misuse and thousands more suffered complex health problems. The government also estimated that around three million people in England and Wales take illegal drugs at a cost to society of approximately £20 billion a year. The drugs trade generates significant levels of violence and is believed to be responsible for around half of all murders in England and Wales.

2 Tackling the problems caused by illegal drugs is complex. It involves disrupting the organised gangs which supply and distribute drugs, and providing effective treatment and recovery services to help people with addictions. Central and local government bodies are involved, ranging from police and law enforcement agencies, who seek to disrupt organised crime, to local authorities and service providers, who offer treatment and support to people with a drug addiction. The Home Office leads on UK drug legislation, UK borders and organised crime, policing and crime reduction in England and Wales. The Department of Health & Social Care (DHSC) is responsible for overseeing the substance misuse treatment and recovery sector.

3 Illegal drugs are not a new problem. Successive governments have sought to reduce the supply of drugs and lessen their impact on individuals and society. Despite these efforts, the government recognised that the situation was deteriorating, with deaths related to drug misuse increasing by 80% between 2011 and 2021. The Home Office and DHSC therefore asked Dame Carol Black to undertake an independent review to inform government’s thinking on what more could be done to tackle the harms from illegal drugs.

4 In July 2021, Dame Carol concluded that “the current situation is intolerable” and “the public provision we currently have for prevention, treatment and recovery is not fit for purpose, and urgently needs repair”.1 In response to Dame Carol’s recommendations, the government published a new 10-year drugs strategy – From harm to hope – (the strategy) in December 2021.2 The strategy focuses on breaking drug supply chains, creating a “world class treatment and recovery system” and achieving a “generational shift” in the demand for illegal drugs. The government announced a £900 million increase in funding for 2022-23 to 2024-25 and committed to long-term targets to reduce drug use and drug-related crime and deaths. The government established the cross-government Joint Combating Drugs Unit (JCDU) to co-ordinate and oversee the development and implementation of the strategy. In addition to the Home Office and DHSC, the other departments involved are the Ministry of Justice (MoJ), the Department for Work & Pensions (DWP), the Department for Levelling Up, Housing & Communities (DLUHC), and the Department for Education (DfE).

The scope of our report

5 It is almost two years since the government introduced its latest drugs strategy and less than 18 months remain in the current funding period to March 2025. This report examines whether the government is well positioned to achieve the strategy’s 10-year ambitions. It covers:

the development of the 2021 drugs strategy, its objectives and funding (Part One);

progress in implementing the strategy (Part Two); and

the approach to achieving the strategy’s long-term outcomes (Part Three).

6 It is too early to conclude whether the 2021 strategy will reduce the harm from illegal drugs. It will take time for new funding and interventions to address a complex set of issues, and many of the indicators used to measure progress lag behind activity. This report therefore assesses whether departments are making the planned progress in implementing the strategy, and whether the JCDU has an effective approach to understanding the impact it is having and managing the risks to achieving the strategy’s aims. It does not examine the effectiveness of interventions at the local level.

Key findings

Strategy vision and objectives

7 The 2021 strategy is based on thorough independent analysis of the actions needed to tackle the harms from illegal drugs. Dame Carol Black’s analysis provided a detailed assessment of the scale of harm caused by illegal drugs and the weaknesses in the government’s previous approach. The strategy responds to all but one of Dame Carol’s recommendations and reflects consultation with stakeholders. Overall, it has been welcomed across government. However, some local service providers told us the strategy reinforces – rather than helps to address – the stigma attached to people who use drugs, and questioned whether it struck the right balance between dealing with people who use drugs through the criminal justice system versus directing them to treatment services (paragraphs 1.7, 1.8 and 2.2).

8 The government established new structures and provided a renewed focus on efforts to tackle the harm from illegal drugs. The government has set out its ambitions to reduce the harm from illegal drugs by 2031, including the outcomes that it is seeking to achieve. It established a ministerial role to provide leadership and has created the JCDU to encourage government departments to work together to achieve the strategy’s aims. The government committed £900 million to implement the strategy and established 106 new local partnerships across England. These changes have strengthened cross-government working, establishing clear accountabilities for tackling substance misuse and encouraging collaboration between public health and police and crime commissioners (paragraphs 1.10 to 1.12, 2.2 and 2.6 and Figure 6).

9 The strategy has not yet led to a fundamental shift in departments’ approaches or begun to address the complex causes of illegal drug use. The 2021 strategy focuses on the same core themes as the 2010 and 2017 strategies – to reduce demand, disrupt supply and improve treatment and recovery for the worst-affected individuals who use drugs. Departments have used nearly all of the new funding to continue or expand existing projects or, in the treatment sector, reverse some of the declines in funding seen over the last decade. For example, DHSC funding for adult substance misuse treatment to local authorities fell by 40% in real terms between 2014-15 and 2021-22, with 42 unitary authorities seeing falls of 50% or more. The JCDU and departments recognised that the current three-year funding allocation will not fully address all of the weaknesses diagnosed by Dame Carol Black. DHSC has sought to maximise the impact of the new funding by targeting initial allocations to local areas facing the greatest harm. However, addressing structural and complex issues involves a range of interventions from across government – including tackling homelessness and addressing mental health needs (paragraphs 1.5, 1.7, 1.8, 1.12, 1.13 and 3.9).

10 The strategy aims to reduce the demand for drugs, but government does not yet have the evidence to know how to do so. Despite previous strategies also seeking to reduce the demand for drugs, the departments did not have a strong evidence base on the type of interventions that are effective. In May 2022, the Advisory Council on the Misuse of Drugs concluded that the UK did not have a functioning drug prevention system and that significant investment was needed to rebuild prevention infrastructure and co-ordinate support services. The Committee of Public Accounts’ report on Alcohol treatment services also highlighted that DHSC needs to better understand and do more to prevent people from needing treatment for alcohol and substance misuse.3 The Home Office allocated £0.05 million of the strategy’s funding to research how to reduce drug use across society and DHSC allocated £0.3 million for research on the drivers of increasing drug use among children and young people. A new working group – chaired by the JCDU – will develop proposals for new initiatives to reduce drug use among children and young people, and will consider the need for new funding in 2025 (paragraphs 2.20 and 2.21 and Figure 9).

Progress to-date

11 The JCDU established effective arrangements to initiate the strategy but now needs to evolve its role. It has worked closely with departments to co-ordinate a cross-government response to implementing the strategy, including a joint bid to the 2021 Spending Review. It oversees progress and delivery risks through a new board structure and monitors delivery plans for each workstream. However, the JCDU has not yet assessed how it can work more effectively with central and local government partners to understand the impact of projects and judge what changes are needed to achieve the strategy’s 10-year aims. It must sustain momentum in implementing the strategy, with local government looking to the JCDU to continue to provide leadership and clarity on the long-term response (paragraphs 2.2, 2.3, 3.9, 3.13 and 3.14 and Figure 10).

12 The new local partnerships are improving collaboration but are at different levels of maturity and the JCDU does not yet understand how this is impacting the provision of local services. Following the introduction of the strategy, all local areas created a Combating Drugs Partnership, nominating a senior responsible owner to co-ordinate and lead their response. The JCDU provided guidance to the partnerships but has no formal powers to direct them. Progress since has varied, with only 30% of partnerships completing a local delivery plan by the JCDU’s deadline of December 2022, and there are wide variations in the bodies involved. The JCDU understands the extent of these local variations but has not fully assessed the impact on the provision and quality of local services, although department-led evaluations have started to assess this. The JCDU’s evaluations have found that the partnerships had enabled greater collaboration between stakeholders, improved local accountability and created a strong sense of local commitment (paragraphs 1.11 and 2.4 to 2.6).

13 Progress implementing the strategy is mixed. Departments can demonstrate tangible progress in some areas of the strategy. For example, the Home Office has increased activity to reduce the supply of drugs and local government has recruited 1,224 new drug and alcohol workers, already exceeding the target of 950 new staff by 2024-25. However, departments have made slower than expected progress implementing some projects, which meant that not all of the 2022-23 funding allocation was used. Departments underspent by £22 million (15%) across the treatment and recovery workstream and by £8 million (64%) on the reducing demand workstream. The DHSC’s delays in finalising the allocation of the public health grant in 2022-23 and 2023-24 have also made it more difficult for local authorities to commission new services and recruit staff. Local service providers also highlighted that inflationary pressures and cost of living price rises had affected their ability to recruit and retain staff, and provide treatment and recovery services. In April 2023, the JCDU, working with departments, recognised the risks, rating four of the five strategy ambitions for the treatment and recovery workstream as ‘amber’’ or ‘red’ (paragraphs 2.9, 2.11, 2.12, 2.16, 2.17, 2.19 and 2.26).

Achieving the strategy’s aims

14 Tackling the harm from illegal drugs represents a significant long-term challenge. Local authorities have welcomed the new funding provided for 2022-23 to 2024-25 but cautioned that a long-term response is needed to replace lost services and support people with complex needs. Through our engagement with local government bodies, we identified a range of challenges to achieving this:

Uncertainty over longer-term funding: the government has committed funding until 2024-25, in line with the end of the current Spending Review period. The lack of certainty after 2025 restricts the ability of local authorities to recruit and plan strategically, with some already asking service providers to plan to reduce services beyond 2025 in the face of uncertain funding.

Administrative resource constraints: shortages in administrative and commissioning staff can place pressure on local authorities’ ability to bid for central government funding and comply with monitoring arrangements. This also creates risks to the quality and value for money of services being commissioned.

Workforce gaps: there are staff shortages in the treatment and recovery sector, with shortfalls of medical professionals such as clinical psychologists and psychiatrists. It will take time to rebuild the capacity and expertise needed to achieve benefits, such as reducing caseloads, and provide tailored, expert support.

Difficulty co-ordinating a cross-sector response: tackling criminal gangs or dealing with vulnerable people requires a joined-up central–local government response. People with complex needs come into contact with a range of services, which cut across departmental responsibilities, including those connected with mental health, homelessness, employment, accommodation and justice. These services need to provide integrated support to minimise the risks of gaps and overlaps and provide the necessary support to vulnerable people and their families.

An insufficiently targeted approach: reductions in treatment services over the past decade have meant there is insufficient focus on targeting different cohorts of people affected by drugs, such as children and young adults, women and people from different ethnic backgrounds. These groups may have differing needs and require tailored support to encourage engagement with treatment services (paragraphs 3.5, 3.9, 3.12, and 3.13 and Figure 10).

15 Achieving impacts will take time – the JCDU and departments face a challenge to understand and demonstrate the impact that the strategy has made by 2025, when they need to bid for funding at the next Spending Review. The JCDU has worked with departments to set out the strategy’s 10-year aims and developed a series of measures to assess impacts, including the progress it is seeking to achieve by 2024-25, which is the end of the initial funding period. The Home Office is making progress against activity-based targets to disrupt the supply of illegal drugs. However, the JCDU does not yet know how strategy funding is affecting outcome targets, such as reducing drug use, and establishing this will be difficult. Given the complexity of the issues, it will be challenging to determine a causal link between strategy initiatives and changes in outcome indicators such as the level of drug use, crime, and drug-related deaths. It may be difficult for the JCDU to identify and demonstrate the impacts of drugs strategy funding by 2024-25, given the delays in allocating funding and the lag between recruiting new staff and seeing the impact on services. The JCDU will have limited outcome data to measure progress in the first three years and local variations will take time to show in national indicators (paragraphs 2.9, 2.24 to 2.28 and 3.9).

16 The JCDU has not established sufficient evaluation capability for a programme of this size and complexity. Delivery departments are responsible for evaluating projects undertaken through the strategy. The JCDU’s role is to bring these together to understand impacts and progress in delivering a complex, cross-departmental strategy. However, the JCDU has no formal authority to influence departmental project evaluations and has limited evaluation resources, with only one person responsible for overseeing the evaluation of the programme. The JCDU will draw on departmental assessments of the impact of funding in the prioritised local areas and the quality of local interventions, including examples of innovative approaches. It is therefore reliant on departmental evaluations of strategy-funded projects but has not yet established a full picture of this work. Further, the Home Office has not yet established how to evaluate the total impact of work on the supply of drugs and drug-related crime. The JCDU is undertaking further evaluations and developing its approach to assessing the strategy’s impact but still faces a significant challenge to understand these impacts before the next Spending Review and understand operational issues, such as the extent to which the strategy’s performance measures create perverse local incentives (paragraphs 2.28 and 3.3 to 3.11).

17 The JCDU does not yet have a long-term plan for achieving the strategy’s aims. It has focused on the funding period to 2024-25, monitoring progress against delivery plans for the three workstreams and assessing the risks to the strategy’s ambitions. The JCDU has not yet developed a plan beyond 2025 to build on progress in the first three years. It has begun preparations for another joint bid at the 2025 Spending Review, establishing the steps that are needed, but its evaluation work is behind schedule. To support planning, it will need to better understand the impact of initiatives, and how they are contributing to desired outcomes, so it can judge how to modify the existing approach (paragraphs 3.8 to 3.10 and 3.14).

Conclusion on value for money

18 In 2021 the government estimated that the harm caused by illegal drugs costs society £20 billion each year. Its 2021 drugs strategy, led by the cross-government Joint Combating Drugs Unit, has provided new impetus to efforts to address these harms, and committed £900 million to 2024-25. The strategy has established new partnerships across central and local government, and local authorities are taking steps to rebuild the workforce that was lost over the past decade. But these measures alone will not address all of the barriers to achieving a long-term reduction in drug use, deaths and related crime. The issues are complex and will require a sustained long-term response.

19 To inform government’s response, the JCDU and relevant departments need to develop a deeper understanding of the impacts of government spending, working closely with local service providers to understand and help address the practical challenges they face. The JCDU and departments need to be realistic about what is achievable in the first three years and assess how to adapt their approach to achieve the strategy’s 10-year outcomes. In doing so, the JCDU should seek to provide confidence to local government that this is a long-term commitment. It must also urgently develop a plan to reduce the demand for illegal drugs. The current lack of emphasis on preventing illegal drug use means that departments risk only addressing the consequences, rather than the causes, of harm. The government will only achieve value for money if it builds on the initial momentum of the new strategy and develops a longer-term, funded plan that delivers a joined-up, holistic response.

Recommendations

20 These recommendations are intended to help the JCDU and departments build on the strategy’s early momentum and support the achievement of the planned outcomes over the next 10 years.

a The JCDU should work with departments to agree its role over the remainder of the 10-year strategy to ensure that roles and responsibilities are clear and its limited resources are directed in the most effective way.

b The JCDU and departments should work with HM Treasury to agree what is achievable before the next Spending Review. They should determine how to realistically demonstrate the impact of funding in the first three years, considering the lag time before interventions affect outcome data, the time needed to set up and evaluate interventions and the difficulty of assessing localised responses in national metrics. They should consider more in-depth assessments of local authorities included in the first phase of funding allocations, comparing their progress against other areas.

c The JCDU and departments should strengthen their approach to evaluating impacts and understanding ‘what works’ by:

developing and publishing a long-term evaluation plan, supported by sufficient resources, to develop a deeper understanding of the impacts of strategy funding; and

reviewing the extent to which the programme’s performance measures create perverse incentives for service delivery, and consider whether there is sufficient emphasis on quality of services and long-term recovery.

d The JCDU and departments should maximise the impact of local partnerships by developing a deeper understanding of local variations, identifying innovative practice, areas that are lagging behind others and what is needed to strengthen responses. They should also consider how to engage other parts of government to develop a ‘whole system’ response, considering all of the factors that affect the demand for drugs and support effective recovery.

e The JCDU and departments should develop and publish a long-term plan to deliver the 10-year strategy. As part of planning for the next Spending Review, the JCDU and departments should assess how the next phase of the programme builds on the first three years and fixes the problems previously diagnosed by Dame Carol Black. The JCDU should use a theory of change to develop a compelling, evidence-based case for the long-term benefits and value for money of tackling the harms caused by illegal drug use to inform funding decisions at the next Spending Review.

f The JCDU and departments should work with HM Treasury to provide greater certainty on future funding for the strategy. This includes:

exploring the potential for indicative commitments over the life of the strategy; and

DHSC identifying and resolving the reasons for delays in allocating funding to local authorities and streamlining its processes to provide as much time as possible to plan and commission new services after 2024-25.

1 Dame Carol Black, Review of drugs part two: prevention, treatment, and recovery, July 2021 (viewed on 18 July 2023). Available at: www.gov.uk/government/publications/review-of-drugs-phase-two-report/review-of-drugs-part-two-prevention-treatment-and-recovery

2 HM Government, From harm to hope: A 10-year drugs plan to cut crime and save lives, December 2021 (viewed on 11 July 2023). Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1079147/From_harm_to_hope_PDF.pdf

3 Committee of Public Accounts, Alcohol treatment services, Fifty-fourth Report of Session 2022-2023, HC 1001, May 2023.

Part One

The government’s 2021 drugs strategy

1.1 This part summarises the background to the government’s From harm to hope drugs strategy (the strategy), its aims and how it is funded.

Background to the 2021 strategy

1.2 In December 2021, the government estimated that the costs associated with illegal drug use were £20 billion per year. Drug-related crime makes up approximately 48% of costs, with the harms from drug-related deaths and homicides making up 33%. Most of these costs (86%) arise from the 300,000 people who use opiates and crack cocaine across England.4

1.3 Since 2010-11, the proportion of the population who have taken illegal drugs has remained largely unchanged (Figure 1). In the year ending June 2022, 9.2% of 16–59-year-olds in England and Wales reported having taken drugs at least once within the past year, with 2.7% having taken Class A drugs.5 These proportions are higher for younger adults, with 18.6% of 16–24-year-olds reporting having taken drugs within the past year, and 4.7% reporting having taken Class A drugs.

1.4 While the proportion of people using illegal drugs is broadly stable, the number of deaths from drug misuse in England has been increasing since 2012 (Figure 2). Between 2011 and 2021, the number of deaths increased by 80% to 2,846, the highest since records began. Almost half of drug deaths in England and Wales related to opiates.6 The supply and distribution of illegal drugs is also linked to serious and violent crime, with around half of homicides in England and Wales linked to drugs. The number of drug-related homicides increased by 58% between 2011-12 and 2021-22 to 360 homicides.7

Trends in spending on substance misuse treatment

1.5 In the past decade, the Department of Health & Social Care (DHSC) funding for substance misuse treatment and, more broadly, public health funding, has fallen.8 Annual spending on adult drug and alcohol treatment decreased by 40% (£340 million) in real terms between 2014-15 and 2021-22. Of the 150 unitary authorities in England, 140 have reduced funding for substance misuse treatment during this period. Forty-two of these areas saw a fall of 50% or more. Only nine unitary authorities have increased funding, ranging from a 9% increase to a 195% increase (Figure 3). Overall, this has contributed to:

the closure and amalgamation of some treatment and recovery service organisations and an overall reduction in service quality;

a reduction in the number of adults and young people in treatment;

the de-professionalisation of the treatment workforce, with gaps across a range of skills and roles; and

variation in treatment outcomes across England, with the North of England having worse outcomes relative to London and the South-East.9

Trends in the number of adults in treatment

1.6 The number of adults in treatment for drug misuse in England fell by 7% between 2010-11 and 2021-22, from 221,000 to 205,000 (Figure 4). Over the same period, the number of young people (under-18s) in treatment for substance misuse decreased by 50% to 11,300.10,11 In 2021-22, individuals receiving treatment for opiate misuse accounted for 69% of adults in treatment. However, in 2021-22, in 98 out of 150 unitary authorities in England, 48% or more of the people who used opiates and/or crack cocaine were not in treatment (Figure 5). The lowest proportion of users not in treatment was in Northumberland (28%) and the highest proportion was in Thurrock (78%).

The 2021 drugs strategy

1.7 The government has published two drug strategies since 2010. The 2010 and 2017 strategies had the same aims of reducing illegal drug use, focusing on reducing demand, disrupting supply and improving treatment and recovery. 12,13 In 2019 the Home Office asked Dame Carol Black to undertake an independent review to inform its thinking on what more could be done. The government recognised that the harms caused by illegal drugs were worsening, with drug-related deaths at their highest recorded level. In 2021, Dame Carol called for a ‘whole system’ approach to sustaining recovery from addiction, reversing the cuts to treatment and recovery services, and putting the need to make reducing demand for illegal drugs a core component of the government’s approach (Appendix Two).14

1.8 In response to Dame Carol’s recommendations, the government published the From harm to hope strategy in December 2021.15 The strategy addressed all but one of Dame Carol’s recommendations and its main aims are to:16

break drug supply chains – preventing drugs from entering the country, disrupting organised crime groups, closing county lines and targeting local dealers;17

deliver a world-class treatment and recovery system – improving the quality and capacity of drug treatment services, as well as helping individuals with employment opportunities, accommodation and their mental health; and

achieve a generational shift in the demand for drugs – by changing public attitudes, introducing tougher sanctions for people who use recreational drugs, improving drugs education for children and young people, and investing in a range of programmes that will support at-risk young people and their families.

1.9 By the end of 2031, the government is aiming to reduce drug use to “a historic 30-year low”. The strategy set out long-term aims to reduce overall drug use, deaths and crime. The government also set interim targets for 2024-25 relating to reducing drug-related deaths and crimes, getting more people into treatment and disrupting criminal gangs.18

Roles and responsibilities for achieving the strategy’s aims

1.10 The government recognised that the drivers of drug use are complex and cut across the responsibilities of a range of departments and organisations (Figure 6). It took steps to ensure the strategy had senior-level support and a collaborative approach to delivery, including:

establishing a ministerial post responsible for combating drugs;

creating a Drugs Strategy Ministerial Forum, which brings together all the relevant secretaries of state, the Combating Drugs minister and wider partners to steer overall delivery of the strategy and ensure joint accountability for cross-government systems;

appointing the Home Office’s most senior official as lead permanent secretary for the strategy and creating a Drugs Strategy System Leaders Board to provide cross-system senior level accountability;

creating the Joint Combating Drugs Unit (JCDU), a cross-government team hosted by the Home Office to coordinate government activity – including a joint bid to the 2021 Spending Review – and oversee delivery of the strategy;19 and

clarifying departmental responsibilities for different aspects of the strategy.

1.11 Much of the work required to achieve the strategy’s aims will be carried out at the local level. To provide focus and a greater degree of accountability, the JCDU invited local areas to create Combating Drugs Partnerships (CDPs) to better coordinate the work of relevant bodies, including police, probation, healthcare and treatment providers. Each CDP has a named Senior Responsible Owner (SRO), who is accountable for implementing their local strategy.20 These CDPs do not have a common size or structure but typically cover areas at least the size of an upper-tier local authority.

Funding the strategy

1.12 To implement the strategy, departments have allocated £903 million of strategy funding over 2022-23 to 2024-25, taking total planned spending on tackling illegal drugs to £3.1 billion over this period.21 Of this, departments allocated £768 million to improve treatment and recovery, £105 million to disrupting supply and £30 million to reducing long-term demand. The allocation to treatment and recovery reflected the need to rebuild capacity in the sector (paragraph 1.5) and DHSC’s understanding of the potential benefits of investment.22 By contrast, the Home Office and other departments responsible for delivering the strategy did not have strong evidence on how to reduce long-term demand, and the funding allocation reflected the need to develop a better understanding before scaling up spending.

1.13 Departments allocated nearly all of the additional funding to continue and expand existing projects. For example:

the Home Office extended Project ADDER by two years and expanded its roll-out of Drug Testing on Arrest to 36 police forces; 23

DHSC is disbursing funding to local authorities through the Supplementary Substance Misuse Treatment and Recovery grant. Local authorities have discretion on how to use this funding, based on local needs and priorities, within a framework designed by DHSC;

MoJ/HM Prison & Probation Service created 35 new Incentivised Substance-Free Living Units in prisons and enhanced existing measures to reduce drugs being smuggled into prison;

DWP is working with DHSC to expand its Individual Placement and Support programme, first trialled in 2018, to cover all local authority areas in England by March 2025; and

DLUHC increased the number of local authorities receiving funding from its Rough Sleeping Drug and Alcohol Treatment Grant from 63 to 83 by April 2023.

4 The breakdown of the costs of drug-related harms is included in Dame Carol Black’s review.

5 The Misuse of Drugs Act 1971 divides drugs into three classes according to the harm they are judged to cause to the user and/or society. Class A drugs are considered the most harmful. Cocaine (crack and powder), heroin, LSD, and methamphetamines are examples of Class A drugs.

6 An opiate is a natural or semi-synthetic substance that is derived from the opium poppy plant. Opium, heroin, and morphine are examples of opiates. The terms ‘opiate’ and ‘opioid’ are often used interchangeably. In accordance with the From harm to hope strategy, this report refers to ‘opiates’ throughout.

7 Data on drug-related homicides in England and Wales were not collected prior to 2011-12.

8 The public health grant funding fell in real terms from £4 billion in 2015-16 to £3.2 billion in 2020-21 (a reduction of 20%).

9 Treatment outcomes include: completion of treatment; dropped out or left treatment; transferred to another service (in or not in custody); died; other.

10 Figures for young people include those in treatment for alcohol misuse.

11 In 2021-22, a further 39,000 adults and 553 young people in secure settings were also in treatment.

12 HM Government, Reducing demand, restricting supply, building recovery: supporting people to live a drug-free life, December 2010 (viewed on 18 July 2023). Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/98026/drug-strategy-2010.pdf

13 HM Government, 2017 Drug Strategy, July 2017 (viewed on 18 July 2023). Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/628148/Drug_strategy_2017.PDF

14 Dame Carol Black published her review in two parts. Part one provided a detailed and comprehensive analysis of the illegal drugs market in the UK, including the violence caused by it. Part two set out Dame Carol’s recommendations for drug prevention, treatment and recovery.

15 The government published its formal response to Dame Carol’s recommendations on 27 July 2021. The response is available at: www.gov.uk/government/publications/independent-review-of-drugs-by-dame-carol-black-government-response/government-response-to-the-independent-review-of-drugs-by-dame-carol-black

16 The government did not accept one of Dame Carol Black’s recommendations, specifically: “that the Department for Work & Pensions (DWP) augment Jobcentre Plus support by equipping staff to reach out into the community and work more intensively with those with complex needs, including working in drug and alcohol treatment services with people with addictions”. At the time, DWP was not able to commit to specific activity on outreach to those with a substance dependency at a national level, given the need to be able to respond across all of its priorities.

17 County lines is the name given to drug dealing where organised criminal groups use phone lines to move and supply drugs, usually from cities into smaller towns and rural areas.

18 The National Combating Drugs Outcomes Framework defines disruptions as: Major disruption: Significant disruptive impact on an organised crime group, individual or vulnerability, with significant or long-term impact on the threat. Moderate disruption: As above but with noticeable and/or medium-term impact on the threat.

19 The other departments which form part of the JCDU are: the Ministry of Justice, the Department for Work & Pensions, the Department of Health & Social Care, the Department for Levelling Up, Housing & Communities, and the Department for Education.

20 Senior Responsible Owners are typically a Director of Public Health, a Police and Crime Commissioner or the chief executive of the Integrated Care Board.

21 Total funding inclusive of public health grants and law enforcement funding.

22 DHSC estimated that every £1 spent on harm reduction and treatment gives a combined health and justice return of £4.

23 Project ADDER focuses on co-ordinated law enforcement activity, using the criminal justice system to divert people away from offending. It aims to ensure that more people get effective treatment, with enhanced recovery provision.

Part Two

Progress implementing the strategy

2.1 This part provides an update on progress implementing the government’s From harm to hope drugs strategy (the strategy).

Arrangements for implementing the strategy

2.2 Our good practice guide for cross-government working sets out the principles that departments and other bodies should adopt to achieve shared outcomes.24 We assessed arrangements for implementing the strategy against the three principles for ”setting up cross-government working”:

Developing a shared vision: there was a high level of awareness of the strategy across central and local government, and non-governmental bodies. It has been widely welcomed, with stakeholders commenting that it had created a “national expectation” to work together and enabled local areas to develop plans relevant to their local needs. However, there were differing views on how the strategy balanced dealing with people who use drugs through the criminal justice system versus directing them towards treatment services. Some bodies commented that the strategy risked reinforcing – rather than helping to address – the stigma attached to people who use drugs. Others felt it was not clear on how to reduce demand and missed an opportunity to target specific groups, particularly preventing young people from using illegal drugs and supporting older age groups.

Defining responsibilities and accountabilities: the arrangements for implementing the strategy focus on improving coordination at national and local levels. The creation of national and portfolio boards and Combating Drugs Partnerships (CDPs) has helped to coordinate activity, facilitated joined-up working and strengthened accountability.

Leadership: to date, the strategy has benefited from senior political buy-in, with the then Prime Minister endorsing the original vision and approach. The creation of a ministerial post focused on illegal drugs, the nomination of the Home Office permanent secretary and creation of a senior officials board has raised the profile of the strategy.

2.3 The Joint Combating Drugs Unit (JCDU) provides central support for the strategy. It is responsible for strategy and policy, including the development of a long-term delivery model; overseeing implementation; and analysis, including strategy-wide evaluation and collating the next Spending Review bid. The government’s original intention was to build the capacity of the JCDU to a “viable minimum” of 14 staff, including three people from the Department of Health & Social Care (DHSC) and two each from the Ministry of Justice (MoJ) and the Department for Work & Pensions (DWP). In June 2023, the JCDU had expanded to 13 full-time staff, including secondees from the Home Office, DHSC, MoJ and DWP, and 2 unfilled posts.

Local partnerships

2.4 Recognising the importance of local service delivery to achieving the strategy’s outcomes, the Combating Drugs minister asked local areas to create new CDPs to bring together relevant organisations and provide a single point of contact for central government. The JCDU published guidance for local areas, setting out who should be involved and a timeline for their creation, but had no formal powers to enforce compliance. By September 2022, 106 local areas in England had established a CDP and nominated a senior responsible owner (SRO).

2.5 The CDPs cover different geographical areas. For example, Northumbria has established a single CDP whereas Merseyside has five local CDPs. In 70% of partnerships a Director of Public Health is the SRO, while others have nominated a Police and Crime Commissioner, a senior police officer or a senior local official. The JCDU has no statutory powers to mandate how CDPs work but has issued guidance on which organisations should be involved. However, there are wide variations in the make-up of CDPs. More than 94% of CDPs have police and probation representatives at their meetings, but 23% do not include substance misuse treatment providers. There were lower levels of engagement across CDPs from some other core partners, notably prisons, and other relevant partners, such as community health providers. The JCDU told us that it plans to test whether this differentiation leads to variations in practice across local areas and capture examples of good practice and innovation.

2.6 The JCDU expected CDPs to have completed a local needs assessment by November 2022 and create a local strategy delivery plan by December 2022. By March 2023, 75% of CDPs had completed needs assessments and over 30% had developed their delivery plan. CDPs are having a positive impact in bringing people together and there are examples of innovative new approaches. A JCDU evaluation found that, while in the early stages of development, these partnerships had enabled greater collaboration, improved local accountability and brought a strong sense of local commitment. The JCDU engages regularly with the CDPs alongside on-going departmental engagement with local bodies and service providers.

Progress to date on the strategy workstreams

2.7 We reviewed progress against the strategy’s workstreams:

disrupting drug supply chains;

developing a world-class treatment and recovery system; and

reducing the long-term demand for drugs.

Disrupting supply

2.8 In total, the Home Office allocated £277 million over 2022-23 to 2024-25 to reduce the supply of drugs. It allocated funding to on-going projects to disrupt the supply and distribution of illegal drugs across England, such as the County Lines Programme. It has also expanded work to disrupt international drug trafficking and improve security at the border. This allocation includes £84 million of additional funding provided as part of the 2021 drugs strategy although, as it was part of the total allocation, the Home Office was not able to provide a precise breakdown of how the strategy funding was being used. The MoJ also allocated a further £21 million to this work (Figure 7).25

2.9 In April 2023, the JCDU, working with departments, reported on progress in 2022-23, rating the delivery of five programmes as ‘green’, one as ‘green/amber’ and two as ‘amber’. The main achievements included:

the County Lines Programme was expanded from three to four police forces (adding Greater Manchester Police).26 Police operations closed 1,417 county lines, a 15% increase on 2021-22;27

Project ADDER was expanded from five to 13 areas.28 This was done before an independent evaluation of whether the programme was achieving its intended impacts;

2,974 major/moderate disruptions of organised criminal gangs, exceeding the annual target; and

the MoJ had recruited 75 of 83 staff for the Crime in Prisons Taskforce and Serious Organised Crime Unit and enhanced vetting checks, deploying drugs detection equipment in 50 priority sites.

Treatment and recovery

2.10 Departments have allocated £768 million of strategy funding to the treatment and recovery system over 2022-23 to 2024-25 (Figure 8).29 DHSC leads on this workstream and distributes funding through the Supplementary Substance Misuse Treatment and Recovery grant (SSMTR) to help rebuild substance misuse services. The strategy funding builds on additional funding of £80 million for substance misuse services in 2021-22, and maintains increased funding for all local authorities.30 DHSC used the strategy funding to provide a further uplift for the 50 local areas with the greatest need in 2022-23, another 50 areas in 2023-24 and all local authorities in England by 2024-25.31,32 In 2022-23, the first 50 local authorities each received an average of £1.1 million of additional funding. DWP, MoJ and the Department for Levelling Up, Housing & Communities (DLUHC) have also allocated £152 million of strategy funding, working with DHSC’s Office for Health Improvement and Disparities.

2.11 DHSC announced the 2022-23 funding allocations to local authorities on 13 April 2022, after the beginning of the financial year to which they related. Before the COVID-19 pandemic, public health grants were released in the December before the financial year to which they related, to give local authorities time to plan how to use them. The 2022 late announcement of the supplemental funding led to delays in commissioning services and recruiting new staff. Local authorities either had to take risks by commissioning services without guaranteed funding, or wait, which can create gaps in local services as it can take local authorities up to six months to recruit new staff or commission new services. The DHSC announced funding for 2023-24 and 2024-25 on 16 February 2023. This was three months later than originally planned, due to the need to confirm departmental strategic priorities and corresponding financial budgets with new ministers.

2.12 Over the past decade, the drug treatment and recovery sector has lost capacity and skills due to reductions in national funding (paragraph 1.5). The drugs strategy set an ambition to recruit 800 more medical, mental health and other professionals and 950 more drug and alcohol and criminal justice workers by 2024-25. In 2022-23, local authorities have used strategy funding to recruit new staff, exceeding annual targets by recruiting 1,224 drug and alcohol staff, including some focused on criminal justice settings, nurses, pharmacists and social workers. However, recruitment of psychiatrists, psychologists, and non-consultant grade doctors fell short of the 2022-23 targets. Retaining staff has also proved challenging, with the sector experiencing high levels of turnover. In 2022-23, turnover was 12% for NHS treatment providers and 27% in third-sector treatment providers. Across all providers, 37% of staff had been in post for less than a year. Treatment providers that we spoke to highlighted the consequences of resource shortfalls and an inexperienced workforce, emphasising the need to create better pathways for staff to join the sector, such as accreditation, and improving retention.

2.13 DHSC committed to producing a treatment workforce strategy by December 2022, but has not done so. It now expects to publish this and a capability framework in autumn 2023. DHSC told us that it was necessary to develop a capability framework before setting out the strategic approach to rebuilding the workforce.

2.14 The NHS Long-Term Workforce Plan acknowledged the importance of increasing the number of mental health professionals to help with drug treatment interventions. Drug and alcohol treatment services moved under local authority commissioning (with other public health services) following the Health and Social Care Act 2012. In most cases, this means that drug and alcohol treatment and mental health treatment are delivered separately. Dame Carol Black’s review recommended that there needs to an improvement in the skills and knowledge about managing co-occurring conditions in both mental health and substance misuse services. The NHS Long-Term Workforce Plan suggested ways to increase the number of mental health professionals, including training in alcohol and drug screening, but did not include a plan to achieve this. DHSC and NHS England are working on a joint action plan to improve mental health treatment for people using drugs and alcohol, which will consider what training is needed and what roles support local services.

2.15 DHSC has faced its own staffing shortfalls on the treatment and recovery workstream. It identified the need to recruit 17 new project management staff but this has not been possible due to a DHSC-wide recruitment freeze. In February 2023, a programme review concluded that maintaining the recruitment freeze would make delivery of the treatment and recovery programme unrealistic. DHSC told us that it addressed this by recruiting staff using an exemptions process, extending contracts for business-critical posts and redeploying staff from other areas, allowing it to progress the treatment and recovery workstream.

2.16 Departments have made mixed progress against targets in the first year, with a £22 million (15%) underspend on the treatment and recovery workstream in 2022-23. An internal DHSC review rated its approach as ‘amber’.33 Local service providers also highlighted that inflationary pressures and cost of living price rises had affected their ability to recruit and retain staff and provide treatment and recovery services. In April 2023, the JCDU, working with departments, also rated achievement of four of the five treatment and recovery ambitions as ‘amber’ or ‘red’, including:

limited progress towards the target of 54,500 additional treatment places by March 2025, with some 2,600 new places by March 2023;

local authorities were asked to make it easier for people in the criminal justice system to get treatment. DHSC reported that criminal justice referrals have been increasing since April 2021, and this trend is continuing;

MoJ and DHSC are not on track to reach the target of providing co-ordinated treatment support for people moving from prisons to community treatment. Our May 2023 report showed only 37% of prison leavers with a substance misuse treatment referral were engaged in community-based treatment within three weeks of release in 2021-22.34 Referrals had risen to 42% in March 2023 but DHSC and MoJ acknowledge further progress is needed; and

data to track trends in drug-related deaths are not yet available. However, there was no notable decrease in the number or proportion of deaths during treatment in 2022-23, which DHSC uses as a proxy for its target.

2.17 As of April 2023, departments had demonstrated examples of progress, including:

MoJ and HM Prison & Probation Service (HMPPS) opened six new drug recovery wings and 25 new ‘Incentivised Substance Free Living’ wings in prisons.35 HMPPS had recruited 18 new drugs strategy leads for Category C and women’s prisons;

DHSC issued Housing Support Grant payments to 28 local authorities; and

DWP, working with DHSC, expanded the Individual Placement and Support (IPS) programme from 46 local authority areas to 66, with plans to roll-out to all areas in England by 2024-25.

Reducing long-term demand

2.18 The Home Office has allocated £25 million over three years for projects to reduce the demand for illegal drugs among adults. DHSC also allocated £5 million to an innovation fund to identify solutions to prevent and intervene early in use of recreational drugs, exploring ways to reduce demand (Figure 9).

2.19 In 2022-23, the Home Office did not start projects on schedule, contributing to a £8 million (64%) underspend on the 2022-23 allocation to this workstream. In April 2023, the JCDU and Home Office rated the delivery of four of the 11 programmes as ‘amber’ or ‘red’. The Home Office has:

expanded the use of Drug Testing on Arrest to help understand the link between drug use and other crimes. The period from March 2022 to June 2023 saw an increase in the number of forces reporting conducting Drug Testing on Arrest, with 33 forces reporting 58,649 completed tests to the Home Office. The Home Office issued funding for 2023-24 in May 2023, two months into the financial year to which the funding related; and

delayed the project to use Out of Court Disposals (OOCDs) to enable police officers to refer people who use drugs into treatment or drugs awareness courses, rather than the criminal justice system. The Home Office has yet to announce when this project will begin.

2.20 Despite previous initiatives to change behaviours in the 2010 and 2017 strategies, the Home Office and delivery departments did not have a strong evidence base for what works to reduce demand for drugs. The Committee of Public Accounts’ report on Alcohol treatment services also highlighted that DHSC needs to better understand and do more to prevent people from needing treatment for alcohol and substance misuse. The Home Office assessed that very few UK or international efforts have changed behaviour, including large–scale public information campaigns. Given this lack of understanding, it committed £0.05 million to research how to reduce drug use across society and expected to complete research into young peoples’ behaviours in summer 2023.

2.21 The Home Office sought advice from the Advisory Council on the Misuse of Drugs (ACMD) on preventing drug use among vulnerable people.36 The ACMD’s May 2022 report concluded that “the UK lacks a functioning drug prevention system, with workforce competency a key failing in current provision”.37 The ACMD highlighted the need for significant, long-term public investment to rebuild prevention infrastructure and coordinate support services across domains to increase the likelihood of healthy development of young people, including efforts to address inequalities. In May 2023, the Drugs Strategy Ministerial Forum commissioned a working group to take stock of the support available for children and young people across government and to assess opportunities to go further. The working group – which will be chaired by the JCDU – will develop proposals for new initiatives to reduce demand for drug use among children and young people, and will consider the need for new funding at the 2025 Spending Review.

2.22 Drug use among young adults (16–24 year–olds) is double the rate seen among adults and is increasing at a faster rate. The JCDU recognises that building resilience in children and young people is crucial to reducing demand. Drugs education is part of the statutory health education curriculum for all state–funded schools and the Department for Education plans to publish the outcomes of a national survey covering drug education in early 2024. The Home Office has paused its proposed expansion of messaging to students at university, although DHSC continues to inform young people of the harms and risks around drug taking via the FRANK website, which receives around one million visits a month. DHSC and other departments are investing in a range of programmes that provide early, targeted support for young people and families most at risk of substance abuse.

2.23 The Home Office is also seeking to toughen sanctions for people who use ‘recreational’ drugs, making clear that it views unlawful possession as a crime. In October 2022, it closed the consultation on its ’Tougher Consequences‘ White Paper, setting out an escalatory approach for people found in possession of drugs, particularly cocaine.38 The Home Office is considering consultation responses, which will help shape the future policy direction in this area, and told us that a government response will be published in due course. It has also commissioned research into potential interventions to reduce recreational drug use and is considering how to develop its findings into future work.

Progress against the strategy’s long-term outcomes

2.24 In the From harm to hope strategy, the government set out its ambitions for the 10–year period to 2031. The JCDU has developed three strategic outcomes to address the harm from illegal drugs relating to reducing drug use, reducing drug-related deaths and reducing drug-related crime. It also set three intermediate outcomes relating to reducing drug supply, improving recovery outcomes and increasing engagement in treatment. In July 2023, the JCDU set out 12 measures to monitor progress towards these outcomes.

2.25 The JCDU, working with departments, will need to demonstrate the strategy’s impacts in 2024-25, which is the end of the initial funding period, to support the case for additional funding at the next Spending Review. As of September 2023, it had limited data to understand impacts for some of the intended outcomes, including progress in reducing drug-use and the success of treatment recovery programmes. It is reliant on national data releases, which will restrict its ability to measure progress against outcome measures by 2024-25. The JCDU and departments have better data for measures based on operational targets, such as the closure of county lines and disrupting criminal gangs, and also use internal management information and proxy measures to monitor progress for outcomes such as reducing drug-related deaths.

2.26 The JCDU faces a significant challenge in demonstrating progress against some of the strategy outcomes. In some areas, such as preventing drug-related deaths, there is a lag between allocating funding and observing the impact on national data. The delays in distributing local authority funding (paragraph 2.11) also mean it will take longer to recruit staff, improve the quality of services and deliver better patient outcomes. For other outcomes, such as reducing drug-related crime, it will not be straightforward to understand the impact of strategy funding, given the wide range of factors that affect crime rates.

2.27 In the 2021 strategy, the Government committed to achieving the following targets by 2024-25:

Preventing nearly 1,000 deaths.

Increasing treatment capacity by 20% with at least 54,500 new treatment places.

Preventing nearly 740,000 crimes, including 140,000 neighbourhood crimes through increases in drug treatment.

Closing more than 2,000 county lines.

Delivering 20% more major and moderate disruptions against organised criminals.

The JCDU plans to start bringing together evidence for the next Spending Review bid in 2024 and has been working with HM Treasury on this. However, given issues with data availability and complications in measuring progress, the JCDU has not yet agreed a realistic set of expectations with HM Treasury to understand the impact of funding in the first three years. Further, many of the strategy-funded projects will not have been in place long enough to make an impact and have completed evaluations by then.

2.28 The strategy’s performance metrics can also create perverse incentives or unintended consequences at the local level. For example, the target to complete treatment programmes may encourage local authorities to move people out of treatment when they require longer-term support. DHSC has developed a new measure aimed at showing treatment progress but this measure is based upon self-assessment by drug workers and their patients and may not remove the risk of perverse incentives. The government’s evaluation evidence also shows that disrupting criminal activity can lead to increased violence.39 There is scope for the JCDU and departments to develop a deeper understanding of how performance metrics affect behaviours at a local level, including how metrics are reflected in commissioning contracts, how data are recorded and whether there is sufficient emphasis on the quality of services.

24 National Audit Office, Good practice guide, Cross-government working, July 2023. The guide sets out good practice for setting up, delivering and improving cross government working.

25 These figures represent departmental funding allocations following the Spending Review settlement in December 2021.

26 The police forces involved are: Metropolitan Police, Merseyside Police, West Midlands Police and Greater Manchester Police. These forces have piloted new operational tactics, promoted best practice among police forces and targeted the finances associated with county lines.

27 The National County Lines Co-ordination Centre defines two types of line closure. Type 1 is when the closure of a county line results from the arrest and charge of a line holder. Type 2 is when the closure results from the deactivation of a phone line/number associated with the county line. In 2022-23, police forces reported 1,364 Type 1 closures, which exceeded the annual target of 875 closures.

28 Project ADDER focuses on co-ordinated law enforcement activity, using the criminal justice system to divert people away from offending. It aims to ensure that more people get effective treatment, with enhanced recovery provision.

29 These figures represent departmental funding allocations following the 2021 Spending Review settlement.

30 In January 2021, the government announced £148 million of new funding in 2021-22 to cut crime and protect people from illegal drugs. This included £80 million in drug treatment services across England.

31 DHSC has set out the range of interventions that can be funded and, within this, local authorities have discretion on how to use funding based on local needs.

32 DHSC is prioritising local authorities that are experiencing the highest harm (including the rate of drug deaths, deprivation levels, opiate and crack cocaine prevalence, and crime levels).

33 This was based on the Infrastructure and Projects Authority’s assessment scale.

34 Comptroller and Auditor General, Improving resettlement support for prison leavers to reduce reoffending, Session 2022-23, HC 1282, National Audit Office, May 2023.

35 Incentivised Substance Free Living Units are designed to encourage offenders to break their addiction by providing extra time out of cell for education and work opportunities and, if they stop using drugs, the prospect of being transferred to a drug recovery wing for six months of intensive, abstinence-based treatment.

36 The ACMD is the UK government’s independent advisory body on drugs. It has provided advice on how vulnerable people can be prevented from first using and then developing dependence on drugs.

37 Advisory Council on the Misuse of Drugs, Drug Misuse Prevention Review, 16 May 2022 (viewed on 2 October 2023). Available at: www.gov.uk/government/publications/drug-misuse-prevention-review/acmd-drug-misuse-prevention-review-accessible

38 Home Office, Swift, Certain, Tough: New Consequences for Drug Possession, July 2022, white paper, CP 723.

39 HM Government, An evaluation of the Government’s Drug Strategy 2010, July 2017 (viewed on 5 September 2023). Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/628100/Drug_Strategy_Evaluation.PDF

Part Three

Challenges achieving the strategy’s aims

3.1 This part assesses how the JCDU and departments are evaluating progress and tackling the challenges to achieving the long-term outcomes set out in the government’s 2021 From harm to hope drugs strategy (the strategy).

The approach to evaluating impacts

3.2 In December 2021, we reported on government’s progress in using evaluation evidence across its spending programmes.40 Our work highlighted the importance of evaluating the impacts of interventions to understand ‘what works’ and inform decisions on how to improve. We have assessed the approach to evaluating the drugs strategy using these principles.

Responsibilities for evaluation

3.3 Departments are responsible for evaluating each project funded by the drugs strategy and the Home Office and Department of Health & Social Care (DHSC) lead on evaluating the disrupt supply and treatment and recovery workstreams.41 The Joint Combatting Drugs Unit’s (JCDU) role is to bring together these evaluations and make a judgement on what further evaluation work is needed to understand the impact of the strategy. Its aims are to assess:

what processes and approaches have worked well;

the impact of the whole strategy against its aims, including progress against the outcomes framework; and

the value for money achieved across the whole strategy.

Progress evaluating the strategy

3.4 Departments are undertaking evaluations on projects funded through the strategy, either individually or in combination, including ongoing projects which already have evaluations underway (for example, Project ADDER). Portfolio boards monitor progress on the strategy’s three workstreams, covering 87 delivery areas, but progress in evaluating impacts across these workstreams varies:

DHSC, in collaboration with the National Institute for Health and Care Research, has commissioned an evaluation of the increased investment in the treatment and recovery system. This includes a process evaluation of the implementation of the treatment and recovery portfolio and in-depth evaluations of specific programmes where evidence gaps have been identified or where programmes have been newly developed. DHSC expects this evaluation to be completed by summer 2025;

the Home Office undertook a feasibility study to assess how to measure the impact of the disrupt supply workstream. This indicated that none of the evaluation options would be robust enough to establish a reliable value-for-money assessment for the workstream and impact should be evaluated at intervention level, with some evaluations likely to provide a more definitive assessment than others. The Home Office plans to develop further its understanding of the impacts of its work to reduce drug-related crime; and

the Home Office and DHSC have chosen not to conduct a portfolio level evaluation for the reducing demand workstream as, in their view, this wide-ranging portfolio will be adequately covered by project evaluations. The JCDU told us that it also plans to conduct a lessons-learned exercise to collate good practice and explore how to reduce the demand for drugs (paragraph 2.21).

3.5 To inform its evaluation of the strategy, the JCDU has commissioned research into its approach and the cross-government response:

In June 2022, it developed a methodology to assess the potential added value of the cross-government approach to delivering the strategy. This included a ‘theory of change’ to understand how strategy inputs and activities might lead to desired outcomes and impacts.

In April 2023, it assessed local delivery, including the creation of Combating Drugs Partnerships (CDPs). This identified ways to improve central/local government working, such as longer-term funding and longer timescales to meet requests. It also identified barriers to partnership working, such as difficulties with data sharing; gaps in services undermining a ‘whole system’ approach; competing priorities and a lack of resources; and a need to target different cohorts of people who use drugs. The work also began to explore ways of assessing the impact of the strategy over the period to 2024-25.

3.6 In April 2023, the JCDU submitted a separate bid to the Shared Outcomes Fund for £1.0 million to evaluate how the Combating Drugs Partnerships are working.42 HM Treasury confirmed to us that it had approved the bid. As part of this research, the JCDU will seek to understand how best to evaluate the strategy as a whole and develop the approaches proposed by its previous research. This project was not affordable within the strategy’s funding and will provide two additional staff in the JCDU. The JCDU expects to complete the evaluation by March 2025.

Evaluation challenges

3.7 The JCDU has established an over-arching evaluation strategy but has lacked evaluation resources, with one person responsible for bringing together departmental evaluations and managing its own evaluations. It engages with departments but has no formal authority to set evaluation objectives for projects and has lacked the capacity to influence the design of evaluations. It also has limited capacity to identify gaps or analyse results of evaluations to develop its understanding of ‘what works’. The JCDU has established a cross-strategy analytical group and uses this group to ensure evaluation approaches are aligned and focus on strategy outcomes.

3.8 The JCDU had expected to map departmental project evaluations, and commission further work to fill gaps, by early 2023. It is undertaking work to bring together departmental project evaluations but has not yet developed a complete picture. It is therefore behind its schedule for co-ordinating evaluation work in preparation for the next Spending Review. The JCDU is now identifying gaps in the evidence needed for the next Spending Review and is commissioning further work to develop a methodology to evaluate the strategy’s impact. The JCDU, HM Treasury and departments are exploring opportunities for another joint bid in 2025, and the JCDU is taking forward a programme to develop plans and establish timelines.

3.9 Tackling the harm caused by drugs often involves treating and supporting vulnerable people with complex needs who are accessing a range of services. It is inherently difficult to understand which interventions – or combination of interventions – are leading to changed behaviours and improved outcomes. It will also take time for interventions to show results. Robustly evaluating the impact of the strategy workstreams and understanding how project funding is contributing to long-term outcomes will be a significant challenge. In particular:

implementing multiple projects at the same time makes it more difficult to understand which projects are making a difference to outcome measures; for example, the Ministry of Justice (MoJ) has allocated strategy funding to 10 projects to improve security in prisons and probation;

in the treatment and recovery sector, local authorities have discretion on how funding is used, within a menu of eligible interventions. Variations in approaches between local authorities will mean in-depth analysis is needed to compare across local areas to understand which initiatives are leading to changes in outcomes;

DHSC and MoJ have initially prioritised strategy funding allocations to local authorities and prisons with the highest harm. This means that they will initially need to understand impacts by assessing changes at a local level. National outcome data may take time to reflect local impacts;

the JCDU will have an incomplete evidence base to inform decisions at the 2025 Spending Review as the department-led project and workstream evaluations are likely to still be in progress. This will limit the amount of evidence on the impacts of interventions; and

it will be difficult to separate out the impact of strategy funding on projects which also receive funding from elsewhere. As the Home Office has not differentiated the additional strategy funding from other funding to disrupt the supply of drugs (paragraph 2.8), it will be difficult for it to assess the marginal benefit of this additional funding on discrete programmes.

3.10 As the JCDU and departments prepare for the next Spending Review, they need to develop a deeper understanding of what works and base future funding bids on an assessment of how inputs and activities lead to outcomes. They have not yet assessed whether existing interventions go far enough to address the weaknesses diagnosed by Dame Carol Black and achieve the strategy’s 10-year ambitions. This will involve working with departments to determine whether the approach in the first three years – which is based on expanding existing projects and rebuilding the treatment workforce in areas of highest harm – will create a holistic, cross-system approach to dealing with vulnerable people with complex needs and tackle increasing drug use in younger age groups. The JCDU and departments could also do more to identify and disseminate innovative new practices as our engagement with local service providers highlighted examples of new local initiatives.

3.11 The JCDU has taken steps to strengthen mechanisms for sharing good practice across local authorities. For example, it is seeking to exploit existing networks managed by DHSC and HM Prison and Probation Service (HMPPS) and has developed a senior responsible owner (SRO) network, including plans to work more closely with the Association of Police and Crime Commissioners and the Association of Public Health Directors. Such developments should help to address feedback from local government about the need to develop stronger feedback loops.

The challenges of achieving the strategy’s long-term outcomes

3.12 A wide range of factors create risks to the government’s ability to achieve the strategy’s 10-year outcomes. For example, as with any long-term programme, a new government could take a different view on the relative priority of this work. Departments themselves may also face evolving pressures and competing priorities that could affect the funding or capability available to progress the strategy.

3.13 Local organisations emphasised that a long-term response was needed to rebuild treatment services and develop a holistic joined-up response. They told us they faced a range of practical challenges and identified barriers to sustaining services (Figure 10). This included the lack of certainty around future funding and workforce shortages, which restrict their ability to commission and deliver new services. They also highlighted the need to focus on improving the quality of services, ensure support services from other sectors are available and better target different cohorts of people who use drugs.

3.14 To date, the JCDU has focused on the first three years of the strategy (2022-23 to 2024-25), which reflects the initial funding commitment. Departments have also developed workstream plans which extend to 2024-25. The JCDU has not yet developed a longer-term plan to build on the first three years and create a programme-level approach to achieving the strategy’s 10-year outcomes. In September 2023, it had just started work to develop this.

3.15 The JCDU developed a high-level ‘theory of change’ when designing the 2021 strategy.43 However, this contained insufficient detail to understand how interventions are expected to influence long-term outcomes. For example, it did not provide a clear explanation of the causal chains, the context, risks or assumptions. We have seen no evidence that a ‘theory of change’ was used to inform the strategy’s funding allocations – the JCDU produced a ‘system level’ theory of change in June 2022, after funding allocations had been decided. DHSC also developed a theory of change for the treatment and recovery workstream, but local authorities have discretion on how they use strategy funding (paragraph 2.10).

40 Comptroller and Auditor General, Evaluating government spending, Session 2021-22, HC 860, National Audit Office, December 2021.

41 The approach is based around testing, learning and evaluation as work progresses to ensure money is targeted effectively towards the most impactful interventions.

42 The Shared Outcomes Fund was launched by HM Treasury in 2019. The 2021 Spending Review announced that the Fund would run for a third time, with £200 million available to finance pilot projects that aim to innovate ways of working across the public sector.

43 A comprehensive theory of change seeks to identify the causal chains that are expected to bring about the desired change at a programme level. It should identify what is required for the intervention to succeed and the assumptions on which the programme is based.

Appendix One

Our evidence base

Interviews

1 The study team carried out interviews with officials from Home Office, Department for Work & Pensions (DWP), Department of Health & Social Care (DHSC), Ministry of Justice (MoJ)/HM Prison & Probation Service (HMPPS), HM Treasury, the Joint Combating Drugs Unit (JCDU) and beyond central government. We also spoke to local government representatives from Combating Drugs Partnerships (CDPs) including in Hackney, Cornwall and Northumbria. The majority of these were conducted via Microsoft Teams but some were face-to-face. Interviews have included officials or representatives from the following:

JCDU – Head of unit; evaluation lead, local engagement lead, strategy lead, analytical/metrics team;

Home Office – Drugs Supply and County Lines Unit (various); lead for Reducing Drugs Demand;

DHSC – Office for Health Improvement and Disparities Drugs team (various);

MoJ/HMPPS – Substance Misuse Group and Drugs Strategy Development;

Department for Levelling Up, Housing & Communities (DLUHC) – Homelessness and Health policy team; policy lead for rough sleeping and housing support agenda;

DWP – policy lead for employment support agenda, including the Individual Placement and Support programme;

HM Treasury – Home Office and DHSC spending teams;

National Police Chiefs’ Council drugs lead;

Chair of the Association of Police and Crime Commissioners;

Leadership team of Collective Voice (coalition of drug treatment and recovery service providers); and

Metropolitan Police County Lines and Project ADDER representatives.

In the majority of cases, we posed questions including but not limited to: the design and set–up of the strategy and its structures; the scale and nature of the problem; the risks and challenges around the timely distribution of funds; the appropriateness of metrics; effective evaluation of projects and their attribution; and the difficulties in demonstrating impact on a complex issue in a short timescale.

Document review

2 Between February and June 2023 we reviewed a wide range of published and unpublished documents from various departments/teams (JCDU, Home Office, DWP, DLUHC, DHSC) and other bodies to inform our work. These included business cases, board papers and minutes (both cross-strategy and at the different strand levels), budgeting and other planning documents, risk reports, internal briefing documents, project and programme evaluations, delivery plans and programme data and metrics.

3 We reviewed these documents to gain a better understanding of how the JCDU and its partners have set about implementing the 2021 drugs strategy, the planning and metrics that have been put in place and what early progress has been made to date. All documents received by the study team or external sources were recorded in an evidence log.

Case studies

4 We selected four CDPs to give us coverage of several aspects of the context. Cornwall was our pilot, in which we tested our approach and questions, which fed into later sessions. The remainder were selected to give us coverage of: an example of high-drugs harm (Merseyside); an example of good practice (Northumbria) and disruption of supply (Hackney). In each case we have interviewed at least the CDP senior responsible owner (SRO) or a delegated colleague. Between March and June 2023 we conducted all four planned engagements. We drew together interview data, analysis of statistics around drug harms, and funding (both historical and current/future allocations).

Call for evidence

5 We issued a ‘call for evidence’, inviting written submissions from a number of relevant representative bodies, including:

the Local Government Association

the Association of Directors of Public Health

the Prison Governors Association

the Association of Clinical Psychologists

the Association of Police and Crime Commissioners

the NHS Addictions Provider Alliance

the English Substance Misuse Commissioners Group

Collective Voice

College of Lived Experience Recovery Organisations

6 We received nine returns from the bodies we invited to submit. We adopted this approach as we believed a targeted request for evidence from relevant professional groups would provide us with an indication of their perspectives regarding the set–up and initial implementation of the new strategy and its structures; early progress in achieving its aims; and the challenges faced in demonstrating this in a relatively short period of time. The responses received validated this approach and provided useful triangulation for other evidence sources such as interviews and the case studies.

Quantitative analysis

7 We used data provide by DHSC to examine the changes in public health spending on substance abuse treatment between 2014-15 and 2021-22. With  assistance from the National Audit Office (NAO) economics team, we converted these figures to 2022-23 prices. These data were then used by the NAO mapping team to create a heat map showing these percentage changes across the period.

8 We also took data from the National Drug Treatment Monitoring Service’s website via an application programming interface (API), which enabled us to determine the percentage of people who use opiates and/or crack cocaine in each local authority area who were not in treatment. These data were then used to create a heat map showing the situation across English local authority areas.

Appendix Two

Dame Carol Black report

1 We have set out our assessment of the government’s response to the recommendations made by Dame Carol Black.

Design and Production by NAO Communications Team
DP Ref: 012238-001