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Below is a draft for a new entry on the National Treatment Agency for Substance Misuse. This is a work in progress – please do not edit this article until it is a live page.



The National Treatment Agency for Substance Misuse (NTA) is a special health authority of the National Health Service. It was set up in 2001 to improve the availability, capacity and effectiveness of treatment for drug misuse. The agency's remit is England-wide and it oversees adult drug treatment, and drug and alcohol treatment for children and young people.

The NTA is not a treatment provider, but works to improve the commissioning of services, promote evidence-based practice in drug treatment and improve the skills of the drug treatment workforce.

The agency's headquarters are in Lambeth, south London; in addition, there are nine regional offices that together cover the whole of England.

Background
The 1980s had seen significant growth in drug treatment provision and concerns over the spread of HIV had led the Conservative government to adopt measures based on harm reduction. The Advisory Council on the Misuse of Drugs recommended an expansion of methadone prescribing in 1993, which led ministers to appoint a taskforce in 1996 to assess the effectiveness of treatment services, albeit "… in relation to the principal objective of assisting drug users to achieve and maintain a drug-free state." The government's 1995 strategy, Tackling Drugs Together, had also advocated increasing treatment for drug misusers.

The taskforce commissioned a study of treatment processes and outcomes called NTORS (National Treatment Outcome Research Study), which followed a population of 1,110 people in treatment over five years, publishing major reports at one-year and five-year intervals. The conclusions of the study were that all four of the treatment methods it investigated had brought about measurable improvements. In addition, the executive summary of the one-year follow up stated that: "for every extra £1 spent on drug misuse treatment, there is a return of more than £3 in terms of cost savings associated with victim costs of crime, and reduced demands upon the criminal justice system."

The subsequent Labour government under Tony Blair announced its intention to expand drug treatment in the 1998 Drugs Strategy, with the primary aim of reducing acquisitive crime The National Treatment Agency was formed in 2001 to allocate and manage the increased funding, increase access, reduce drug-related deaths and improve standards across the drug treatment sector. Paul Hayes, formerly chief probation officer for south-east London and a member of the Advisory Council on the Misuse of Drugs, was appointed chief executive.

Drug treatment in England
Drug treatment is provided by a mixture of NHS, voluntary sector and private provision. Resources for drugs services come from a pooled treatment budget, made up of funding from the Department of Health and Home Office, which is further supplemented by local authorities and the NHS – in 2008/09, total spending will be £398m. Services are commissioned at a local level by, or on behalf of, 149 drug action teams (or their equivalents). NTA regional teams provide guidance on spending this money to provide a full range of services, such as access to advice and information, needle exchange, psychosocial interventions, community prescribing, assessment, stabilisation and detoxification, and residential rehabilitation. Drug action teams formulate strategies to deliver treatment in their areas that provide criteria against which NTA regional teams evaluate them.

The most recent Home Office estimate of the number of problematic drug users in England is 327,466 In 2006/07, 195,464 people were recorded as being in contact with structured treatment services.

Harm reduction and substitute prescribing
When people enter treatment, the priority is to stabilise their often chaotic lives. Opiate misusers – the majority in treatment – are typically given oral methadone, initially taken under supervision at a pharmacy or treatment centre. Buprenorphine (Subutex®) is also used as a substitute medication. In 2007, 2.4 million prescriptions of methadone for substance dependence were written, an increase of 60% since 2003. Methadone-based treatments for opiate addiction are the most widely used therapy worldwide and the most thoroughly evaluated. Clinicians in the UK who treat drug misusers are expected to prescribe to published clinical guidelines, which also lay out the full range of treatment available.

Prescribing substitute medication to misusers of stimulants – such as amphetamines, cocaine and crack – is considered ineffective and treatment is based on psychosocial therapies.

Guidance from the NTA advocates tailoring treatment to individuals depending on circumstances and clinical judgement, rather than advocating a single definition of recovery for everyone in treatment, such as indefinite maintenance on substitute drugs, or abstinence: "A harm reduction approach recognises that a valid aim of drug interventions is to reduce the relative risks associated with drug misuse, by a range of measures such as reducing the sharing of injecting equipment, support for stopping injecting, provision of substitution on opioid drugs for heroin misusers and support for abstinence from illegal drugs."

Needle exchange schemes have been in use in the UK since 1987 and their growth has increase over time. In 2006, the Health Protection Agency report Shooting Up recommended increases in the volume of injecting equipment distributed to service users and the NTA now collects this information.

Links to criminal justice and prisons
A key tenet of the formation of the NTA was to get more offenders into treatment, as a means of reducing crime. In 1998, the government had shifted the emphasis from wholly voluntary treatment to more coercive treatment, with the introduction of Drug Treatment and Testing Orders (DTTOs) in the Crime and Disorder Act 1998. In 2003, the Home Office and the NTA developed the Criminal Justice Interventions Programme (CJIP), which introduced drug testing on arrest for certain trigger offences.

In 2004, CJIP became the Drug Interventions Programme (DIP). From December 2005, under the heading Tough Choices, aspects of the Drugs Act 2005 were introduced, which placed further demands upon people in custody. The Home Office has published data showing reductions in acquisitive crime in DIP areas.


 * See Drug Interventions Programme for more information.

In prison settings, the Integrated Drug Treatment System (IDTS) aims to increase the quantity and quality of drug treatment in prisons. Measures include substitute prescribing in prisons, integrated clinical and psychological treatment, and better links between prison and community treatment to ensure consistency of care.

Major initiatives

 * Better access to treatment. Against a backdrop in 1998/99 of 85,000 people in treatment and an average waiting time of nine weeks, the Updated Drug Strategy of 2002 set the target to double the number of people in treatment by 2008, a figure that the NTA had met by 2006. The Drug Strategy also called for "maximum waiting times from referral to receipt of treatment should be no more than two weeks for in-patient detoxification and GP prescribing and three weeks for all other forms of treatment" by 2004, a target that was largely achieved.


 * Reducing drug-related death. Reducing drug-related deaths was part of the UK government’s 1988 Drug Strategy, as drug-related deaths had risen throughout the 1990s, peaking in 2000. Since 2000, the overall trend has been downward, although deaths from heroin and morphine have remained constant.


 * Models of Care. Models of Care was published in 2002 and was the first national framework for the commissioning of adult substance misuse treatment in England. It laid out a four-tiered model for service delivery, with increasing levels of intervention. The guidance was updated in 2006, with a greater emphasis on harm reduction and care planning.

Based on long-term (mostly US) studies – in particular the Drug Abuse Reporting Program and the Drug Abuse Treatment Outcome Studies – the NTA made retention in treatment for at least 12 weeks a target, as this period has been associated with better treatment outcomes.
 * Treatment Effectiveness strategy. In July 2005, Tony Blair launched the Treatment Effectiveness strategy. Key goals of the strategy were to improve retention and treatment completion, maintain the improvements in waiting times, and help users reintegrate into the community by providing help with education, employment and housing.


 * Treatment Outcomes Profile (TOP). In 2007, the agency developed a tool for drugs workers to monitor the outcomes of treatment, which would yield measurable data on substance use, injecting behaviour, crime, and health and social functioning, rather than only using indirect measures such as waiting times and retention in treatment.


 * Workforce improvement. The agency has put in place competence-based training for workers, commissioners and practitioners with the Skills for Health organisation, and a joint workforce strategy with the Home Office.


 * Drug treatment statistics. The NTA monitors the performance of the drug treatment sector through the National Drug Treatment Monitoring System (NDTMS) and information on individuals in treatment is released on a monthly basis. NDTMS replaced the incumbent regional drug misuse databases when the NTA took over data collection from the Department of Health in 2003. Since April 2008, providers of specialist alcohol treatment have also been asked to submit data.


 * Young people's treatment. The NTA oversees drug and alcohol treatment for young people. It has published assessment criteria for young peoples services and has recently taken on more responsibilities in conjunction with the Department for Children, Schools and Families.


 * Implementing the 2008 Drug Strategy. The government's latest Drug Strategy emphasises the outcomes of drug treatment, particularly reintegration and recovery, and moving people through and out of drug treatment.

Criticisms
Some drug professionals have criticised the government's criminal justice motives behind the expansion of the drug treatment sector. Danny Kushlick, director of the Transform Drug Policy Foundation, said: "… most of our money is spent on enforcing the law and the policy appears to be tough on crime. The government is effectively implementing a crime reduction policy masquerading as treatment." The UK charity Release also strongly opposed the Testing on Arrest and Required Assessment measures in the Drugs Act 2005, which became components of DIP.

Several commentators, including Professor Neil McKeganey and Theodore Dalrymple, have been critical of the expansion of methadone and other substitute prescribing. The debate intensified with the publication of Breakthrough Britain, the report of the Conservative Party's Social Justice Policy Group, headed by Iain Duncan Smith. The report argued that “… maintenance methadone prescribing which perpetuates addiction and dependency has been promoted under current policy while rehabilitation treatment has been marginalised”, and advocated treatment approaches based on abstinence, a view shared by Professor McKeganey. Paul Hayes, chief executive of the NTA, has responded to these criticisms in a Guardian interview.