Uncharted Waters

It’s very hard to gauge the scale of unregulated
therapies being offered for addiction issues, but
a quick trawl of the internet will throw up endless
options. Those in the field may know almost at a
glance which are reliable, respectable and
effective but members of the public may well not.

They may also be in a desperate situation and willing
to try anything for themselves or their loved ones.
‘There needs to be some kind of mechanism for
a member of the general public to look at a website
and know whether something has safeguards and
guarantees,’ says Kevin Flemen of KFx. ‘The wider
public don’t know the differences between all the
different organisations and treatments. Compare a
new age clinic and a hypnotherapist both doing
smoking cessation, for example. It may be a very
good and responsible hypnotherapist, and regulated
by various industry bodies, but how does a member
of the public differentiate between those two
practitioners, neither of whom are doing nicotine
replacement therapy or NHS work? They’re both
private. If I’m not offering a regulated therapy then
there is simply no governance.’

At the moment, private clinics are regulated by
the Healthcare Commission under the Care
Standards Act 2000, but only when they are GP-led
and issuing prescriptions. A nurse-led clinic is not
subject to regulation. ‘Anybody who wants to set up
a service that’s not GP-led can do so,’ says chief
executive of FDAP, Simon Shepherd. ‘Private
healthcare services are regulated by the Healthcare
Commission, but what constitutes a healthcare
service is quite interesting – you would assume it
was anything that offers healthcare, including
clinics, but it’s not. You can run a nurse-led clinic for
drugs and alcohol in the private sector and there’s
no way of quality-assuring it. There’s no way of
knowing the scale of the problem, but it’s big
enough that something needs to be done. The
alternative to regulation is whistle blowing – as a
field, we draw attention to things we’re concerned
with – but the problem with that is it doesn’t get out
to the wider public.’

Residential services are regulated, as, clearly,
are NHS services, while day care and non-residential
services run by the voluntary sector are effectively
quality assured by the commissioning teams. ‘If
they don’t think the services are good enough they
can put them out to tender again, so mainstream
drug and alcohol treatment provision is broadly
overseen to make sure that the system on offer is
appropriate and offered at a reasonable level of
quality,’ says Shepherd. ‘Some of these systems
are by no means perfect but at least if you know
there’s something absolutely outrageous going on
there’s a way of pulling the plug on it. If a street
agency is offering a below par service, ultimately the
commissioners of the service will pick that up. The
bit that falls through the gap is any service that
doesn’t seek government funding.’

One lever is that trading standards departments
and the Advertising Standards Authority (AAA) can
investigate to make sure spurious claims are not
being made about the services on offer. ‘This only
provides limited protection for the public,’ says
Shepherd. ‘Trading standards are local authority
departments, so if you’re offering a national service
who’s responsible for that? And you have to convince
advertising standards that it’s worth investigating
because they get thousands of complaints. At the
end of the day, they’re not experts in this field and not
really in a position to make effective judgements.’
Counselling, meanwhile, is unregulated but
counsellors should be accredited, and the AAA does
not allow addiction counsellors to advertise their
services in directories such as the Yellow Pages and
yell.com, on the basis that there is no recognised
body quality-assuring their work. ‘There are really tight
restrictions on what counsellors can claim to offer,
particularly around drugs and alcohol,’ says
Shepherd. ‘Yet if you set up a nurse-led private clinic
and say you’re offering quasi-medical care then that
appears to be OK. We would want to see only
counsellors who have had proper training around
substance misuse being able to provide private
counselling services around these issues, but there
are counsellors who are not accredited by a
recognised body providing services.’

But isn’t there an argument that there may be
lots of new, innovative and exciting treatments out
there and they should be given an opportunity? ‘We
cannot allow people providing services that fly in the
face of available evidence to continue to operate
unchallenged,’ he says. ‘We can allow free innovation
and services that don’t have an evidence base
to underpin them, provided there’s a strong
theoretical base or rationale and that they are then
subject to thorough examination. They should only
be offered for a trial period while they’re being
investigated, and offered as unproven services, not
treatments. You can allow for innovation through that
process – you can trial stuff but the public needs to
be aware it’s a trial.’

The danger, of course, is not just that people are
fleeced by perhaps unscrupulous and unqualified
practitioners; it is also the very real health risks
associated with such a vulnerable clientele. If people
withdraw from opiates or alcohol without the
prescription of any substitutes in order to rely on an
‘alternative’ therapy, then they could be at great risk.
‘The cost of getting it wrong for this client group is
immense,’ says Simon Shepherd, ‘for the client, their
family and for wider society. And there are very real
dangers with this client group of getting it
catastrophically wrong – if you try and encourage
someone with a long history of alcohol dependency
to stop drinking overnight, they will die, simple as
that. Nobody should be working with alcoholics
unless they’re fully aware of the medical realities, so
it’s critical that we have some form of control.’
‘The biggest thing in all of this is that if there’s an
evidence base then you can prove it, and if you can
prove it then that’s fine,’ says Sharon Carson, chief
executive of EATA. ‘But if there’s no evidence base
then it’s a big problem. The question is around what
we are doing in the sector to regulate what is
happening and make sure that people accessing the
treatment are getting treatment of the best quality.

We have an accreditation programme which we
encourage our members to apply for because we can
guarantee a level of quality in service delivery that
way, but we’re not a regulatory body. At the moment
there are a few things in place but there’s no
regulated collective checklist and nothing that all
types of treatment organisations have to
demonstrate that they’ve complied with. It definitely
needs to be raised on the agenda.
‘What we do as an organisation is to try work
with central bodies to say we need to improve the
quality of treatment,’ she continues. ‘There are
things that can be done as a sector to ensure we
have the appropriate treatment and we need to start
working on those – it’s been on the agenda but it’s
not been particularly high on the agenda and that’s
got to change. In any treatment sector, you have
huge amounts of regulation and standards, and
drugs and alcohol is falling behind.’
‘Encouraging membership of voluntary schemes
is not a solution,’ says Kevin Flemen. ‘As long as
other practitioners can practise regardless of these
schemes, then the voluntary system is meaningless.
Rather than just having a competency framework,
there should be some benchmarking for the general
public which allows them to establish if the service
meets basic minimum standards. This would allow
any member of the public to visit a website and see,
via some simple authentication system, that it is a
legitimate service with, say, a bronze, silver or gold
status or something like that. We need a threshold to
say that basic minimum standards are being met by
this organisation, which doesn’t necessarily vouch for
the effectiveness of the therapy but works on the
basis that it’s a therapy that is at least recognised by
the drugs field rather than being some Mickey Mouse
quackery, and that criminal record checks and things
like that have been carried out.

‘If I want to be FDAP approved there’s a regulatory
framework in place, but if I don’t want to be approved
then there’s no strategy for stopping me practising
and I find that astonishing,’ he continues. ‘It’s a
bigger issue than just drugs, it’s the huge
unregulated alternative practices market, everything
from allergies to cancer treatment. But I think
ultimately the Department of Health should regulate
the field – I don’t think it should be up to the field
itself to regulate, and I don’t think it’s about DANOS
competencies. I do think there needs to be a clear
licensing system, but it’s a huge thing to take on, and
the Department of Health doesn’t see it as their role
– I find it amazing that no one sees it as their role.
We can spend five years lobbying for strategic
change, but during that time thousands of people are
going to be ripped off by rogue traders.’

source: Drink and Drug News U.K