THE LIVERPOOL MODEL:
A POPULATION BASED APPROACH TO HARM REDUCTION
Howard Seymour* and Gail Eaton"
*Health Care Development, Liverpool, Merseyside, UK; **Eaton Associates, Reading, Berkshire, UK
This paper is based upon one presented to the 8th International Conference on Harm Reduction, held in Paris in March 1997.
The model of harm reduction developed on Merseyside in the mid- I 980s was based on a population approach to achieving the public health goal of reducing the harm to health associated with drug misuse. A particular concern at that time was the risk of HIV, but there was also concern about the health of a group considered to be under-served by general medical services. To achieve the goal, services were developed which would attract a majority of those at risk within the community, not simply the few who wished to s top using drugs, and which would enable contact with the target group to be maintained so as to bring about the necessary changes in behaviour required to reduce risk. This population-based approach to harm reduction has now been lost and very little attention is paid to what is required to meet public health objectives amongst the total population at risk. Instead, interventions are developed to provide for the needs of the few attracted to and able to gain access to services. In Merseyside the aim was to provide the greatest good for the greatest number, consideration being paid to all those at risk, and it is only this approach which will meet public health objectives.
Since the 1980s, harm reduction has been the model approach to drug misuse. There is now, annually, an International Conference on Harm Reduction, where the great and the good describe practice, or rather lack of it, in many parts of the world, comment on it and where the Rolleston Award is offered forservices to harm reduction This year was the 8th International Conference and it was held in Paris.
The first conference was held in Liverpool and it was in this city, and the area surrounding it (Merseyside and Cheshire), that harm reduction was first adopted in the UK to tackle the major public health probem of drug misuse.
In the early 1980s Liverpool had gained a reputation as 'smack city'. It was estimated that there were 20 000 opiate users in the region. Smoking was the common route of administration, but injecting was becoming more prevalent. The major concern at hat time was to prevent an HIV epidemic, but we were also concerned about other health risks associated with drug misuse and health care provision for drug misusers. We knew that through using impure street drugs users risked overdose and contaminated injecting sites, the latter exacerbated by poor injecting technique, and there were risks to health associated with poor lifestyle. Also, they under-used, and were under-served by, general medical services.
At that time, health care services for drug misusers, with a few notable exceptions, were based on 'curing' them; the goal was abstinence - a very difficult thing to achieve. Only a few hundred were in touch with these services, many being offered serial detoxification. For the majority who could not, or did not want to, stop using drugs there were no services. As a Regional Health Authority with responsibility for the health of those living in Mersey (Merseyside and Cheshire) it was agreed with the then Chairman of the Authority that we had a responsibility to look after the health of those young people misusing drugs and the health of the communities in which they lived.
We had a clear aim which was to reduce the impact of high-risk drug taking on the health of the individual and the community.
In Mersey, we set out to pursue this aim though prevention. We were not principally concerned with primary prevention - that was, and is, the role of a wider alliance of organisations in the community. Though, whilst there is little evidence to demonstrate its effectiveness, it was our policy that the NHS would do its utmost to support the primary prevention of drug use, we knew that it was within our power to reduce the damage caused to those already misusing drugs - secondary prevention.
What we needed to do was to bring about changes in the behaviour of drug misusers consistent with reducing harm. A number of independent objectives (not a hierarchy) were set for all drug and health care services:
· to reduce sharing of injecting equipment (and unsafe sex);
· to reduce injecting drug use;
· to reduce street drug use;
· to reduce drug use;
· to increase abstinence.
We were not convinced we were able to achieve the last objective on a population basis.
THE LIVERPOOL MODEL
To meet these objectives we adopted a population based model in developing our strategy for harm reduction, not the Rolleston model, and it is this population approach which distinguishes the Liverpool model from others.
Rolleston clearly offers a message consistent with harm reduction: the aim is one of enabling drug misusers to lead a full and healthy life. What distinguishes it from other models of drug misuse is its philosophy - that addicts are sick and in need of medical treatment and care. More importantly, it argues that as addiction is difficult to cure, the aim is most effectively achieved by maintaining the addict on substitute drugs. But Rolleston is nothing more than a medical model of drug misuse and brings with it all the trappings of such a model of health care based on one to one professional-client relationships. It can deal well with reducing harm on an individual level, offering the client/patient what is considered best for them.
In an ideal world, Rolleston could have served our needs. In a less than ideal world, with different practitioners having the clinical freedom to choose to provide what they considered best for their patients, most in Liverpool did not accept the so-called British System espoused by Rolleston, and drug misusers, who did not wish to become abstinent, did not seek their help. Furthermore, a medical model does not require a consideration of those who are not patients of individual practitioners, nor of its cost effectiveness as compared with a model which seeks to address the total at-risk group. If we were to achieve our aim and bring about change within the whole population of high risk drug misusers, whether they wanted to stop using drugs or not, we needed a different model one which would enable us to achieve the greatest good for the greatest number, not one which centred on individuals, interesting cases and worthy causes. We needed to look towards preventing harm for the 20 000 individuals whose drug misuse threatened not only their own health but that of the communities in which they lived.
ADOPTING A POPULATION MODEL OF HARM REDUCTION
Imperatives were set, based on a public health approach, to:
· make contact with the whole population at risk, not just the few who were already in touch with health care services;
· maintain contact, in the belief that, at the very least, if they are in contact drug misusers may be influenced to change their behaviour;
· make changes in their behaviour (to meet objectives).
We needed to develop services which were attractive to large numbers of drug misusers and were effective in bringing about changes in their behaviour. We therefore consulted drug misusers themselves and appointed a coordinator with street-level knowledge. It is in this respect that our services were consumer led: we did not simply give drug misusers what they wanted; we needed to consider cost and clinical effectiveness.
A range of user-friendly and non-judgemental interventions were considered appropriate:
· syringe exchange;
· substitute prescribing.
We believed that offering clean injecting equipment on an exchange basis - a simple low-threshold, no questions-asked transaction - would be attractive to large numbers of injecting drug misusers. It was simply common sense that such a service should be nonjudgemental and treat drug misusers with respect (i.e. be user-friendly). Also that it should, where possible, be separate from, and unconnected to, any other treatment service. We offered substitute drugs as a means of attracting drug misusers into services where we could meet their health care needs, and viewed methadone prescribing as a cost-effective means of helping them reduce use of impure street drugs with all the associated health risks. Outreach was developed as a strategy to get in touch with those drug misusers not attracted to other services and which would offer them, if nothing else, basic prima, ry care interventions: information, advice and clean injecting equipment. Drug misusers took up syringe exchange in large numbers. In the first 10 months, 733 came to the syringe exchange in Liverpool and 70 new drug misusers came each month (Carr and Dalton, 1986).
By 1988 we developed the Liverpool syringe exchange scheme into a new type of primary health care service for users, offering advice on safe injecting, treatment for abscesses, other injecting-related health problems and HIV testing (hepatitis vaccination was offered later). Between 1986 and 1993 syringe exchange schemes were established throughout the region: the two biggest schemes, in Liverpool and Wirral, were separate from other health care services, whereas smaller schemes were attached to community drug teams and drug dependency units, it not being cost effective to establish them separately. The proximity of schemes to drug treatment services was not ideal and, in time, we established pharmacy syringe exchange schemes thereby providing improved access to clean injecting equipment services.
Drug misusers were also attracted to the drug dependency unit which, soon after it was established, offered maintenance prescribing and not simply detoxification. In the first two years, 1019 opiate users came to Liverpool DDU (Fazey, 1988). Drug treatment services in Mersey were responsible for one-third of the methadone prescribed in England in the late 1980s.
Outreach always proved a problem - we were never able to get it right. Services, or rather those responsible for services, never got to grips with a population-based model of harm reduction: workers adopted the professional/client model, took on caseloads of drug misusers and advocated for them in all aspects of their lives. It was never understood that outreach is a strategy for making contact with the target group, those hard to reach, so as to be able to deliver primary care interventions.
Over the next five years, by offering appropriate interventions, we were in touch with an estimated 50% (10 000) of the high-risk drug- misusing population in Mersey. Today, in that area, we have syringe exchange schemes which, by 1996, had been in touch with over 12 000 injectors (personal communication, Drug Monitoring Unit, Sexual Health and Environmental Epidemiological Unit, University of Liverpool Department of Public Health, 1997) together with three of the biggest drug services in England - offering between them substitute prescribing for over 3200 opiate users -plus a number of smaller services bringing the total to about 5000 (information provided to the NHS Executive North West by drug treatment agencies, 1996).
We met some of our objectives:
sharing was reduced considerably - it is no longer a part of the culture of drug misuse;
drug misusers did accept oral substitute drugs not all, but most, and those who did not were offered injectables (about 10%);
there was a reduction in the use of street drugs for people who came to us;
we achieved little in the way of abstinence - we did not expect to.
HIV did not become endemic in the population. In Mersey, to date, 20 cases of HIV have been reported associated with injecting drug use. For those in services we saw a healthier population: fewer infections, fewer injecting sores. We have seen very few deaths - about 0.06% of the population. Sadly, hepatitis B and C are prevalent (personal communication, Drug Monitoring Unit, 199 7).
Loss of the Population-based Approach
That was the past. Our population-based approach has for the most part, been lost. Elsewhere in the UK it was never properly understood and implemented. There appears to be much confusion about harm reduction: rather than being seen as a means to achieve service goals, it is often offered as an add-on to what staff do with clients. Staff do not do harm reduction- rather it should result from what they do.
Where there is some notion of reducing harm through clinical/medical intervention - substitute prescribing - we have what might be defined as the Rolleston model, not really a model of harm reduction at all, but simply what medical practitioners do, i.e. care for and treat individual patients. It is not, therefore, outside and different from a professional doctor- patient relationship.
Adopting the Rolleston model of harm reduction frees practitioners and others (policy makers, purchasers and provider managers) from a consideration of the management of service requirements to meet public health objectives. In Mersey our aim was to make changes within the whole population of drug misusers, whether they wanted to stop using drugs or not, and we needed to make and maintain contact with large numbers of them if we were to achieve this. We needed to offer cost-effective and clinically effective interventions which required a planned, organised and business-like approach with:
· clear aims and objectives;
· a clearly identified target group - those at high risk of ill-health;
· services designed to ensure that they could provide for large numbers, not simply a select few, thereby achieving the greatest good for the greatest number;
· awareness of cost and benefit, given the need to serve large numbers;
· basic core interventions - substitute prescribing and syringe exchange;
· management information systems to monitor activity and achievement.
We did not want what can be seen in many services under the heading of harm reduction, pilot projects never fully implemented; a lack of concern for the impact of interventions on the total population at risk (with no measurement of the percentage of the target population reached); a constant drive to innovate for the sake of innovation - as if offering new interventions to reduce boredom rather than to improve efficiency and effectiveness; a search for the latest jewel to catch the eye of politicians.
When we spoke of rejecting the medical model we meant rejecting a model of care based on one-to one professional/client relationships, which though it could provide the very best for the few in touch with services, failed to provide for those not in touch or on waiting lists, and which felt justified discharging the awkward and difficult. We did not reject the need for interventions requiring the skills of health care professionals, though not all our proposed interventions required such skills.
What happened, however, was a rejection of medical terminology and skills: drug misusers in need of medical interventions, and therefore our patients, became clients and nurses became drugs workers. Services implemented a plethora of practices adopted from professions outside health including counselling. What was not lost was the one-to-one profess ional/client relationship and the focus upon individuals, rather than upon the whole population at risk. Instead of substitute prescribing, which is all many patients want, services insisted on developing relationships with users while setting numerous obstacles to the receipt of a prescription which, of course, involved a medical professional.
Services which shun the troublesome, the chaotic and those not wishing to abstain fail to address the public health issues. The majority of services neglect basic health care issues; apart from HIV, preventing ill-health and promoting improved health is forgotten. Expensively trained health care professionals working in drug services have assumed the mantles of social workers and counsellors: they advocate and befriend; they seek to rehabilitate, but fail to offer appropriate advice and care concerning health; they have become deskilled. Many services continue to have an insatiable need to work towards cure - abstinence - even when they know it to be very difficult to attain for all but the most committed.
Much can be done to maintain and improve the health of drug misusers (and their families) by offering the simplest interventions, ensuring that infections and minor illnesses are treated, offering hepatitis vaccination, giving advice on safer sex and safer injecting, and providing access to other services (for example, sexual health and maternity). Consequently, staff require primary health care skills. Yet large numbers of health professionals working in drug services have mental health skills, though only a very small percentage of drug misusers have serious mental health problems and are often referred to general psychiatric services, where they are not welcome and are often treated inappropriately. Conversely, social workers and probation officers seconded to drug services become drugs workers, no longer using their core skills.
We need to eliminate professional practices not relevant to the core interventions of drug services. Counselling may fit nicely with what has become a professionally defined relationship, but we need to ask why all drug misusers need counselling, let alone whether they want it. We are sure that certain interventions are well thought of - aromatherapy, shiatsu and acupuncture - but are they cost effective? Furthermore, we need to return to a proper definition of user-friendliness, not one based on befriending or advocating for so-called rights of users. Such userfriendliness is often juxtaposed with what many drug misusers regard as a very non-user-friendly insistence on having a professional one-to-one relationship no prescription without counselling and striking those who do not comply from caseloads - thereby leaving some once more at risk to both themselves and the community.
Diversification of the Target Group
The target group for services has diversified without any proper consideration of whether or not health can actually do anything for the majority of this expanded group. Cocaine users are asked to attend health care services which have little to offer - there is no 'cocanone'- causing frustration to all. Inviting recreational users to hard-pressed services will simply flood them; such drug use does not represent a high risk for the vast majority and most will control their use.
Diversification of the Goal
To the public health goal have been added new goals - to improve the quality of life and to reduce crime which can only serve to dilute and confuse. The goal of health care services is not to reduce crime. If drug services seriously seek to reduce crime, they need to set goal-specific objectives and offer interventions appropriate to meeting such objectives, e.g. drug prisons and treatment police. The fact that offering drug treatment has the added outcome of crime reduction is another matter: it is a spin-off of offering health care; it is not the purpose of health services, though is a very welcome additional benefit.
Improving the quality of life moves us in the direction of offering services to individuals rather than to the population as a whole, and sadly we cannot afford this. Rather than looking at interventions, in particular substitute prescribing, as promoting public health and the health of the individual, an inevitable consequence of adopting a clinical mode-I of service, based on a one to-one professional/client relationship rather than a public health model, is that prescribing has come to be seen as a right. Once seen as a right, regardless of whether there is any benefit to the health of the individual or the community, prescribing assumes obligations and we return to the issue of sanctions.
Without adding new goals, an effective healthcare service for drug misusers can show a benefit in other areas of concern. Those who are at highest risk of ill health are also at highest risk of other harms, for example crime and poor family relationships. If we develop appropriate interventions for this group founded on a population based model of health care, we will, as an add-on, contribute to a reduction in all the risks. But if we really want to use drug treatment as a strategy to reduce crime, we need to develop objectives specific to that goal (which may be similar but not identical to health objectives) and interventions which probably have a punitive dimension. To be effective, the strategy will need to he population based, offering interventions which will achieve the greatest good for the greatest number rather than for the few.
What we now have are professionals in the drug world constantly adapting to attempts by government to achieve a quick fix -'gesture medicine' offering interventions based more on the careers, jobs and enthusiasms of staff, and on working practices developed outside health; interventions offering easy solutions and low investment, rather than addressing the task at hand.
We need to return to a purer approach based on what works. In the UK, HIV is perceived as less of a threat (yet it is still there!), but drug misusers, particularly injecting opiate users, are still at high risk of ill, health and continue to be under-served by health care services. We need a primary care oriented service (not to be confused with GP care but rather holistic health care, focusing on the whole person), which can ensure that those at high risk receive clear and managed access to health care (accident and emergency, mental health, maternity and sexual health services) and can provide all necessary primary care including dealing with, as best we can, their drug misuse. These services need to be knowledge based, offering what we know works, and be properly managed.
The wider social, educational and economic needs of drug misusers should he met through an organised alliance of services, criminal justice, counselling, housing, employment and education. In England there is now a mechanism of inter-sector groups, Drug Action Teams which could, and should, manage this.
We need a properly managed approach to service provision, based on a clarity of goals, target groups and objectives. The core interventions for reducing harm on a population basis are syringe exchange and substitute prescribing. The benefits of proper provision are known: not huge numbers of ex drug users, we are not very good at that, but healthier drug misusers and healthier communities. We need to plan interventions carefully to meet objectives. Interventions should be based on well-focused research. Proper information systems should be developed which will enable us to manage our services effectively and efficiently and make improvements in what we do the Drug Misuse Database, currently used in the UK, simply will not do.
Gail Eaton, Research and Management Consultant, Eaton Associates, Hemington, Purley Village, Reading RG8 8AF, UK. Tel: 0118 9843026. Fax: 0118 9843026. Email:
CarrJ, DaltonS (1986). Syringe exchange: the Liverpool experience. Druglink, Institute for the Study of Drug Dependence (May/June).
Fazey CJS (1988). The Evaluation of Liverpool Drug Dependency Clinic: The First Two Years, 1985-1987. A Report to Mersey Regional Health Authority.