Supervisors Hear Progress and Persistent Gaps in San Francisco��������������������������������������Treatment on Demand Report

Supervisors and city agencies gathered Oct. 27 for a hybrid hearing on San Francisco's annual Proposition T "Treatment on Demand" report, taking stock of treatment capacity, wait times and unmet demand for substance use services. The meeting, sponsored by Supervisor Rafael Mandelmann, juxtaposed Department of Public Health data showing measurable improvements with community and criminal‑justice testimony about continuing gaps and delays.

Supervisor Rafael Mandelmann, who called the hearing, framed the issue as both lifesaving and unresolved. "Treatment on demand is more than a quarter century old in San Francisco," he said, adding that the city must measure "how many people we're losing as a result of our inability to provide treatment on demand." He noted sharp increases in overdose deaths in recent years and urged clearer reporting so the board and mayor can pair the reports with budget decisions.

Dr. Hillary Conins, director of Behavioral Health Services at the Department of Public Health, presented DPH's view of the continuum of care and the department's timeliness metrics. DPH reported that, within the San Francisco Health Network, about 11,000 patients were identified with a substance use disorder in 2021 and roughly 40% received a substance use service in the network. Using existing entry‑point measures, DPH reported median wait times of under one day for withdrawal management and a median of about four days to admission for 90‑day residential programs in recent data, and noted a threefold increase in buprenorphine prescriptions over the last decade.

"We are doing better than national data," Dr. Conins said of the Health Network's reach, while acknowledging the department's limits in measuring people who never present to services. DPH also highlighted recent pilots that improved hospital‑to‑residential referrals and noted a new bed optimization study in development.

Community providers and oversight partners urged caution in reading the headline numbers. Laura Thomas of the San Francisco AIDS Foundation and the Treatment on Demand Coalition warned that documented access still misses people who do not show up to the door because of prior bad experiences, language barriers, or dual mental‑health and substance‑use needs. "There are a lot of people who fall through the cracks," she said, calling for expanded low‑threshold services, workforce pay equity for peer and outreach staff, and a community process for spending opioid‑settlement funds.

Representatives from the criminal‑justice system described additional operational barriers. The Adult Probation Department and the District Attorney's collaborative courts said jail and court populations face delays from DPH paperwork and Medi‑Cal residency rules that can add weeks or months before a required residential placement. Chief Crystal Tulak of Adult Probation highlighted a drop in average wait times in some funded programs after improved interagency processes, but urged more step‑down beds and culturally competent services for monolingual Spanish speakers and people with dual diagnoses.

Supervisors pressed DPH on whether the city is meeting the original spirit of Prop T, which requires DPH to "maintain an adequate level of free and low‑cost medical substance‑abuse services and residential treatment slots commensurate with demand." Dr. Conins and other presenters said the data system is improving but stressed federal confidentiality limits and cross‑agency silos make it hard to capture all unmet need. DPH officials asked for continued collaboration to expand measurement, retention metrics and post‑residential supports.

Public safety and treatment officials agreed on some next steps: expand bilingual and dual‑diagnosis capacity; scale successful pilots (for example, a hospital referral improvement that placed many patients into residential care within 24 hours); strengthen data systems to track retention as well as initial access; and identify where more beds and workforce investments are needed. The committee voted to file the hearing record for the Board of Supervisors.

What happens next: supervisors asked DPH and partner agencies to return with deeper analysis of gaps identified in the report, and requested a bed‑optimization plan and clearer, auditable metrics on unmet demand.

Sources: Remarks and slides presented by Dr. Hillary Conins (DPH), testimony from Adult Probation Chief Crystal Tulak and staff, Treatment on Demand Coalition presenters and public comment.