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here can’t be too many commissioners of community drug and alcohol
services who are lying in their baths thinking, ‘If I had a clean sheet of
paper and could completely redesign my treatment system, it would look
exactly like the one I’ve got.’ Equally there can’t be many service users
who are similarly thinking, ‘If we could completely redesign an addiction
treatment service that works for us, it would look exactly like the one we have.’
Commissioners work very hard to deliver treatment systems that are safe, deliver
what the evidence and guidance says works, meet targets, and come in at a price
that the local health economy can afford. The good commissioners will also be
listening to what their service users want as well, which isn’t always the same thing.
Most legacy treatment systems are the product of an evolutionary process, with
some local services just springing up, some mandated by statute, and others added
over time as situations dictate and resources allow – an abstinence service here, an
alcohol service there, a street agency, DIP, NHS mental health service, some GP-run
services, etc, etc – and each one (usually) with its own information system,
buildings, management structures and gate-keeping criteria. None of them talk
much to each other, not many understand who is responsible for what, and service
users bounce around this patchwork system getting a bit of this, a bit of that. Some
find that they just don’t seem to fit any of the criteria for any service, and give up.
Rationalising all of this makes abundantly good and obvious sense. Get one
provider to be responsible for everything – one management structure and one set
of buildings to pay for, one cohesive team of personnel that can absorb
fluctuations in staffing without falling over, everyone talking to each other in one
information system. And just one place for service users to turn up to, where they
can get help at whatever stage they are at in their addiction ‘journey’ – from drop-
in needle exchange and advice, through specialist prescribing and psychosocial
interventions, to detox, relapse-preventing aftercare, family and carer support, and
links to employment, housing and so forth. Everyone works to shared protocols and
practices, at one place, with pathways to everything that is needed. There is one
treatment system that can encompass more than one treatment philosophy, with
just one phone number to call.
Such systems are true ‘integrated’ treatment systems. There are many that
claim to be integrated, but are in fact one building that houses several different
services, or integrated in that you get most things but still have to go somewhere
else for, say, your DIP worker. Others look as if they are integrated because there is
just one name for the service, but then you find that it is a confederation of
providers with disparate approaches.
All of these may work to a greater or lesser extent – there are some excellent
examples of multiple providers working well together and some which struggle,
but if you build fault lines into a system, the chances are that tensions can turn
these fault lines into fractures. And inevitably, to try to pre-empt fracturing and to
make it all work, there are a million more weekly meetings to get all parties
around the one table to thrash it all out.
With so much to gain, full integration seems to be a ‘no-brainer’, and indeed
many treatment systems have been recommissioned in this way in recent years –
but what are the risks? What is there to lose?
Well the obvious risk is that ‘all of your eggs are in one basket’. Can the provider
really deliver all that they promised in their glossy tender document? Do they
understand clinical risk, and are their governance structures sound? Do they have
financial stability and have they done this before? Do they have the relevant local
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Commissioning
expertise to provide what’s needed?
The past decade has seen a shortlist of rapidly growing not-for-profit providers
emerge as ‘the usual suspects’ in these big recommissioning exercises – they have
amply demonstrated their safety, strength and skills in whole systems change, as well
as delivering greatly improved cost effectiveness in the presence of squeezed budgets.
So the outcomes of contracting whole system change have in the main
vindicated the theory behind integration – but they come at a high price. Aside
from financial cost, these revolutionary events are enormously destabilising and
demoralising for existing providers. To not win a tender to retain your service feels
like everything you have done before has not been good enough – all the
relationships with service users and surrounding agencies that have taken so long
to build up will be torn apart.
Rumours and myths abound about the incomers, senior staff leave, taking
their skills and experience with them, and while all the professionals are worried
about their jobs, the users of the service are frequently forgotten – and they have
real concerns too. However, in the main, incoming providers recognise these
concerns and work hard to mitigate their effects by retaining current service staff
and recruiting locally, thereby maintaining existing relationships and local
knowledge.
So where massive change is needed revolution can be painful, but change
happens quickly. But what then? After revolution comes a need for stable evolution
– it’s a delusion to think that you can keep on getting better and better value,
round after commissioning round, by cyclical ‘winner takes all’ retendering which
risks providers being forced every three years to offer more for less. Addiction
treatment already provides outstanding value for money – uniquely as a medical
treatment, it returns its costs many times over. Isn’t it time to add to
recommissioning strategies some subtle fine-tuning to support quality and
stability, rather than just the ‘big bang’ option?
Of course services that are demonstrably failing need transformation, but what
the great majority of decent functional services – and those who use them – need
is stability. When the system is right and services are adequately resourced then
staff with the right skills will stay in post, and will be able to deliver evidence-
based effective interventions, which take time to train and perfect.
This last point about training has been one of the unforeseen casualties of
short-term commissioning, and has the potential to profoundly erode the skills
base in addiction medicine in the future: the NHS has been the bedrock of
treatment provision and training for the past 60 years. The rapid move away from
NHS-provided addiction services has dislocated the traditional provider of training
from the workplace where experience can be provided.
In the new treatment landscape, the independent sector has the workplace
experience, the skills and the willing to take on the training role – but the training of
clinicians and indeed of generic workers who are specialising in addiction work takes
the sort of time that short-cycle commissioning makes almost impossible.
As someone who works for one of the above mentioned ‘usual suspects’, this
might appear to be a self-serving argument – but the essential point is unarguable:
good integrated services need to be well designed, but they also need to be nurtured,
as do the clients that they serve and the workforce they employ. Commissioning
needs to be radical when big change is needed, but subtle when it is not.
Gordon Morse is the medical director of health and social care organisation
Turning Point, www.turning-point.co.uk
‘Addiction treatment already
provides outstanding value
for money – uniquely as a
medical treatment, it returns
its costs many times over.’