The ACMD Report on Drugs Commissioning: Back to the Future?

This week the Advisory Council on the Misuse of Drugs published its report on the Drug and Alcohol Commissioning system in England.   Government hasn’t responded yet, and to be honest much of the trade press and media gave it very little coverage.   A good and thoughtful blog piece on this report and some of the issues it raises by Will Haydock rewards reading.

This report is a mixed bag but we shouldn’t ignore it

I’ve heard a number of policymakers and thought leaders be frankly dismissive of this report.  And I think that’s a shame.

There are some real mixed aspects of this report. First what I think are the downsides:

  • It feels like an approach of suspicion towards local authorities. They more or less ignore the joint Public Health England, Local Government Association and Association of Directors of Public Health report on drugs commissioning. Were the findings of that report, that actually a number of things which needed to change were being changed, just inconvenient to their narrative, one wonders? Picking one set of what’s gone before (back to pre-2012) while ignoring the other (the ADPH/PHE/LGA Report) just makes it easier to dismiss your report, without looking to see if there’s anything salvagable of value in it.
  • The report doesn’t engage with the substance of the Government’s new strategy other than demanding that it does several things they want. It doesn’t welcome what’s good in the Strategy and doesn’t really critique what’s problematic.  How can we take seriously a report about commissioning which doesn’t engage with a strategy whose impact on that commissioning system will be wide-ranging? On any view, that’s a mistake. And it makes it even easier to dismiss this report.
  • The report doesn’t engage really with the financial climate for the public sector, preferring to take an uncritical and somewhat rose-tinted view that everything will be better if we just hand drugs back to the NHS. This is naïve in the extreme given where NHS finances are now.
  • A nostalgia for the pre-2013 days which is not only unrealistic but shows some convenient amnesia of some of the things before 2013 which were not good. Putting drugs services back into the NHS is not going to protect them, that is a completely false hope in my view.  The report feels like it wants to hark back to a presumed Golden age when the National Treatment Agency  (remember them) ran things, and the NHS had control of drug and alcohol commission. Oh it was so much better, then. Except it wasn’t

In addition, there are two things in particular I regret about this report.  The first is it’s a pity they don’t mention any of the cuts to Local Authority budgets really, except some mention of the Public Health Budget and I think they take an overly selective reading of their own 2015 survey.

The second is that this is yet another report, giving yet another – sometimes overly partial – narrative.  Some have said this is really a narrative on behalf of the provider sector.  Writing reports feels like a rather dated tactic these days.  Getting together and discussing constructively issues between commissioners, providers and researchers is the approach that’s needed. Writing disgruntled reports back and forth seems to slightly miss the point in a system that needs us, more than ever, to work together.

Finally, I think they don’t sufficiently factor in the significant changes in demographics, use and epidemiology since 2012.  The drug and alcohol world is a different one in terms of trends, users, evidence and policy.  Going back to 2012 is not the answer. Arguing for the best funding and best commissioning and provision we can get now, is.

The report more or less lacks the nuanced and balanced understanding we have a right to expect from an organisation which should know better, and which should have done its job better.

So, we have a report which, given what I’ve said above, would be easy to dismiss, lends itself in the way it has been put together to not being taken seriously, and looks to some people as naive and partial. I think we need to look beyond all that and really think through this report.

The signals in the noise: Some good points

In the midst of what feels like a great deal of noise and lament, there are some good things and some sensible points. They do point out some areas where the system needs to work better.

They acknowledge some good things about the changes since 2013 – but spend little time telling us what they are before proceeding almost straight away to say everything else has more or less gone downhill.  I can’t help thinking they’re making a selective and overly rose-tinted reading of recent history.

My own view of where we are is rather more nuanced than this report. Some things are better, some things are more challenging, and some challenges endure – we didn’t have research right in 2012, for example, We still don’t have it right now.  The idea that the drug treatment system was ideal or even “really great” before 2013 is an unsupportably revisionist view of history.

Worth looking at the key conclusions and recommendations

It’s worth looking at their key conclusions and recommendations because while there are some things in here I find really problematic, there are some areas where they have a point and we need to listen.  It’s just a shame that rather than talk to commissioners, they feel it’s more appropriate to shout at them.

ACMD Report Conclusions and Recommendations

My take on these

Conclusion 1

Despite the continuation of the ring-fenced Public Health Grant to local authorities until April 2019, reductions in local funding are the single biggest threat to drug misuse treatment recovery outcomes being achieved in local areas.

 

 

This is the only point where they really acknowledge reductions in funding, but their point is reductions by commissioners, not reductions by government.

More and more people are saying that the government needs to reverse the cuts to public health, and these cuts are increasingly damaging. It would be good is ACMD felt able to join that call. They didn’t. I think that’s a mistake.

Recommendations

National and local government should give serious consideration to how current levels of investment can be protected, including mandating drug and alcohol misuse services within local authority budgets and/or placing the commissioning of drug and alcohol treatment within NHS commissioning structures.

 

Mandation of services seems to be everyone’s knee-jerk solution to this, so we mandate more and more of a smaller and smaller pot of money. All that does is make the job of running a public health system undoable.

Mandation is not the answer to this, reversing the cuts is the answer. Government has decided to impose cuts across the public sector, the drugs sector is no more special than any other part and cannot be exempt. Are drugs services more important than safeguarding children?  The more you mandate, frankly the more you pass the problem elsewhere to the rest of the system. More and more mandation is an appealing, but ultimately false, solution.

National government’s commitment to develop a range of measures which will deliver greater transparency on local performance, outcomes and spend should include a review of key performance indicators for drug misuse treatment, particularly those in the Public Health Outcomes Framework (PHOF), to provide levers to maintain drug treatment penetration and the quality of treatment and achieve reductions in drug-related deaths.

 

 

 

 

This recommendation doesn’t feel well thought through, which suggests the authors don’t understand the reporting which exists.

Reporting is already transparent with lines explicitly on drug misuse within the reporting on the ring fenced grant. The Public Health grant already has 26 lines of reporting, including substance misuse, for around £50m in my Authority’s grant. By comparison social care reporting lines are less than 10 for £300m . Benchmarking service costs is already done by CIPFA and can be publicly gained from government data on the Public Health grant. This recommendation completely misses the point.

The local health and wellbeing board or local drugs board and local authority are the places to consider and address “falls in treatment penetration”. This recommendation seems to want to re-instate the performance management of the old National Treatment agency.

There is enough transparency in the PHOF and other indicators, combined with the new strategy and guidance. We don’t need yet another additional range of measurements.

Conclusion 2

The quality and effectiveness of drug misuse treatment is being compromised by under-resourcing.

 

This is too sweeping, even if they have a point. Resourcing is not the only issue, even though it is an issue. Models of care, changes in demographic patterns and population need get very simplistic analysis in this report in some places.

The PHE and LGA report identified that commissioners have said in a number of places services needed reconfiguration to meet changed need and changed models of service. This conclusion just ignores the joint PHE, LGA and ADPH work on drugs commissioning.

There is another opportunity for ACMD to argue that the public health cuts need to be reversed here.

Recommendations

National bodies should develop clear standards, setting out benchmarks for service costs and staffing to prevent a ‘drive to the bottom’ and potentially under-resourced and ineffective services.

 

 

What do they actually mean by this? I don’t know. I’m not sure they do either.

This isn’t benchmarking, this feels like an attempt to set a national tariff or a minimum payment or go back to the market management arrangements of the old National Treatment Agency. That could have some merit, or it might not. But this recommendation should have been clearer and more focused about what mechanisms and structures they feel will help.

The Government’s new Drug Strategy Implementation Board should ask PHE and the Care Quality Commission to lead or commission a national review of the drug misuse treatment workforce. This should establish the optimal balance of qualified staff (including nurses, doctors and psychologists) and unqualified staff and volunteers required for effective drug misuse treatment services. This review should also benchmark the situation in England against other comparable EU countries. This is a helpful recommendation. Most commissioners I know would welcome a workforce review of skills and workforce needed for the future including workforce redesign. Simply basing workforce on models of workforce pre-2013 is not the answer to the changed epidemiology, policy and financial climate
Conclusion 3

There is an increasing disconnection between drug misuse treatment and other health structures, resulting in fragmentation of drug treatment pathways (particularly for those with more complex needs).

 

This is nothing new, and was recognised long before the new system came into place. We need to do something about it though, and they do us a service by reminding us.

The new drugs strategy, The 2017 revision of the Orange book clinical guidelines and the recent PHE guidance on co-existing morbidities actually provides opportunity to advance this agenda, as does the mental health crisis care concordat.  Much of this disconnection is because the system as a whole is fragmented. Putting treatment services back in the NHS won’t solve that.

Recommendation

Local and national government should consider strengthening links between local health systems and drug misuse treatment. In particular, drug misuse treatment should be included in clinical commissioning group commissioning and planning initiatives, such as local Sustainability and Transformation Plans (STPs).

This is a mostly sensible and welcome recommendation. Inclusion in STPs and strengthening links good, and making links with CCG and other plans. But has ACMD forgotten we have Health and Wellbeing Boards? (Ok, they’re not always wonderful either, but please, don’t just ignore an entire sector.
Conclusion 4

Frequent re-procurement of drug misuse treatment is costly, disruptive and mitigates drug treatment recovery outcomes.

 

 

Procurement can be a two-edged sword, if not done well and purposively. It can be a great tool for developing quality, and it can be a disrupter. The key thing here is to do it well and sensitively.

This conclusion could have been more nuanced, and identify in much better detail some of the ideas and suggestions for making this happen. There are numerous reports of places where re-procurement has been necessary to secure service improvement.

Recommendation

Commissioners should ensure that recommissioning drug misuse treatment services is normally undertaken in cycles of five to ten years, with longer contracts (longer than three years) and careful consideration of the unintended consequences of recommissioning. PHE and the Local Government Association (LGA) should consider the mechanisms by which they can enable local authorities to avoid re-procurement before contracts end in systems that are meeting quality and performance indicators.

 

In and of itself this isn’t the answer. Long contracts with a complacent provider don’t help anyone. I think the report though is calling for some kind of stability and relationship, and that makes sense. A key issue for us as commissioners is how we work well with the rest of the system to do that. To my mind this is a call for better system leadership and commissioning, and seen in that light we should give it serious thought.

Procurement is part and parcel of the legal framework of commissioning and providing services, many other areas have used it to improve outcomes and there is evidence that this has happened since 2013 on a range of public health services.

Procurement conducted well can remove unintended consequences and be a tool for improving quality, cost and outcomes. Done badly it can have the effects the report laments.

Systematically seeking to avoid re-procurement is both unlawful and seeks to thwart the intentions of value for money and effectiveness that procurement can, used well, address.

Conclusion 5

The ACMD is concerned that the current commissioning practice is having a negative impact on clinical research into drug misuse treatment across NHS and third (voluntary) sector providers. Many treatment providers are third sector and current research structures are not designed to recognise them. System churn due to recommissioning and reduced resources mitigates the stability and infrastructure required for research.

 

This is not new. Drug treatment services in many places have long been outside the NHS, and issues of research capacity, research structures and even things like provision and management of Specialist Registrars and Speciaist Trainees have been issues. We do need to ensure these issues are addressed constructively.

 

 

 

Recommendation             

The Government’s new Drug Strategy Implementation Board should address research infrastructure and capacity within the drugs misuse field. Any group set up to work on this should include:

·       government departments;

·       research bodies such as the Medical Research Council (MRC) and the National Institute for Health Research (NIHR); and

·       other stakeholders.

A sensible recommendation which we should support , but it should also include commissioners.  The lack of mention of local authority commissioners, once again, feels sadly like distrust.

 

 

 

 

 

 

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