A fragile picture

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Commissioning is struggling under relentless rounds of cuts. DDN hears about the need to collaborate to keep clients moving forward.

TV Set‘There are many of us working in isolation with growing portfolios beyond drugs and alcohol.’ Niamh Cullen is giving her perspective of the challenges faced by commissioners. As a public health manager in Halifax, she is balancing the increased workload with ever-dwindling resources. ‘It’s not the time to be fixed to service specs,’ she says. ‘We need to work in an agile way to adapt to continuous change.’

Niamh Cullen - public health manager in Halifax
Niamh Cullen is a public health manager in Halifax

Cullen and her fellow commissioners in England are no strangers to the need to adapt. In 2013, the NTA was merged into Public Health England and drug and alcohol budgets were transferred to local authorities, controlled by directors of public health. Since then, the landscape has shifted beyond recognition as services fight for survival and vie for priority. Commissioning with a ‘client centric’ approach has meant thinking creatively about ways to stay ahead of the countless challenges.

Many of the trusted partnerships have been dismantled through this period of change, she points out. Furthermore, a great deal of back office resources have had to be sacrificed to prevent further cuts in services. Cullen has joined a growing network of commissioners from different parts of the country who are trying to energise the commissioning process and harness mutual support.

Chris Lee, a public health specialist in Lancashire, is one of the enthusiasts behind this initiative and a founding member of The English Substance Use Commissioners Group (ESUCG), formed earlier this year as a forum for commissioners (DDN, June, page 11). While the coronavirus pandemic has dominated most of the year, the idea behind the group will drive it beyond the immediate crisis. It’s a ‘safe space’, he says, ‘to learn together and develop best practice for the years ahead, taking into account all that the sector and local government has been through in the last seven years or so.’

The lack of formal mandated structures has left commissioning fragile in some parts of the country, and it’s a picture the group wants to change. ‘Partnership involvement and relationships can be hit and miss between different areas, which doesn’t seem fair on people who need support,’ says Will Haydock, senior health programme advisor at Public Health Dorset. The group is devising a workplan, but is waiting for the recommendations of Dame Carol Black’s review (DDN, July/Aug, page 5) to avoid any duplication or inconsistency.

They are, however, certain that their plan will focus on developing best practice and workforce skills in all different areas – including tier 4 (both detox and rehab), criminal justice commissioning, and complex needs. Reducing drug- and alcohol-related deaths will be at the top of the agenda.

Best Practice

One aspect of commissioning that comes through very strongly in the ‘best practice’ conversation is the need for it to be a natural part of the public health agenda. The ESUCG talk about how drugs and alcohol issues should be everybody’s business, permeating into all areas of social care, education and all aspects of life.

Networking right across the sector is key to this, says Niamh Cullen, and making sure that substance misuse services are linked into primary care networks and local developments and are on the ‘front foot’ of what’s happening locally.

‘Trust is key, alongside mutual respect and equality,’ she says, ‘and it’s important to include everyone, the sub-contracted smaller providers too. We need to share risks – sometimes big ones, particularly working in an environment of contract extensions.’

A strong relationship between commissioners and providers increases capacity for strategic work, says Cullen. The other essential partners are of course the service users, and the group is keen to talk about co-production rather than service user involvement to make sure it is never tokenistic. ‘The task is ensuring that co-production is common practice, and we should focus on how that is embedded rather than on service user involvement,’ she says. ‘We hope to move to a dynamic and co-produced service specification to further improve outcomes.’

Commissioning of substance misuse services in Wales is the responsibility of area planning boards, and these are made up of members of the ‘responsible authorities’ which form the community safety partnerships in Wales. The area planning boards also have responsibility for providing strategic leadership to deliver the Welsh Government’s substance misuse strategy across their regions, and so commissioning decisions are made taking into account both the long-term vision of prevention, and the current needs of a region’s population.

Partnership

Partnership decision-making is at the core of the commissioning process, and there are close relationships with Welsh Government, explains Eleri Probert, a commissioning programme manager. The benefits of this have been seen during the COVID-19 pandemic: the Welsh Government responded promptly to local clinicians seeking to expand a pilot of long-acting buprenorphine by investing in a rapid national roll-out, with positive results.

The Welsh Government’s public health perspective requires a much wider approach across the health, social care, housing and education sectors to meeting the needs of people using substance misuse services. ‘We aim to design services around people,’ she says, and this involves ‘trying to improve the pathway for people using services through joint commissioning for outcomes and exploring looking at how best to align provision throughout the system.

‘As commissioners we are always trying to balance the challenge of providing effective, high-quality, evidence-based, joined-up treatment and support, with the longer-term vision of prevention,’ she says. ‘We take a public health approach but there’s always more we can do… it would be really useful to discuss these challenges with commissioners from other areas of the UK to learn from each other.’

DAAT Retention

The London borough of Southwark has retained a drug and alcohol team (DAAT) structure, which gives the team a clear remit to commission treatment and support services related to this client group. The enormous challenge related to this is that their budget has been severely reduced.

‘When I joined Southwark, when the PCT still existed, there were 11 people between the DAAT and the PCT, doing the functions that two of us now do,’ says Iain Gray, a commissioner with 15 years’ experience. Partnership working was easier with a larger team, but with only two people, partnership working is an area that has suffered.

Iain Gray - commissioner in Southwark
Iain Gray is a commissioner in Southwark

‘With the cuts, you look at it on paper and try to make sense of it. We have cut X, Y and Z as they’ve asked us to, but they still come back for more,’ he says, knowing that it will keep getting worse. He worries particularly about the vulnerable clients who are bearing the brunt of local services being sliced away. ‘When I started there were seven or eight detox units in London – there is now one, for the whole of London,’ he says. ‘That doesn’t mean that we don’t use other detoxes outside of London, but for complex clients who have poor mobility, poor motivation, is sending them on a train up to The Wirral easier than getting them on a bus up to City Roads? No, it’s not. It’s so obvious.’

Despite the many challenges, connections with local treatment services are still strong and essential to putting service users first. ‘We collaborate and consult heavily in the design of services,’ says Gray, which influenced them to invest in a dynamic purchasing system for commissioning residential rehab and residential detox services– a flexible framework that’s working well to match clients to services around the country. ‘We took on board what our local services said and their experiences previously with dynamic purchasing systems to make sure we didn’t make the same mistakes,’ he says.

As with colleagues all over the country there’s a weary acceptance of a difficult climate but a strong will to push through to get the right result for those who will most feel the impact. As Gray says, ‘Everything in the garden isn’t rosy, but we are determined to get clients’ needs met.’

This article has been produced with support from an educational grant provided by Camurus, which has not influenced the content in any way.