Commissioning for change

An independent expert faculty has been set up to consider a vital new approach to commissioning. Mark Gilman, Paul Musgrave, Niamh Cullen, Terry Pearson and Chris Lee explain the context and the plan of action.

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Important progress in developing services for managing problematic opioid use has transformed the outcomes for people with serious drug problems. This has been achieved through a balance of innovation and careful allocation of resources.

Coming together as a group of commissioners with extensive experience, we needed to look at the pathway leading to these successes, to enable us to review the challenges facing us today. Our aim was to define questions that are central to the ongoing development of care.

This pathway to developing opioid dependence treatment may be divided into a series of stages, with defining characteristics:

Initial problems related to heroin
The 1950s saw increasing non-therapeutic opiate use, a trend which continued to grow throughout the 1960s. Early strategies to address dependence focused on prescribing opioid agonist medicines, with methadone a common and effective choice for many. Residential rehabilitation centres were set up following relatively unsuccessful results with outpatient treatment.

Exponential growth of the problem
Treatment approaches emerged in the 1970s. Prescribed methadone doses were often challenged and inpatient treatment duration limited in response to increased demand and financial pressures. Subsequent explosive growth of problem drug use in the 1980s and 1990s led to a resurgence in ‘maintenance prescribing’ and introduction of on-site dispensing facilities with supervised consumption. Treatment availability and coverage were lower than they are today, locally governed, commonly led by NHS specialists and funded to provide services in a relatively limited capacity.

Expansion in treatment
The National Treatment Agency was established in the 2000s with the aim of addressing the increasing problem of heroin use by improving treatment availability and reducing waiting times. More resources and organisational change gave rise to a competitive provider market, while new models of care were designed with an emphasis on performance management. Innovative thinking led to a step change in successful outcomes for people with problematic opioid use.

Evolution: a shift in focus
Recently the incidence of new heroin use has reduced. The existing cohort of approximately 150,000 people remains engaged with treatment services, with potentially greater needs related to comorbidity. The treatment system and method has evolved: policy has promoted focus on recovery-oriented and abstinence-based approaches, and concurrent mental health disorders have received greater attention. In parallel a step-down in resources has occurred in many locations, placing stronger focus on the need to achieve efficiency and cost-effectiveness in providing services.

Challenges today
While funding for treating opioid-related disorders is decreasing in many areas, there has not been an equivalent change in working practices to compensate. At the same time, drug-related deaths have been increasing in all four nations, linked to the ageing population and also unexplained factors. In many cases, services are essentially delivering less of the same, which is keeping the system ‘ticking over’. Looking to the future, it is relevant to consider if services are achieving the impact the population needs and deserves. And in parallel, how can we focus on innovation to maintain continuing improvement in outcomes?

There are a number of areas of innovation: use of digital technologies to provide psychological interventions, different forms of opioid agonist medications, and options to better address comorbidities such as hepatitis C virus (HCV) infection. It is important for commissioners to consider how innovation can play a role in continuing to improve care, while balancing budgets. There is already evidence of a new group of injectable opioid agonist therapies from various pharmaceutical companies which, if approved for prescription in UK, may allow treatment to be delivered with injections weekly or monthly.

Current spending with community pharmacies on medications, supervised consumption and dispensing is substantial. There may be opportunity to restructure services to allow direct supply of medications or on-site storage at clinics, allowing resources to be redirected. Understanding the balance between innovation and organisational change is key in this instance.

Evolving treatment options pose questions about the different ways in which therapy is tailored to the needs of the individual. In some cases, medications for opioid dependency are used chaotically as part of a wider cocktail of drugs; for others it is part of a long-term fluctuating but largely stable lifestyle, while for some it is a tool to help achieve recovery or abstinence. Do the services we commission build treatment systems with the ability to tailor interventions to the individual?

Questions may focus on whether all parts of treatment are employed to best effect – particularly psycho-social interventions. Do the treatment services we commission make the best use of the right kind of quality psychological and social therapies?

Considering future optimisation, commissioners should consider the readiness of the workforce providing care. Is the workforce appropriately skilled, and could a smaller number of competent staff be more efficient and effective? Is comprehensive training, supervision and support provided?

Collaboration is also key to future success. Do care pathways remain largely isolated from parts of the public sector that serve the same target audiences? Greater integration with mental health and housing services could help to reduce duplication.

Equally important is the approach to measuring performance. Do the outputs we measure as a part of the commissioning process tell us enough to improve health and wellbeing, while reducing offending and safeguarding fears?

Addressing questions such as these is key if continuous improvements in treatment and social outcomes are to be delivered while managing the balance of resources – an essential equation for commissioners in achieving continuing improvements in outcomes for all.

Key questions for commissioning

1. Planning based on individual needs
How can commissioning approaches assist providers in planning high quality support, by skilled staff, for groups with different aims, goals and characteristics? How can we improve outcomes while focusing resources effectively? We need to consider introducing case management functions and systematic commissioning for mutual aid.

2. New thinking and innovation
Consider how commissioning can build in new thinking to services which may reduce the need for resources directed to managing misuse and diversion risk, and ensure efficiency in medicines delivery – for example, by using innovative product formulations of opioid agonist therapy, which may not require resource intensive use of dispensing services or supervised consumption.

3. Integration and collaboration
Can commissioning ensure that specialist services better align with partner services (mental health, housing, social services, probation, police, justice, etc), to avoid duplication, create efficiency and improve continuity of care? Can we align competencies systematically so that the right skills are used most efficiently?

4. Using the right measures
How can commissioners ensure a complete holistic assessment of impact, including real world measures of health, wellbeing, crime, safeguarding and resource utilisation? Commissioners need to make decisions based on insights from a broad set of outcome measures.


This article represents the authors’ personal views.


  1. I have been out of commissioning now for over 3 years. I was involved from the mid 1980s across drugs and alcohol, through the biggest wave of Class A and immunological challenges.

    For all the flaws of the NTA a great deal was achieved. That achievement to my mind was to a great extent driven by a sometimes unholy NHS, Local Authority and Criminal Justice alliance, but with a limited presence of user and recovery perspectives.

    Mental Health and Housing were never really properly integrated. So some but not enough foundations.

    What happened afterwards led to the building of even more impressive new structures amid the shifts of resource to CCG and Local Authority and Public Health.

    That should have meant the critical underpinning of the foundations with Housing and Mental Health. That should have seen the structure develop new understandings between treatment and recovery. It’s not just about the money what we have is a house built on poor foundations.

    The loss of the criminal justice / recovery analysis into large scale forced marriages caused by commissioning from these competing funding groups has been a distaster and threatens the legacy of what was achieved.

    What has been lost to me is a very simple lesson I remember that lovely man Don Lavoie teaching his local authority and health and criminal justice partners way back in the 1980s.

    Joint Commissioning meant we all share a pot, and that pot gets used for the greater good. I am not impressed by the shared vision for physician, mental and public health, criminal justice, housing, ETE and recovery.

    This expert forum is based on collective knowledge and vision I really respect. I seriously worry whether there is just something rotten in the state of Denmark as to the new foundations of commissioning power blocs. Mental Health, Criminal Justice and Housing need to have equal status.

    This group offers a fresh perspective whilst being realistic. The simple vision of Don Lavoie still holds a powerful message in straightened times of who is at the table and what’s in the pot and why.

    The woeful lack of vision to embrace the recovery movement and recovery housing – the brightet hope alongside new treatments in 50 years – risks being squandered.

    I wish you every success – it needed to be said.

  2. Commissioning for substance misuse needs a specialist approach, particularly to engage with the ACO/ICS agenda which varies in different regions and local areas. Not one size will fit all to meet the needs of service users, their families and improve their recovery journey

  3. Good article. What is apparent in the current commissioning environment is the generalising of commissioning across local authorities, leading to poor analysis of need, poor engagement and, consequently, poor decision making. Money is being wasted on ideas rather than need, because no one connects the pieces anymore. Partnership work, so fundamental to complex health and wellbeing cases, is best driven by a common understanding of shared responsibility and shared outcomes. That’s always been difficult, made increasingly so now by fractured thinking at the very top, which has fragmented commissioning across three different structures, NHS, CCG and local authority/Public Health that see themselves in competition, even if they’re unwilling to admit that publicly.

    The one thing I would take issue with in the above is what seems to be a focus on the effect – the use of a substance which needs to be resolved. What needs to be resolved is the causation – the background, be it peer pressure, abuse, mental health, which leads many to self-medicate, to misuse substances. How do we as people face this? By seeing each person we label pejoratively, an addict, or worse, as a human being like us, someone who is a mother, sister, aunt, brother …
    How do we, as commissioners, resolve this? We can’t.

    Only those who experience the effect can do that. Commissioners need to be able to provide the tools to assist that process.

    If any commissioner/Authority is brave/far-sighted enough to try, distributed networks, together with time-banking offer some solutions for individuals to break away. As humans we all like to live in networks of like-minded people – it’s easy and we’re lazy. Those who are locked in a cycle of substance misuse, need to be offered the opportunity to break from their homogeneous networks to ones that are more varied. Time banking, as envisaged by American civil rights lawyer, Edgar Cahn, offers part of the solution: providing a reason to integrate, an inspiration to change. But this has to be a bold move, energising thousands, not the few, establishing communities that thrive and don’t pay lip service to people’s aspirations, because of local attitudes. Treatment is an adjunctive, a means by which we help people focus on their aspirations and their innate skills to move to where they need to be.

    As providers/commissioners we should be privileged to work with people who have survived so much and who currently are so let down by our system.

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