Has commissioning lost its way – or are there opportunities to be grasped? DDN reports.
The commissioning structure needs an overhaul, according to the ACMD Recovery Committee, which recently advised government of the drastic effects of funding cuts (DDN, October, page 4). Since commissioning was moved to public health structures in local authorities in 2013, there have been dramatic reductions in local funding that ‘are the single biggest threat to drug misuse treatment recovery outcomes’, says their report, Commissioning impact on drug treatment.
The stark truth for the treatment sector, ACMD Recovery Committee, service user representatives and many commissioners themselves is that the level of disinvestment is causing drug-related deaths. ‘The loss of funding is resulting in drug-related deaths, blood-borne viruses, crime and human misery,’ the committee’s chair, Annette Dale-Perera told the Drugs, Alcohol and Justice Cross-Party Parliamentary Group.
Gathering evidence for the report brought strong evidence of an overall reduction in funding of around 12 per cent, she added. ‘There was a definite decrease when money went over to local authorities. But many commissioners and providers told of cuts that were more severe than shown.’ DDN is hearing of cuts of up to 30 per cent in some areas.
The situation is no surprise. Blenheim chief executive John Jolly said at the latest meeting of the parliamentary group, ‘I take no joy in arriving where I said we’d be five years ago, when everyone said I was shroud waving.’ The difference now is that it’s being felt all over the country and the effects are critical – on service users’ lives and on the skillset of a sector whose workforce are voting with their feet at having their wages cut and their roles merged and changed beyond recognition.
Current commissioning practice is taking much of the blame for the disastrous slide into chaos being felt by the sector. Such is the cut-throat climate of retendering that treatment agencies are paring their tenders to the bone – or walking away from areas where they just can’t make the funding work. Bristol City Council received no bids from service providers when attempting to retender drug and alcohol support services recently, with feedback that the money offered was just too low.
Those that have ‘gone for it’ at any price find themselves tethered to uneconomic contracts with the risk of harsh ‘payment by results’ penalties and financial liabilities that come with TUPE arrangements for transferring staff. The sector is still shuddering from the recent demise of Lifeline and speculating on a toxic mix of contributing factors. Many are angry that their winning bid helped to drive tender prices down to a dangerous new low and blame the commissioning team for exacerbating a ‘race to the bottom’ culture.
Jolly is among the providers who recognise that local authorities are ‘between a rock and a hard place’, with dwindling budgets and some difficult choices to make: ‘do you spend on substance misuse, or do you spend on social care for the elderly? They’re in a difficult space.’ Blenheim is on the commissioning rollercoaster with everyone else, having to remodel services to try and fit new specifications. The experience of working for decades in a neighbourhood suddenly counts for very little against shaving a third off the contract price. There’s no getting away from the fact you have to do much more with fewer resources.
The loss of expertise is one of the many things that bothers him. Gone are the days of specialist services for different substances. Everything – including alcohol, cocaine and stimulants, which would have had specific services a short time ago – is combined into the same service, which ‘can be a problem if people don’t see that it’s for people like them’. Young people’s drug services are no longer standalone, but combined with sexual health services.
‘People are returning to opiate use because
they’ve got absolutely nothing to lose.’
This contraction of services has meant a cut in the skilled workforce, which does not match well with a depressed economic climate and emergence of new drug trends – young people are returning to opiate use after a generation away, and the growing threat of more fentanyl deaths looms. Drug and alcohol use accompanies deprivation all too readily, and street homelessness is commonplace. ‘In every major city now, you’re seeing street homelessness in a way that we’ve not seen for a decade, maybe 20 years,’ says Jolly.
Furthermore, the cuts mean people who use services are often couch surfing, in hostels, or living rough, he explains, and ‘many of them are returning to opiate use because they’ve got absolutely nothing to lose’.
Bill (not his real name) is a drugs worker who is being transferred from one service provider to another, as part of retendering. He blames the last round of tendering for bringing an assortment of providers together to create a system that did not work. ‘By the end of the process, what you’ve got is a complete history of poor key-working, inappropriate allocation, poor assessment and a situation where the top staff, who had come over from the NHS or previous places, had been replaced by kids without any real experience or qualification,’ he says.
He describes how it felt to be caught in the middle of the process. ‘Since the tendering process began, there was an exaggerated bonhomie about the success of partnership working, which was unrealistic,’ he said. ‘There was some fairly desperate grabbing of intellectual property, which was grubby, and there was a real sense of isolation for the individuals involved in the process. And for people in active recovery, people in the community, there was a sudden loss of the security they’d built up in those five years.’
‘We had a 40 per cent relapse rate
among service users and a huge
drop in engagement.’
Most disturbingly, ‘in the six months after we announced the contract was lost, we had about a 40 per cent relapse rate among service users and a huge drop in engagement,’ he says. ‘So it’s been devastating on the community and devastating on individuals.’
He believes that the cost-cutting led to cutting corners with staff training and development and a dismissive attitude towards peer support. Assessments of new clients were conducted through a deficit-based approach – ‘when did you last commit acquisitive crime?’, ‘when were you last a sex worker?’, rather than an asset-based assessment with scope for ‘holistic solutions from the get-go’. His service has lost its way, he believes, and the ability to see that ‘prescribing isn’t anything but a tool. It isn’t a raison d’être’.
Bill is also worried that this blinkered culture is making the workforce slow to react to trends and the ‘constant shift in the way people are doing drugs’. The commissioning process has brought the focus away from specialist services based on the needs of the area; so it doesn’t, for instance, allow for the fact that solvent abuse has soared during the past five years, or that staff have come across ‘strange behaviours and violent reactions’ among cocaine users that has left staff wondering if investigation is needed into what they are actually taking.
Such matters became absorbed in the business of jobs being reassessed, and staff being asked to take on more responsibilities for the same money. Bill thinks staff no longer have the time or the vision to understand that in so many cases, substances are the least of their clients’ problems.
‘It doesn’t matter what commissioning process is happening if somebody has got no house, no benefits, no transport, no food, no friends,’ he says. ‘We’re working in the age of isolation, and every single person I work with now has got multiple complex needs.’ He worries that ‘things have to get really bad before they start to get any better’, adding ‘many of the good workers have already walked away… If we have many more cuts, I don’t know where we’ll go really.’
‘I’ve been a provider myself – I can believe that there are bad things that happen out there,’ says Sarah Hart, senior commissioner at Haringey. But despite the very obvious challenges, she does see many opportunities with the move into public health at the council.
‘It lets me meet more partners around the table,’ she says, describing her work on improving life expectancy, bringing health checks and interventions for long-term conditions to hard-to-reach groups and ‘further integrating substance misuse into broader public health’.
As far as the money is concerned, ‘the important thing is to have commissioners who ensure that substance misuse services don’t get disproportionately affected’ – which she acknowledges is difficult when those who use council services are likely to be economically disadvantaged.
One of her main challenges is to keep community safety colleagues on board, she says, ‘because as we know, it was the crime that got the money’. The 33 per cent cut in MOPAC grants (money provided by the Mayor’s Office for Policing and Crime) has led to some particularly tough decisions, pitting the value of the Drug Intervention Programme (DIP) against services to tackle gang culture, and violence against women and girls.
Another difficulty has been having less time than before to work with providers, ‘particularly if a provider is struggling’. Gone are the days of specialist commissioners holding provider meetings to look at best practice – and gone are the days also when larger commissioning teams could work strategically with partners in probation and housing. There are no longer even the youth leads to work with schools.
It’s become more important for providers to showcase what they’re doing, feeding evidence of their work to commissioners, ‘so they become passionate about substance misuse’, she says. Having come into commissioning via the substance misuse worker route she needs no convincing, but is aware that in many areas providers will need to ‘win hearts and minds’ of their commissioners.
‘Tendering justifies organisations constantly
reviewing what they’re doing… We need
to be saying, is our service right?
Is it fit for purpose?’
The campaign for longer commissioning cycles makes her wary of leaving systems in place that no longer work for clients. ‘Change is difficult in organisations and tendering justifies organisations constantly reviewing what they’re doing and what they’re delivering,’ she says. ‘We get complacent and our clients change. We constantly need to be saying, “is our service right? Is it fit for purpose?” And I’m not sure that without a tender process people would do that.’
The suggestion of a ten-year contract certainly does not appeal. ‘Would a specification that I’d written ten years ago still be relevant? It would say nothing about club drugs, legal highs, over the counter medication. It wouldn’t have anything about recovery in it.’ But she supports the idea of longer tenders with a break clause. ‘I’ve just done a five-year tender – three years plus two. And why it matters is that at the “plus two” stage, the service redesigned itself. If it had been a ten-year contract they might have waited seven years to go “well actually, it’s not quite working”.’
She believes that, as with everything in the sector, it’s about balance – and about recognising that substance misuse services really matter: ‘This isn’t about buying paper, this is about services that people value highly and they get very very frightened when those services are being changed.’ And the welfare of the sector going forward will depend on better partnership working, she says, and a willingness to showcase the work of good providers and organisations – those who add social value.
To fellow commissioners, she suggests: ‘You may well have a provider that’s been in an area a long time and creates jobs and does a lot of extra things in the community – lets people use its buildings, supports homeless charities. It’s about trying to draw that out when you’re tendering, scoring, and evaluating.’
And to providers worried about the ‘race to the bottom’ in stripping a service bare to compete for a tender, she says: ‘I’ve been a provider, and I would say if there’s not enough money in the tender, don’t bid for it. It’s the thing that commissioners most fear, that no one will bid for their tender – but don’t bid against each other.’
In a nutshell…
The ACMD Recovery Committee has made the following conclusions and recommendations in its review of commissioning:
Loss of funding is threatening recovery outcomes
Funding should be protected by mandating drug and alcohol services within local authority budgets or including treatment in NHS commissioning structures. Government needs to review key performance indicators to ensure quality of treatment.
Lack of money is compromising treatment quality
National bodies should develop clear standards. The government’s new Drug Strategy Implementation Board should ask PHE and the Care Quality Commission to lead a review of the drug misuse treatment workforce to achieve a balance of qualified staff.
Drug misuse treatment is disconnected from other health structures
Local and national government should strengthen links between local health systems and drug misuse treatment, and include it in clinical commissioning group planning.
Frequent reprocurement is costly and disruptive
Commissioners should ensure recommissioning drug treatment services is normally undertaken in five to ten year cycles. PHE and the Local Government Association need to support local authorities to avoid unnecessary reprocurement.
Current commissioning practice is undermining research
The new Drug Strategy Implementation Board should include government departments, research bodies and other stakeholders in building effective infrastructure for research.
From the ACMD Recovery Committee’s report, Commissioning impact on drug treatment