CZAR GAZING – How do we get more for less?

As deputy drug czar for the Blair government, Mike Trace oversaw the expansion of today’s drug and alcohol treatment system. In the fourth of his series of articles he gives his personal view of the successes and failures of the past 20 years, and the challenges the sector now faces... Read it in DDN Magazine.

Mike Trace is CEO of Forward Trust

In my last article, I offered to make some suggestions on how the drug and alcohol treatment sector can respond to the current ‘perfect storm’ of increasing demand and reducing resources. In a situation where there is insufficient political support, at central or local government, for a big increase in resources for treatment, we have to find ways of achieving better outcomes for less funding.

The first thing we need to do is get much better at focusing the available resources on delivering the outcomes that matter. This is a challenge to the commissioning and procurement system. Start by defining the desired outcomes much more clearly – the ones that matter to our clients and the community (and therefore politicians) are reductions in drug- related deaths, infections and offending; and increases in purposeful activity, secure accommodation – and family stability.

Each of these are definable and measurable but, 20 years after we established our national treatment system, these outcomes are not routinely reported on in national data systems, few commissioning decisions are based on evidence of their achievement, and few providers bother to conduct research on their achievements against them. I thought we would by now have developed a clear bank of evidence on the extent to which local treatment systems achieved these outcomes and the extent to which individual providers or models of service deliver the desired results.

Instead we have a very thin outcome evidence base, which is a real failing after billions of pounds of investment. This leads to two major problems – it undermines our ability to demonstrate value for money to politicians and taxpayers, and it leaves procurement decisions to be made more on a bidder’s ability to write good bids or manage good processes, rather than on their ability to deliver outcomes.

Secondly, we need to be much better at stimulating behaviour change among our clients, rather than just managing the impacts of continuing high-risk patterns of consumption. Of course, the first behaviour change is towards safer using and engagement with services, but we need to move quickly towards motivating clients to believe they can make changes in their drug use and wider lifestyle, then offering them support and practical help to make those changes.

When people with a history of drug/alcohol dependence are able to make these changes (what we all refer to as ‘recovery’), there are massive benefits for them, their families, and the community. There is also the benefit that pressure is relieved on the overstretched system – people in good recovery make less use of drug/alcohol services, wider health services and social services. They also cease to be a burden on the criminal justice and benefit systems.

Next, we have to be brave enough to do less of something. The demand has increased – from the diversification of drug problems (no longer just daily heroin/cocaine use) and the (perfectly sensible) addition of primary alcohol users to the system. And the resources are reducing – around 20 per cent in the last four years, with most informed opinion predicting that this trend will continue in the next few years.

So, what can we do less of? My focus would be on reducing the paperwork and bureaucracy involved in substance misuse case management – these systems have been built up over many years, and have good reasons for existing, but it cannot be right that scarce face-to-face client time is largely taken up with filling in forms and populating databases. We need to make the client/worker interaction more human again.

Linked to this, we must lose the obsession with doing a little bit with everyone and get better at focusing resources on where we can make a difference. Most services are commissioned on the basis of engaging with the maximum number of clients at minimum cost. This inevitably leads to low intensity provision for most people, when we know that most of them will need deeper help to tackle the social and psychological challenges that have brought them into services. We need to be brave enough to put less effort into those not willing to engage and more into those who are open to changing their behaviour.

Finally, we need to reposition the treatment sector in the machinery of government – with greater health and social focus, but getting back to the original aim of convincing politicians that our sector delivers true cross-sectoral benefits. More about that next month.

Mike Trace is CEO of Forward Trust

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