In the third part of our commissioning series we look at what’s needed to get the sector in the right place to deliver a world-class treatment system.
In the first of this three-part series we surveyed the commissioning landscape after a decade of shrinking budgets (DDN, October, page 12) and in part two we looked at how local areas go about making sure that people with lived experience are part of their partnership structures – in a meaningful way (DDN, November, page 12). In this final part we focus on where we go from here, and what’s ultimately needed for better commissioning.
Two of the words people most often use when it comes to effective commissioning are honesty and trust. Joint commissioning manager at Cornwall Council, Kim Hager, explains that her relationship with provider With You has always been an ‘entirely joint approach’ – one that’s made far stronger by a willingness to be frank on both sides. When the council’s supplier management team carried out an appraisal of the relationship, what came through was ‘high challenge, high support’, she says. ‘We both said, “we’ll take that”. It’s very robust, very challenging, but they know it’s for the right reasons.’
The mutual understanding is that both organisations are constantly learning together, she points out – something she feels is vital. ‘I’ve noticed in some other areas that they devolve so many things to their provider – the case management system, the engagement, everything – but we don’t do that. It’s been dialogue all along – dialogue, challenge, support, and they know we’ll fight their corner when required.’
Meanwhile, trust obviously needs to be an ‘essential component of a strong and positive working relationship with commissioners’, says executive director of services at WDP, Craig Middleton. ‘The commissioners I work with are quite progressive in terms of finding new and exciting ways to solve a problem – that’s genuinely the case. It’s about having conversations with people and saying “this is what’s happening” or “this is what we need” and working together, a co-production of solutions.’ From there, all parties work can work together on a mutually agreed plan – key to delivery of which will be maintaining that trust, he says.
‘I think commissioners are doing that’ agrees executive director of new business at With You, Sarah Allen. ‘As a provider we really invest in building trust with commissioners. I think the more open and transparent we are as an organisation the better.’ The additional funding coming into the sector has led to some ‘really collaborative conversations’ with commissioners, she says, and ‘being really open around saying, “These are areas we’ve not been able to focus on, we want to drive this forward – how do we do that together?” It can also be about making sure the right partnerships are in place outside of these relationships, she stresses, if that’s what’s necessary to meet the needs of service users. ‘No one provider can do everything on their own – we need that collaboration locally. Commissioners are open for that innovation and working with us to do that, and I think that’s really exciting.’
However, while commissioners have been supportive with innovation, up to now providers may sometimes have had to go external sources to fund that innovation.
‘The benefit we have now is that additional money is coming into commissioning teams to be able to work side-by-side with us and see that through,’ Allen says, ‘rather than us hoping that we can secure funding through grants or trusts or additional funding streams to support it. If anything it’s going to help us plan to be more innovative and creative and think longer term, because those other funding streams would normally be one or two years. So I think there’s enormous potential to really grow and embed that innovation across different services.’
The government is making ‘a record investment in drug and alcohol treatment and recovery of £532m over three years, as our part of the bold ten-year drug strategy,’ director of the Addiction and Inclusion Directorate at the Office for Health Improvement and Disparities’ (OHID), Rosanna O’Connor, tells DDN. ‘This is to improve the capacity and also the quality of drug treatment to reduce harm and help people initiate and sustain recovery.’
There is new investment totalling almost £900m over three years, with £780m to improve treatment and recovery – of which £532m will be invested to improve local authority drug and alcohol treatment and ensure more collaborative invigorated partnerships, she says. ‘We want to see high-quality services that meet local need and allow for innovation. As part of this, we are supporting partnerships to foster and support recovery communities and lived experience recovery organisations.’
For commissioning to truly deliver it also needs a robust framework, and the government’s wide-ranging overview of what good commissioning should look like – the Commissioning Quality Standard (CQS) – was published in the summer in response to one of the key recommendations of the Carol Black review. ‘What substance misuse has lacked over the time I’ve been in it – which is a decade – is central leadership on procurement, so it’s useful that commissioners know what they’re working with,’ says executive director of development at WDP, Graham Howard.
Local authority commissioners have traditionally faced a wide range of challenges, he points out. ‘They have to look at what national best practice is, NHS procurement regulations, and their own local team who are across the procurement of all the services a council runs tendering processes for – that could include building contracts, cleaning, waste disposal, all kinds of things.’
These local teams will want to apply consistent standards across those contracts, so if the new standard allows commissioners and procurement teams to work together to tweak tendering methods for drug treatment contracts where needed it will be ‘really useful’, he states. ‘For example, sometimes you get price/quality splits that are very highly in favour of price, which I don’t think are very helpful when investment should be going to frontline delivery as much as possible.’ Commissioners may have had to use that split because the local authority uses it across all its procurement, so ‘more of a sense of central best practice’ for local commissioners to use will be very helpful, he states.
The CQS has been well received, says O’Connor, and ‘aims to support partnerships to improve the consistency and quality of treatment and recovery systems in England. It has been welcomed by commissioners, providers and partners – in particular, feedback has praised how the CQS understands commissioning as a process of system leadership and development. We look forward to supporting local partnerships as they work towards meeting the standards over the course of the drug strategy.’
So are we genuinely entering a new era for commissioning, and the treatment field in general? ‘Notwithstanding the backdrop that public finance and government policy are quite changeable at the moment, I’ve not seen anything like the Dame Carol Black report in the ten years I’ve been doing this,’ says Howard, ‘nor have I seen something that’s actually translated into policy so quickly and with impact. It’s quite difficult to get attention on our sector and that actually managed it, and I think the government investment has actually been very much in line with what the report says is needed.’
Time and investment
‘The investment is long overdue,’ says Allen. ‘It’s extremely welcome and the recommendations in Dame Carol Black’s report are absolutely vital to us as providers to be able to reinvigorate the sector and get back to where we need to be, and we hope that investment commitment to 2025 remains for that stability.’ For the sector to be able to deliver on the strategy it will need that time and investment, she says – ‘without that it will be really hard to achieve some of those commissioning standards.’
Although treatment funding escaped the knife in the chancellor’s recent Autumn Statement, the great unknown remains what will happen to the new investment after the first three years.
‘Hope for the best, prepare for the worst’ might be a wise strategy, says Middleton. ‘We’re having conversations with commissioners trying to understand what the plans are for the next few years, because obviously there’s a commitment up to a certain point but we need to understand what’s going to happen after that as soon as we can. With the new money, the sector obviously has an opportunity to grow again, and we’ve got to bring in a whole new generation of practitioners to meet the expectations of the new investment.’
If the funding is maintained, however, then ‘we should absolutely be seeing its impact in services,’ says Howard. ‘Some of that will take a longer amount of time, because one of the problems Dame Carol Black identified was that certain professional and medical roles have been diminished, and those can’t just be created out of thin air. We need to get people training for them and going through years of study, so even in a ten-year cycle we might potentially only start to see the dividends of that towards the end.’
So does that mean that people should possibly try to manage their expectations? ‘Commissioners and providers need to be both pragmatic in the short term in the context of the current challenges, but also remain ambitious about improving the quality of treatment in the longer term,’ says O’Connor.
‘It’s vital that we increase the skills mix of the workforce if we are to deliver high-quality treatment and recovery systems which reduce harm and help more people to initiate and sustain recovery. OHID has commissioned Health Education England to develop a ten-year workforce strategy that will set out a clear roadmap for the future, including the training of registered professions.’
The government has also commissioned a new drug and alcohol treatment and recovery capability framework, which is due to be published next summer, O’Connor points out. ‘This will be a refreshed drugs and alcohol national occupational standards, reflecting the sector’s current needs. Work will begin soon to scope and develop this framework with the sector.’
Support and development
‘I think we’re in a position where those who want to can seize the ground and make a good job of it,’ says Hager. ‘It’s what’s behind the standard to support commissioners who aren’t experienced, to understand what commissioning is – or could be – the evidence around it and approaches they can take. Those who’ve been around a while know how to navigate that, but we’re a minority.
There needs to be support for commissioners to develop in their role. The standard’s good for that, but it’s about how much people buy into that – how do we develop the learning? In our joint commissioning group we discuss ‘what do we mean by commissioning’, because often what you encounter in local authorities is they just think it’s shopping and procurement. It’s strategic leadership and acting on behalf of the people we represent, making the best use of the resources available. We’re that link. Transforming commissioning isn’t just about transforming procurement – it’s about a learning approach, not a top-down approach.’
‘It’s a really interesting time,’ says Allen, and retaining some of the hybrid models and approaches around staff training and development that developed during the pandemic will be important. ‘That very virtually-based offer – we’ve got really skilled and experienced staff, and we need to make sure those new staff coming in have the opportunity to work alongside and be close to them, and have the combination of face-to-face and different training options.
‘It’s sharing those skills and best practice that’s really going to allow the workforce to develop – a lot of people have worked in this sector for a long time, and we need to value that. We’re going to be having staff coming in with less experience and we need to do as much as possible to wrap around them so they don’t feel overwhelmed by this.
‘I am optimistic and I’m going to remain optimistic,’ she says. ‘I think we also have a huge sense of responsibility. We want to show that this funding works and has impact, and if we want to make the argument for continued investment beyond 2025 we need to deliver on that. We can’t waver on that passion, commitment and enthusiasm – we have to remain committed on that path.’ DDN
We welcome your thoughts, feedback and experiences on commissioning and hope to take the conversation forwards from this series of three articles (Oct, Nov and Dec/Jan issues). Please email the editor.
This series has been produced with support from an educational grant provided by Camurus, which has not influenced the content in any way.