In the wake of Dame Carol Black’s landmark Independent review of drugs, the government announced almost £800m of new funding to rebuild and revitalise the country’s ailing treatment system. But for the money to genuinely transform the treatment on offer the right commissioning structure needs to be in place.
In part one of this series we surveyed the commissioning landscape after years of budget cuts (DDN, October, page 12), and in part two we look at how the sector goes about creating genuine partnerships between commissioners, service providers and – crucially – people with lived experience.
The Carol Black review set out how people with lived experience would need to be central to any treatment system that met the needs of those depending on it, while the new Commissioning Quality Standard (CQS) says that local areas will know they’re achieving the desired level for strategic and commissioning partnership when people with lived experience are included in their partnership structures. But how close are we to achieving that?
‘It’s for commissioners and providers to work in collaboration to create the fertile ground for that to happen, and make sure it’s not tokenistic,’ says executive director of services at WDP, Craig Middleton. ‘You don’t want it to be “we’ve ticked that box, we can move on now” – it’s about how we actually make this work authentically. It’s not easy to do well, but it’s not impossible.’ This means getting ‘all the right people in the room’ and having strong co-production elements with commissioners, service users and providers, he says.
Doing it together
Effective commissioning is always a relationship, stresses joint commissioning manager at Cornwall Council, Kim Hager. ‘Some people see it as a transactional, top down/directional approach, and transactional approaches don’t deliver. We have to do it together. And it’s not just service users and experts by experience – the bit that gets missed out is families and communities. It’s really important that they’re part of that. We need to stop seeing drugs and alcohol problems as happening in isolation because by the time you’ve developed problematic use, you’ve accumulated a bunch of other problems like offending, housing, mental health.’
With some bid processes the involvement of service users is explicit, says executive director of development at WDP, Graham Howard. ‘It will tell you the name of the group that’s been involved, how they’ve done it, and there’ll be an element of the bid where they’ve set a question, or you go to a presentation and there’s a service user panel there. It’s clear that it’s happening.’
However, consultations with service users to create a needs assessment or specification can often be followed by confusion around how they’re actually going to be included in the process. ‘Bidders may be informed that service users are on the marking panel or something like that, but unless it’s black and white in the bid – or you go to a presentation and you’re presenting to service users – it can be hard to know what their levels of involvement are.’
What is good practice?
So what does genuine good practice look like when it comes to involving people with lived experience?
‘One tender I was involved in recently was excellent,’ says Howard.’ It was very clear how they’d done it – the service users had set a question, they were presented to, they were facilitated to ask questions, and they were supported by the commissioners. There have been pockets of best practice like that in tendering for the entire time I’ve been doing it, but hopefully with the new commissioning standard it will become the norm.’
Another example was a bid where providers were asked to describe their offer to service users, which would then be marked by the service users themselves. ‘Instead of trying to give service users the whole bid and them having to get to grips with everything that’s going on, responses described the overall offer, assessing whether the service model would appeal to them directly,’ he says. ‘That felt like really good practice.’
Commissioning is always more effective when there’s genuine engagement with the people the services are commissioned on behalf of, rather than an ‘ivory tower’ approach, Hager states. This means it’s vital to avoid service users being told ‘we’d like you to be involved’ and then nothing is done about facilitating how that can realistically happen – ‘the structures of meetings, or enabling people to participate. It’s not easy, but there’s a wealth of experience out there depending on who you work with and how. Engagement has to be meaningful.’
One of the things her council did that had the biggest impact – ‘and I had to be convinced to do it’ – was creating jobs for experts by experience, she says. ‘We created 12 in the first instance, as sessional workers to be properly employed by the council so that they can contribute to any agenda as part of co-production and collaboration – not just the drugs and alcohol agenda – and be properly paid and supported to do so. It’s been the most impactful thing we’ve done to date.’
Another very obvious way to put people with lived experience centre stage is via lived experience recovery organisations (LEROs). However there aren’t very many areas where the local authority has a direct arrangement with the local LERO, says chief executive of Recovery Connections, Dot Smith. ‘We’re really one of the fortunate ones because we’ve been directly commissioned by the local authority for six years.’ This is partly down to the way the tender was put out, with the commissioner separating the recovery element of the contract, but her organisation also has a very strong relationship with Change Grow Live in other areas where it works on specific parts of contracts – a more typical arrangement.
CLERO is also developing its own quality standard for services, with the website due to go live soon. ‘There are different sized LEROS nationally, but a lot of them are doing phenomenal work without any payment,’ says Smith. ‘We’ve developed some core standards about what a LERO is, and the quality framework we’re working on will fit behind that. Because if you want to be commissioned you’ve got to jump through a few hoops and fulfil a fair few criteria for a local authority to be able to release any sort of funding.’
Many LEROs won’t be in a place where they can do that, she says, at least not yet. ‘There’s a lot of indirect costs if you want to position yourself as an organisation to take on a local authority contract – things like insurance are really expensive – and you need an infrastructure to be able to deal with money that comes with obligations and governance.’ All of this means that a lot of support and capacity building will be needed to develop the LERO landscape to a point where it’s the norm to have well-funded, well-equipped LEROs in each area.
Back in 2018, chief executive of Build on Belief Tim Sampey told DDN that peer-led organisations with strong track records were often excluded from tendering unless they subcontracted their services to a large provider, or else were levered in as ‘added value’ with specifications ‘so fuzzy as to become meaningless’ (https://www.drinkanddrugsnews.com/the-right-focus/).
So have LEROs been marginalised up to now? ‘I think we have, for sure,’ says Smith. ‘A lot are doing a huge amount of work that goes unrecognised and unfunded.’ The issue isn’t so much that commissioners haven’t been taking LEROs seriously enough, but rather that they often don’t understand the concept, she points out. ‘That’s not a criticism – it’s purely because there are still a lot of areas where there isn’t a mobilised recovery community doing this stuff, so why would they know?’
‘Contracts tend to be for whole systems, and that’s not the offer that LEROs want to deliver,’ adds executive director of new business at With You, Sarah Allen, whose organisation has long-standing partnerships with LEROs such as Double Impact in Lincolnshire. The role of LEROs is ‘very specialist and the value they bring is really important’, she says. ‘I think one of the things we can do better is make sure there’s a requirement within service specifications for contracts that LEROs are an active part of.’
One of the challenges is around funding and allocation, she states. ‘If there are always going to be sub-contracted organisations to a large provider then there needs to be a commitment that it’s a long-term relationship, and we absolutely make that commitment with our LEROs. They need that stability and investment in their own infrastructures. A lot of the conversations we have with LEROs are around “if you’re taking on this additional work, what is it you need to support you to do this?” I would welcome it if commissioners ring-fenced money for LEROs in contracts. We also work with LEROs where they have a specific contract in their own right – not every area has a LERO, and as large organisations I think we have a responsibility to not step into that and say “we’ll do everything”.’
Rather they should be looking at how they can support the community to develop their own LEROs so they can retain an independent function away from larger providers, she says.
It’s also important to avoid any situations where simply including a LERO in a contract potentially risks being reduced to its own form of box ticking. ‘What I worry about is things coming out of the centre like “you need to have a LERO in your area”,’ says Hager.
‘I’m always worried by single organisations, because how inclusive and representative are they? The challenge is true representation and inclusivity – how far can you stretch that? Are women adequately represented? People with multiple vulnerabilities? That’s the challenge – how meaningful is it, how inclusive is it, and how far are you prepared to cede power.’
Making partnerships meaningful means actually supporting people to participate effectively, not just inviting them to meetings, she says. ‘I used to train service user groups across the south west, which included things like what commissioning is and the structures and processes that many of us take for granted.
‘As a minimum, it’s really important to equip them to understand the environment they’re working in, as it can be so alien. Even better, move and change your structures and processes, and involve people with lived experience in making them more effective and inclusive. It’s not enough to say it, it’s about what you put in place to make it happen, and the skills that the people need to be able to do that. Most importantly, what we learn through that process, together.’
It’s clear from the CLERO membership that a lot of people and organisations are ‘desperate for somebody to help them to build up that expertise and grow their experience’, agrees Smith – ‘help them position themselves where they can then be commissioned to do the work that generally they’re already doing, but to be paid fairly and equitably.’
Part of the imbalance is that national organisations clearly have much more ‘collateral’ when it comes to bidding for tenders, she says. ‘They just have such a huge infrastructure compared to a local LERO’, while the mechanics of a bidding process can appear impenetrable to anyone with little experience of them.
WHAT ELSE CAN WE DO?
So what else can commissioners be doing to improve the situation? ‘In terms of support to aid development they can ensure that when they’re commissioning LEROs the funding available is enough to provide equitable salaries, because the staff they have are as qualified if not more qualified than staff in some of the larger organisations,’ says Smith. ‘Some of our staff are qualified to masters level – it’s fundamentally wrong to pay minimum wage for a recovery worker. And where there isn’t a LERO visible, the commissioners and larger commissioned organisations need to be looking out to see where there’s one emerging and help them mobilise and grow so that at some point they’re able to have some equity in terms of the commissioning.’
‘I’ve worked in a couple of areas where we partner with well-established service user groups, which now you’d call LEROs,’ says Middleton. ‘On the provider side it’s really about trying to get the balance right between nurturing and being able to share power, being open and embracing it. That’s where it’s happened well. I can see developing more elements of co-assessment in the future – getting people in as part of inspections and audits to tell us how they’re experiencing services and what could be done better.’
‘I think there’s a lot more we can do as providers to support service users, because it’s invaluable that they’re part of this process,’ agrees Sarah Allen. ‘Without them we won’t get the same quality. In terms of the commissioning standards themselves, we have lots of volunteers within services and peer mentors, and we’ve also developed specific paid lived experience roles within the organisation. I think that’s a really good step in terms of working towards those standards and starting to embed them. Yes the commissioning standards are there at the point of the contract, but they need to be there through the life of the contract. That’s how we’re going to know if we’re achieving this – by having that continual review.’
‘I think we’re on the right path for lived experience, and the commissioning framework will help,’ says Smith. But for this to work a lot of it comes back to ‘building trust and brokering relationships’, she says. ‘Trust really is a key word – we’ve got to trust people and trust small organisations. The work that we’re doing as CLERO is just trying to help LEROs build in a way that’s going to position them to be able to get a piece of this pie, because what I’d hate is if they were overlooked because they don’t tick the boxes. That would be an absolute shame.’
But ultimately, when it comes to genuinely involving people with lived experience, ‘you have to be honest about the limits of your ambition – how far you’re willing to give up power or have it taken,’ states Hager. ‘In Cornwall, our ambition for co-production is high. I’ll know I’ve succeeded when they take my job.’
See next month’s DDN for the final part of the series
This series has been produced with support from an educational grant provided by Camurus, which has not influenced the content in any way.