An effective review of commissioning will need input and inspir\u00ada\u00adtion from everyone involved \u2013 practitioners, commissioners, and especially those using services. DDN reports. There have been many calls for a review of commissioning practice as budget cuts have sliced through services and severely curtailed treatment capacity. So the newly formed Expert Faculty on Commissioning\u2019s consultation (page 10) is certainly timely. \u2018The financial squeeze on drug and alcohol services will seriously undermine the quality and effectiveness of services,\u2019 says Annette Dale-Perera, chair of the ACMD Recovery Committee, which at the end of last year announced that the commissioning structure needed an overhaul (DDN, November, page 7). Annette Dale-Perera: Financial squeeze is undermining quality The faculty\u2019s review offers key questions for commissioning, asking how we can ensure skilled staff are providing high quality support, incorporate innovative thinking, make sure that services are well integrated with partner support services, and consider whether we are using the right outcome measures. The question of staff skills and training is being addressed by the Federation of Drug Alcohol Practitioners (FDAP), which is now administrated by SMMGP. Interim executive director Kate Halliday explains that FDAP has been developing an apprenticeship for the sector to drive up standards. A \u2018trailblazer group\u2019, including major employers in the field, is putting forward a proposal to the Institute of Apprenticeships for a Drug and Alcohol Practitioner Apprenticeship level four qualification. Kate Halliday: FDAP's apprenticeships will bring exciting prospects for workforce development The standardisation of training for drug and alcohol practitioners represents an exciting time for workforce development in the sector, says Halliday: \u2018We can hope to see an improvement in the provision of services, the retention of staff and the encouragement of new talent to the field.\u2019 FDAP hopes that the first apprenticeship courses will be ready for roll-out in 2019. The question of adopting more innovative commissioning practice depends on \u2018a fluid dialogue between commissioners and those at the front delivering the services,\u2019 believes Yasmin Batliwala, chair of WDP \u2013 whose organisation, alongside Blenheim and Addaction, supports the Drugs, Alcohol and Justice Cross-Parliamentary Group. The group\u2019s recent Charter for Change called for the creation of a national commissioning ombudsman to address failures in commissioning practice. Yasmin Batliwala: More innovative commissioning depends on a fluid dialogue \u2018By establishing firmly this culture of transparency, the often-byzantine process of allocating funding is made that little bit simpler,\u2019 she says. On the one hand commissioners are put at ease, safe in the knowledge that the money is going to dedicated experts and professionals, and on the other, it instils confidence in the providers on the front line, ensuring that they remain valued and supported. Blenheim\u2019s interim chief executive, Deborah Jenkins, acknowledges that innovation is difficult when commissioners are under such huge pressure to do the best they can, with continuing levels of disinvestment against a rising number of service users. She sums up the \u2018lose-lose situation for commissioners, providers and most importantly service users\u2019, as \u2018tenders are issued where it is just not possible for even the leanest organisation to deliver\u2019. \u2018Commissioners are facing extremely difficult choices about where to cut back,\u2019 she points out. \u2018Do they cut back on needle exchanges, which are perhaps an easy choice but which would lead to wider public health risk of an increase in blood-borne viruses such as HIV and hepatitis C? Do they try to commission innovative digital services which, while largely unproven, are cheaper than face-to-face services and don\u2019t require the overheads of premises? Do they decommission the wrap-around employment, training and education programmes that are designed to help people integrate back into society, sealing that final step on the recovery journey, and without which relapse is highly likely? Or do they cut back on children and young people\u2019s services, where the interventions have the greatest possible lifelong impact for service users and their families?\u2019 Deborah Jenkins: Commissioners need to think laterally, focusing on the return on investment There is no easy answer, she acknowledges, as all these services are crucial in providing highly effective drug and alcohol support services. But her suggestion is that commissioners think laterally, focusing on the return on investment to the wider economy. And yes, she believes there is scope for a more innovative approach. We need to ask ourselves whether there are better ways of commissioning drug and alcohol services, she says, such as \u2018commissioning jointly with CCGs who are responsible for mental health, with police for prevention of drug and alcohol-related crime, and with housing departments. \u2018The same vulnerable and high-risk cohort of people appear in the pathways across all these organisations, so let\u2019s take a people-centric approach and a joined-up view of how to address the problem and complexity surrounding substance misuse.\u2019 \u2018Successful peer-led initiatives take time and commitment to design, implement and grow, and like roses are difficult to revive if allowed to wither and die.' The question of integrating services has to take service user involvement as its starting point, believes Tim Sampey, founder and chief executive of the peer-run service user charity Build on Belief. A lot has changed in service user involvement in the past decade, with peer-led initiatives springing up all over the country \u2013 \u2018Build on Belief and the FIRM in London, Red Rose Recovery and the Recovery Republic in the north of England, SUIT in the Midlands, to name but a very few,\u2019 he says. \u2018In the past couple of months, the importance of these service user initiatives has been the focus of both the APPG Complex Needs and Dual Diagnosis People powered recovery report and the EMCDDA paper, User-led interventions \u2013 an expanding resource? But where do they sit in the commissioning framework?\u2019 Tim Sampey: Service user involvement needs to be built into tenders In too many instances, peer-led initiatives are not written into the tender specification at all, he says \u2013 or if there are, they are levered into service provision as \u2018added value\u2019. In such cases, the specification is often \u2018so fuzzy it risks becoming meaningless\u2019, with the vast potential to add valuable layers of peer support and aftercare completely missed. The practice of \u2018whole system commissioning\u2019 excludes many peer-led organisations with strong track records, who are formally constituted as CICs or charities, from taking part in the tendering process unless they can subcontract their services to a major provider, he points out. He acknowledges that some of the big treatment providers have been highly supportive of such organisations over the past few years, but adds \u2018the buy-in is not universal, and there are those who think it both cheaper and less risky to keep everything in house.\u2019 And while some projects are directly commissioned by local authorities, ensuring their independence, \u2018this practice is not as widespread as it should be,\u2019 he says. Sampey does, however, have news about a different approach that he hopes will become more widespread. \u2018In the past year, two small contracts were put out in Southwark and Medway separately from the main service provision tender, with the specific intention of attracting smaller, bespoke organisations,\u2019 he says. \u2018It\u2019s too early to say if this is the beginning of a trend, or an exception to the rule, but such initiatives are far-sighted and welcomed. \u2018I\u2019ve also heard stories, mostly from the Midlands and the north of England, of commissioners protecting small peer-led initiatives by making it clear that they must be supported by whichever main provider wins the contract,\u2019 he adds. He sees this as good practice. \u2018Successful peer-led initiatives take time and commitment to design, implement and grow, and like roses are difficult to revive if allowed to wither and die. Clearer provision for them in overall tender specifications, smaller bespoke commissioning, and protection for existing services in whole system commissioning would go a long way to ensuring that a lot of the effort, innovation and creativity put into the wider service user involvement agenda over the past decade is not lost.\u2019 As Sampey points out, working with service user networks is invaluable in informing consultation documents and strategy papers around complex needs. An important factor in getting this right is to connect effectively with the many other support services, rather than commissioning for substance misuse as a separate entity. \u2018The drug strategy acknowledges that the drug strategy in isolation can\u2019t deliver the changes that most people need in their lives \u2013 the need to incorporate changes around employment, accessing mental health and physical health services, offending, domestic violence, and caring for your children,\u2019 says Paul Hayes, head of Collective Voice and former head of the National Treatment Agency (NTA). \u2018Drug treatment makes a vital contribution to all of those things, but in isolation won\u2019t address any of them.\u2019 Paul Hayes: Drug treatment cannot be delivered in isolation Commissioning will need to be informed by broader measures than relying solely on the Treatment Outcomes Profile (TOP), he points out. \u2018Just as a whole range of services need to be available to people with drug and alcohol problems, so outcome measures need to reflect what\u2019s happening to people\u2019s lives with broader communities, within all of these domains,\u2019 he says. \u2018TOP is an excellent way of identifying the progress an individual is making towards addressing a number of those issues, but in isolation can\u2019t tell the whole picture about the impact of drug misuse, or its cumulative impact, along with other services, for whole communities.\u2019 The DDN conference on 22 February will give the opportunity to get involved in the commissioning consultation. This article has been produced with support from Camurus, which has not influenced the content in any way.