Commissioners are on a mission to do things better. But how can they take on board the many complex health issues with less money in the pot? DDN reports. There’s much talk of developing innovative commissioning practice – prompted, in the main, by the need to ‘do more with less’. As part of the refining process, many services are letting go of the specialist posts that would have been central to operations just a few years ago. In our March issue (page 20) the alliance of NHS providers, NHSSMPA, highlighted the ‘significant decline in registered staff, including nurses, social workers, clinical psychologists and doctors’ and cautioned that some drug and alcohol services had begun relying on limited clinical expertise. Through a recent suite of documents for commissioners, providers and clinicians, Public Health England (PHE) emphasised the many and varied roles that specialist doctors, nurses and psychiatrists should play in addiction services. These highly trained professionals are, they reminded us, not just there to provide medical treatment in response to highly complex needs – although those are the elements of their roles that cannot be fulfilled effectively by lesser trained and qualified staff. PHE named many other skills that enhance quality and leadership within teams, as well as integrating many public health activities and interventions. Furthermore, they pointed out, specialists can help to coordinate resources in a way that adds cost efficiency to a system stretched to breaking point. MULTI-SKILLED VALUE The fact that nurses are such ‘a multi-skilled breed’ is without doubt why they bring such good value to drug and alcohol services, says Ishbel Straker, a clinical director and board member of the nurses’ association IntANSA. Their expertise in therapeutic engagement, assessment and care planning, health care delivery, disease prevention and prescribing works alongside their commitment to the NMC standards – ‘prioritising people, practising effectively, preserving safety and promoting professionalism and trust’. ‘We are ever evolving to meet our clients’ needs and the needs of our services,’ she says. ‘We work with harm minimisation at the forefront of our minds, while giving advice, assessing and treating through a variety of activities such as vaccinations, lung function tests, wound care, blood sugar monitoring, ECGs and sexual health – all of which are measurable outcomes.’ ‘Looking at the client from the centre of their needs’ has become the way of working at Change, Grow, Live, says Dr Arif Rahman, CGL’s consultant addiction psychiatrist. Far from dispensing with the psychiatrist’s role, CGL have put it right at the centre of their services. ‘It’s really good for the client as it gives them a specialist assessment that’s holistic. We’re medically trained, psychiatrically trained and substance misuse trained… The whole ethos is about getting people to the best of their potential,’ he says. ‘We can identify, support and manage, and if necessary liaise with other specialists around the aspects of clients’ needs. For example, I’m in frequent contact with a pain specialist, a liver specialist and secondary mental health services.’ HOLISTIC AGENDA Many clients find it easier to engage with a substance misuse charity than to access a liver specialist, engage with a mental health team, or ask for testing for blood-borne viruses or screening for respiratory disorders, he explains. So whatever the need, he is in a position to liaise with other specialists to bring care to the client. He talks about ‘a new way of working’ – not losing skills, but adapting them to take account of updated Models of Care and the client’s journey. He acknowledges that there have been cuts to services and restructuring in a lot of places, but feels positive that a ‘difficult few years’ have given ‘an opportunity for looking at things again’. Psychiatry as a profession is in a good place to contribute to a holistic public health agenda, he states, having several decades ago experienced and adapted to changes that are now happening in health and social services. Alongside his client assessments, he feels that one of the most important parts of using his expertise is in finding pathways for clients and linking them to colleagues and partner agencies for their health, psychological and social needs. CREATIVE COMMISSIONING Chris Lee, a commissioner in Lancashire and a member of the new Faculty of Commissioning, agrees with the need to ‘create robust pathways to make sure the skill set is there across all organisations’ – particularly as the treatment system now has so many diverse stakeholders including CCGs, the NHS (and the prison estate), local authorities, Collective Voice and the NHSSMPA. While ‘the front door to treatment has changed’ and clients might enter treatment through one of many different routes, the current challenges mean that leading through specialisms is more important than ever, he says. ‘The money’s going out of the system at 100 miles per hour, but the clinical guidelines have been enhanced. So how do you do that with a population that’s got ever-increasing complex needs?’ This, he believes, makes the case for a different and more creative brand of commissioning. ‘If I sit down and write a specification for a tender this afternoon that mentions an addiction psychiatrist, your bid will come back with an addiction psychiatrist in there,’ he says. ‘But you can commission differently. You can say, “you’ll be working with people with complex needs, people with co-existing mental health and substance misuse concerns. You’ll be dealing with people with long-term homelessness issues, people who are long-term unemployed – and you need to be able to deliver both the clinical and psychosocial model.” ‘You’re not saying that you must have a psychiatrist or a psychologist or whatever – you’re saying, “this is the level of complexity you’ll be working with; what team would you put out?” It’s up to the provider to come back and say what they will give you.’ Lee sees opportunity in the need to mix cost-effectiveness with addressing complex needs, and says ‘that’s where it gets really exciting, because you can start playing around with different delivery options’. Traditional ways of working are not ‘the given’ anymore, right down to the buildings that can constitute one of a service’s biggest overheads. The new way of working can be ‘light and agile’, he suggests – meeting in a coffee shop or a library, using community assets, and freeing up money to spend on staff instead of buildings. LET'S GET DIGITAL Service delivery might be able to incorporate digital support – a Skype call, email contact, text support, people filling in their own assessments online, or contact with a keyworker that can be anywhere. ‘Even people with highly complex needs could get some of their support through digital means – you could do doctors’ appointments by Skype for example to save travelling,’ says Lee, adding that there will always need to be a balance between this and traditional face-to-face meetings. His point is that ‘years ago everyone got the same broad-brush approach, but these days you don’t do it that way. And if the money’s draining out of the system, we can’t afford to be working in old-fashioned ways.’ Furthermore, he believes that commissioners have a responsibility to lead on this open-minded approach: ‘If the commissioner pretends they know everything, you’re robbing yourself of some good ideas,’ he says. ‘The good providers out there have some really innovative ideas.’ This article has been produced with support from Camurus, which has not influenced the content in any way.