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\u2019s much talk of developing innovative commissioning practice \u2013 prompted, in the main, by the need to \u2018do more with less\u2019. 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 \u2018significant decline in registered staff, including nurses, social workers, clinical psychologists and doctors\u2019 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 \u2013 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 \u2018a multi-skilled breed\u2019 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\u2019 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 \u2013 \u2018prioritising people, practising effectively, preserving safety and promoting professionalism and trust\u2019. \u2018We are ever evolving to meet our clients\u2019 needs and the needs of our services,\u2019 she says. \u2018We 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 \u2013 all of which are measurable outcomes.\u2019 \u2018Looking at the client from the centre of their needs\u2019 has become the way of working at Change, Grow, Live, says Dr Arif Rahman, CGL\u2019s consultant addiction psychiatrist. Far from dispensing with the psychiatrist\u2019s role, CGL have put it right at the centre of their services. \u2018It\u2019s really good for the client as it gives them a specialist assessment that\u2019s holistic. We\u2019re medically trained, psychiatrically trained and substance misuse trained\u2026 The whole ethos is about getting people to the best of their potential,\u2019 he says. \u2018We can identify, support and manage, and if necessary liaise with other specialists around the aspects of clients\u2019 needs. For example, I\u2019m in frequent contact with a pain specialist, a liver specialist and secondary mental health services.\u2019 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 \u2018a new way of working\u2019 \u2013 not losing skills, but adapting them to take account of updated Models of Care and the client\u2019s journey. He acknowledges that there have been cuts to services and restructuring in a lot of places, but feels positive that a \u2018difficult few years\u2019 have given \u2018an opportunity for looking at things again\u2019. 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 \u2018create robust pathways to make sure the skill set is there across all organisations\u2019 \u2013 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 \u2018the front door to treatment has changed\u2019 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. \u2018The money\u2019s 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\u2019s got ever-increasing complex needs?\u2019 This, he believes, makes the case for a different and more creative brand of commissioning. \u2018If 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,\u2019 he says. \u2018But you can commission differently. You can say, \u201cyou\u2019ll be working with people with complex needs, people with co-existing mental health and substance misuse concerns. You\u2019ll be dealing with people with long-term homelessness issues, people who are long-term unemployed \u2013 and you need to be able to deliver both the clinical and psychosocial model.\u201d \u2018You\u2019re not saying that you must have a psychiatrist or a psychologist or whatever \u2013 you\u2019re saying, \u201cthis is the level of complexity you\u2019ll be working with; what team would you put out?\u201d It\u2019s up to the provider to come back and say what they will give you.\u2019 Lee sees opportunity in the need to mix cost-effectiveness with addressing complex needs, and says \u2018that\u2019s where it gets really exciting, because you can start playing around with different delivery options\u2019. Traditional ways of working are not \u2018the given\u2019 anymore, right down to the buildings that can constitute one of a service\u2019s biggest overheads. The new way of working can be \u2018light and agile\u2019, he suggests \u2013 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 \u2013 a Skype call, email contact, text support, people filling in their own assessments online, or contact with a keyworker that can be anywhere. \u2018Even people with highly complex needs could get some of their support through digital means \u2013 you could do doctors\u2019 appointments by Skype for example to save travelling,\u2019 says Lee, adding that there will always need to be a balance between this and traditional face-to-face meetings. His point is that \u2018years ago everyone got the same broad-brush approach, but these days you don\u2019t do it that way. And if the money\u2019s draining out of the system, we can\u2019t afford to be working in old-fashioned ways.\u2019 Furthermore, he believes that commissioners have a responsibility to lead on this open-minded approach: \u2018If the commissioner pretends they know everything, you\u2019re robbing yourself of some good ideas,\u2019 he says. \u2018The good providers out there have some really innovative ideas.\u2019 This article has been produced with support from Camurus, which has not influenced the content in any way.