The long game

Gordon MorseAgainst the backdrop of round after round of ‘winner takes all’ retendering, Dr Gordon Morse calls for commissioners to consider evolution over revolution

There can’t be too many commissioners of community drug and alcohol services who are lying in their baths thinking, ‘If I had a clean sheet of paper and could completely redesign my treatment system, it would look exactly like the one I’ve got.’ Equally there can’t be many service users who are similarly thinking, ‘If we could completely redesign an addiction treatment service that works for us, it would look exactly like the one we have.’

Commissioners work very hard to deliver treatment systems that are safe, deliver what the evidence and guidance says works, meet targets, and come in at a price that the local health economy can afford. The good commissioners will also be listening to what their service users want as well, which isn’t always the same thing.

Most legacy treatment systems are the product of an evolutionary process, with some local services just springing up, some mandated by statute, and others added over time as situations dictate and resources allow – an abstinence service here, an alcohol service there, a street agency, DIP, NHS mental health service, some GP-run services, etc, etc – and each one (usually) with its own information system, buildings, manage­ment structures and gate-keeping criteria. None of them talk much to each other, not many understand who is responsible for what, and service users bounce around this patchwork system getting a bit of this, a bit of that. Some find that they just don’t seem to fit any of the criteria for any service, and give up.

Rationalising all of this makes abundantly good and obvious sense. Get one provider to be responsible for everything – one management structure and one set of buildings to pay for, one cohesive team of personnel that can absorb fluctuations in staffing without falling over, everyone talking to each other in one information system. And just one place for service users to turn up to, where they can get help at whatever stage they are at in their addiction ‘journey’ – from drop-in needle exchange and advice, through specialist prescribing and psychosocial interventions, to detox, relapse-preventing aftercare, family and carer support, and links to employment, housing and so forth. Everyone works to shared protocols and practices, at one place, with pathways to everything that is needed. There is one treatment system that can encompass more than one treatment philosophy, with just one phone number to call.

Such systems are true ‘integrated’ treatment systems. There are many that claim to be integrated, but are in fact one building that houses several different services, or integrated in that you get most things but still have to go somewhere else for, say, your DIP worker. Others look as if they are integrated because there is just one name for the service, but then you find that it is a confederation of providers with disparate approaches.

All of these may work to a greater or lesser extent – there are some excellent examples of multiple providers working well together and some which struggle, but if you build fault lines into a system, the chances are that tensions can turn these fault lines into fractures. And inevitably, to try to pre-empt fracturing and to make it all work, there are a million more weekly meetings to get all parties around the one table to thrash it all out.

With so much to gain, full integration seems to be a ‘no-brainer’, and indeed many treatment systems have been recommissioned in this way in recent years – but what are the risks? What is there to lose?

Well the obvious risk is that ‘all of your eggs are in one basket’. Can the provider really deliver all that they promised in their glossy tender document? Do they understand clinical risk, and are their governance structures sound? Do they have financial stability and have they done this before? Do they have the relevant local expertise to provide what’s needed?

The past decade has seen a shortlist of rapidly growing not-for-profit providers emerge as ‘the usual suspects’ in these big recommissioning exercises – they have amply demonstrated their safety, strength and skills in whole systems change, as well as delivering greatly improved cost effectiveness in the presence of squeezed budgets.

So the outcomes of contracting whole system change have in the main vindicated the theory behind integration – but they come at a high price. Aside from financial cost, these revolutionary events are enormously destabilising and demoralising for existing providers. To not win a tender to retain your service feels like everything you have done before has not been good enough – all the relationships with service users and surrounding agencies that have taken so long to build up will be torn apart.

Rumours and myths abound about the incomers, senior staff leave, taking their skills and experience with them, and while all the professionals are worried about their jobs, the users of the service are frequently forgotten – and they have real concerns too. However, in the main, incoming providers recognise these concerns and work hard to mitigate their effects by retaining current service staff and recruiting locally, thereby maintaining existing relationships and local knowledge.

So where massive change is needed revolution can be painful, but change happens quickly. But what then? After revolution comes a need for stable evolution – it’s a delusion to think that you can keep on getting better and better value, round after commissioning round, by cyclical ‘winner takes all’ retendering which risks providers being forced every three years to offer more for less. Addiction treatment already provides outstanding value for money – uniquely as a medical treatment, it returns its costs many times over. Isn’t it time to add to recommissioning strategies some subtle fine-tuning to support quality and stability, rather than just the ‘big bang’ option?

Of course services that are demonstrably failing need transformation, but what the great majority of decent functional services – and those who use them – need is stability. When the system is right and services are adequately resourced then staff with the right skills will stay in post, and will be able to deliver evidence-based effective interventions, which take time to train and perfect.

This last point about training has been one of the unforeseen casualties of short-term commissioning, and has the potential to profoundly erode the skills base in addiction medicine in the future: the NHS has been the bedrock of treatment provision and training for the past 60 years. The rapid move away from NHS-provided addiction services has dislocated the traditional provider of training from the workplace where experience can be provided.

In the new treatment landscape, the independent sector has the workplace experience, the skills and the willing to take on the training role – but the training of clinicians and indeed of generic workers who are specialising in addiction work takes the sort of time that short-cycle commissioning makes almost impossible.

As someone who works for one of the above mentioned ‘usual suspects’, this might appear to be a self-serving argument – but the essential point is unarguable: good integrated services need to be well designed, but they also need to be nurtured, as do the clients that they serve and the workforce they employ. Commissioning needs to be radical when big change is needed, but subtle when it is not.

Gordon Morse is the medical director of health and social care organisation Turning Point,

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