PDF version – Recovery Plus – Commissioning drug & alcohol treatment
Last September, the Advisory Council for Misuse of Drugs delivered to government a report on commissioning structures in treatment services: Commissioning Structures, the Financial Environment and Wider Changes to Health and Social Welfare Impact on Drug Misuse Treatment and Recovery. In February, the government set out its response to the eight recommendations in the report. This clarifies drug and alcohol policies, the status quo of treatment commissioning and future plans. We here summarise the key points impacting every drug and alcohol treatment provider.
Recommendation 1 – Protecting levels of investment
National and local government should give serious consideration to how current levels of investment can be protected, including mandating drug and alcohol misuse services in local authority budgets and/or placing the commissioning of drug and alcohol treatment within NHS commissioning structures.
Government response: We remain firmly of the view that local government is best placed to assess and meet the need for public health interventions, including substance misuse treatment.
The Department of Health and Social Care is seeking evidence of prescribing in regulations of local authority public health activity. Responses are invited by 17 April.
A condition attached to the public health grant is that a local authority must have regard to the need to improve the take up of, and outcomes from, its drug and alcohol misuse treatment services. The Government is considering what steps to take to ensure sufficient transparency and accountability for outcomes from drug and alcohol services in future.
Recommendation 2 – Financial reporting
National government should ensure more transparent and clear financial reporting on local drug misuse treatment services, together with new mechanisms to challenge local disinvestment or falls in treatment penetration.
Government response: We do not agree with this. The current system of reporting of spending by local authorities provides a clear and open record of actual spend on drug misuse services.
Recommendation 3 – Transparency
National government’s commitment to develop a range of measures for greater transparency on local performance, outcomes and spend should include a review of key performance indicators for drug misuse treatment, particularly those in the Public Health Outcomes Framework, to provide levers to maintain drug treatment penetration and the quality of treatment and achieve reductions in drug-related deaths.
Government response: We agree, and the 2017 Drug Strategy makes a commitment to develop measures which will deliver greater transparency on local performance, outcomes and spend. Drug and alcohol treatment data is now included in Public Health England’s new Public Health Dashboard making it easier to compare local authorities’ performance against key indicators including waiting times for drug treatment, proportion of opiate users not in treatment, successful drug treatment completion and deaths in treatment.
The new Home Secretary-chaired Drug Strategy Board will regularly review the expanded set of indicators outlined in the strategy, which includes treatment access or penetration rates.
We expect to begin reviewing the fitness-for-purpose of all the public Health Outcomes Framework indicators in 2018.
Recommendation 4 – Service costs and staffing
National bodies should develop clear standards, setting out benchmarks for service costs and staffing to prevent a ‘drive to the bottom’ and potentially under-resourced, ineffective services.
Government response: There is already sufficient national guidance in place and we are concerned about creating an overly prescriptive framework that unhelpfully ties the hands of local authorities. The Drug Strategy is clear that local drug (and alcohol) treatment commissioners should assure themselves that the services they commission are safe and effective at improving individuals’ health and in helping people recover from drug
dependency. PHE provides cost effectiveness and data tools, and quality governance guidance for local authority commissioners of alcohol and drug services. NICE provides guidance and resources, including Drug Misuse and Dependence: UK Guidelines on Clinical Management of Drug Misuse and Dependence which was updated last December.
The Care Quality Commission supplements local quality governance mechanisms.
CQC continues to enhance its capacity in relation to substance misuse services, and has published a consultation on how the CQC will rate substance misuse services. This will run until 23 March 2018.
Recommendation 5 – National review
The government’s new Drug Strategy Implementation Board should ask PHE and CQC to lead or commission a national review of the drug misuse treatment workforce [to] establish the optimal balance of qualified staff (including nurses, doctors and psychologists) and unqualified staff and volunteers required for effective drug misuse treatment services. This review should also benchmark England against other comparable EU countries.
Government response: The Drug Strategy Board will drive the implementation of the 2017 Drug Strategy. This might include reflecting further on what a national review of the drug misuse treatment workforce might add. We will take into account any relevant evidence of workforce from other countries in the EU and beyond.
Recommendation 6 – Local and national systems
Local and national government should strengthen links between local health systems and
drug misuse treatment. The latter should be included in clinical commissioning group commissioning and planning initiatives, such as local Sustainability and Transformation Plans.
Government response: We accept this and can advise that work on STPs in the NHS is ongoing, led by NHS England. NHS organisations and local authorities have come together to develop ‘place-based plans’ for the future of health and care services in their area. The 2017 Drug Strategy is clear that locally-led recovery systems require close collaboration and effective partnership working to deliver the full range of end-to-end support for those with drug and alcohol problems. Aligned commissioning is required across the housing and homelessness sector, employment services, children’s services, social care, and mental and physical healthcare. To reflect this, the new Drug Strategy Board will be attended by all relevant departments and will hold different elements of the system to account.
Recommendation 7 – Contract length
Recommissioning drug misuse treatment services should be normally undertaken in cycles of 5-10 years, with longer contracts (longer than three years) and consideration of the unintended consequences of recommissioning. PHE and the Local Government Association should consider mechanisms to enable local authorities to avoid re-procurement before contracts end in systems meeting quality and performance indicators.
Government response: The 2017 Drug Strategy acknowledges that re-tendering has often been an effective mechanism by which commissioners stimulated the market, promoted innovation and increased the accountability of services. It also acknowledges that the process can be complex and can generate unintended consequences. Local areas must
remain compliant with relevant regulations and it is their duty to interpret and apply them. The government does not accept that it should mandate particular cycles of commissioning services. However, it agrees that commissioners have a broad range of other mechanisms at their disposal to enhance quality and outcomes, such as performance management and collaborative approaches to improvement. Public Health England will continue to work with commissioners to help ensure appropriate use of recommissioning and other commissioning methods.
Recommendation 8 – Research
The government’s new Drug Strategy Implementation Board should address research infrastructure and capacity within the drugs misuse field. Any group set up to work on this should include government departments, research bodies such as the Medical Research Council and the National Institute for Health Research and other stakeholders.
Government response: The government accepts this recommendation. The government fully acknowledges the importance of research in developing a better understanding of harm and effective responses, and we have funded a number of research studies on aspects of treatment and recovery in recent years, through the National Institute for Health Research. The Drug Strategy makes a commitment to grounding our approach in the latest available evidence. Research needs to be properly resourced it its own right. However, the relationship between research funding and the capacity of the commissioned treatment system to support it is an important issue and we are keen to explore this further with the support of the ACMD. The outputs of this process could then be considered by the Drug Strategy Board if appropriate.