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Commissioning impact on drug treatment: The extent to which commissioning structures, the financial environment and wider changes to health and social welfare impact on drug misuse treatment and recovery.
Advisory Council on the Misuse of Drugs.
[UK] Advisory Council on the Misuse of Drugs, 2017.
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Based on research, financial data and stakeholder surveys and testimonies, the UK government’s official drug policy advisers warn that without significant efforts to protect investment and quality, in England “loss of funding will result in the dismantling of a drug misuse treatment system that has brought huge improvement to the lives of people with drug and alcohol problems”.
Summary The Advisory Council on the Misuse of Drugs (ACMD) is appointed by the UK government under the Misuse of Drugs Act to advise on policy and law in relation to illegal drugs. This inquiry into commissioning was prompted by concerns about the impacts on treatment of changes in health, social care and the criminal justice system in England, evidence of reductions in funding, and the impact of trends in commissioning on drug misuse (and alcohol) treatment outcomes.
To investigate this the Council reviewed the published literature, gathered financial data on drug and alcohol misuse treatment, conducted surveys of substance misuse providers and commissioners, and received evidence from professional membership bodies, Public Health England, treatment providers, and directors of public health.
The accompanying letter sent with the report to government ministers summed up their findings:
What follows are the ACMD’s findings and recommendations as set out in the report’s executive summary. For more detail download the report free of charge. In February 2018 the UK government responded to the recommendations in the featured report. For more on commissioning see the Effectiveness Bank hot topic What about evidence-based commissioning?
Recently there have been significant changes in the commissioning of health, social care and criminal justice structures in England. Drug misuse treatment oversight and commissioning moved to public health structures in England in 2013. Local commissioning moved into local authorities, overseen by local authority-hosted health and wellbeing boards aimed at bringing together the NHS, public health, adult social care and children’s services. National oversight of drug misuse treatment moved from the National Treatment Agency for Substance Misuse (NTA) into Public Health England (PHE).
The ACMD found reports of positive aspects to these changes, such as alignment of drug misuse treatment with other local authority and public health-related issues. However, there also appeared to be negative aspects, including challenges to local authority budgets.
The ACMD heard mixed evidence from surveys and testimonies on whether local strategic commissioning links were functioning well; many substance misuse commissioners and providers pointed to an increasing disconnect with wider health commissioning and provision.
The ACMD found evidence of reductions in local funding for drug misuse treatment in England (from 2008–09 to 2010–11 by around 12%). However, it was difficult to establish a clear picture on more recent trends due to changes in financial reporting and a lack of comparable published financial data. The ACMD received conflicting evidence on trends since 2013–14 from local authority published financial data and evidence from provider and commissioner surveys and case studies. The majority of evidence from providers and commissioners described a level of reduction in funding, which was not apparent in published local authority financial returns. Evidence from the King’s Fund also reported that cuts in public health services were planned up to 2020–21, particularly for drug misuse (and alcohol) treatment. The ACMD noted that NHS leaders had called for adequate investment in drug and alcohol misuse services as being “vital” to prevent unsustainable demands on scarce NHS resources in the future.
Re-procurement of contracts for drug treatment services between service providers and local authorities is a frequent occurrence in England. The ACMD heard evidence of positive and negative impacts of re-procurement. Many commissioners and some providers cited positive impacts of re-procurement in relation to positive drug misuse treatment system change and gaining efficiency savings. However, the ACMD also heard evidence that frequent re-procurement led to ‘churn in the system’ causing instability, disruption of local system performance and negative impacts on treatment outcomes in the short term. From an ACMD survey of commissioners [conducted to gather evidence] for this report:
• 71% (20 out of 28 who responded to the question) reported a negative impact in the three months prior to the start of a contract;
• 66% reported a negative impact in the three months after the start of a contract;
• 62% reported a negative impact up to six months after contract start;
• 44% reported a negative impact a year after contract start; and
• 23% were still reporting a negative impact after two years.
Re-procurement was reported in this survey to be an expensive process for commissioners and providers. Some commissioners reported having to ‘fight’ for contract lengths of more than three years; others were frustrated by delays in local decision-making processes, which led to rushed processes and poor transitions.
There was a great deal of synergy between the views of providers and commissioners from surveys and expert witness evidence. In summary, providers generally perceived that:
• reductions in funding were greater than the official figures portrayed;
• frequent re-procurement of services, particularly when systems functioned well, was unnecessary and a major drain on resources, resulting in ‘churn in the system’ causing disruption and creating ‘risky transition points’ for service users;
• short contracts (of two years or less) and truncated re-procurement timetables were unhelpful, disruptive and had negative impacts on service users’ recovery outcomes;
• workforce management was critical [for] re-procurement with some providers suggesting a lack of leadership from commissioners;
• there were serious concerns among commissioners about the balance of clinical and professional expertise, and whether staff and volunteers without professional qualifications or competence were being lost due to financial constraints.
The ACMD concludes that there is evidence that there have been reductions in resources for drug misuse treatment services (including young people’s substance misuse services). ACMD also considered the King’s Fund report that suggested further reductions are planned to all substance misuse treatment services.
The ACMD is concerned that a system that has been seen nationally and internationally as highly successful is at risk of being undermined. The ACMD is concerned that loss of funding will result in the dismantling of a drug misuse treatment system that has brought huge improvement to the lives of people with drug and alcohol problems.
A loss of funding could lead to decreased treatment penetration and increased levels of blood-borne viruses, drug-related deaths and drug-driven crime in communities. Furthermore, reductions in drug misuse treatment funding are likely to result in reduced capacity and coverage of drug treatment services and/or the quality and effectiveness of drug treatment will be severely compromised if resources are spread too thinly – especially where service users have significant and complex long-term treatment needs. The clinical guidelines on drug misuse and dependence include recommendations on clinical practice and competence. The ACMD is concerned that there could be a mismatch between these national guidelines and what underfunded local drug misuse treatment systems are able to deliver.
The effects of reduced resources appear to be compounded by services at risk of disruptive and frequent re-procurement that drains vital resources and creates a ‘churn’, resulting in poorer service user recovery outcomes, at least in the short term.
Moving drug and alcohol misuse treatment into local authority public health structures appears to have been detrimental to treatment in the context of the financial challenges faced by local authorities. In this complex and changing context it is difficult to see how current levels of drug (and alcohol) misuse treatment coverage and outcomes will be maintained over the next few years without significant extra efforts to protect investment and quality.
The ACMD has reviewed and assessed the report in light of the Government’s recently published 2017 Drug Strategy. While the ACMD welcomes the strategy’s recognition that “effectively funded and commissioned services, targeted at helping people fully recover from dependence” are crucial, decreasing local budgets and a lack of levers make it difficult to see how this aspiration can be delivered.
Despite the continuation of the ring-fenced Public Health Grant to local authorities until April 2019, reductions in local funding are the single biggest threat to drug misuse treatment recovery outcomes being achieved in local areas.
Recommendations National and local government should give serious consideration to how current levels of investment can be protected, including mandating drug and alcohol misuse services within local authority budgets and/or placing the commissioning of drug and alcohol treatment within NHS commissioning structures.
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.
National government’s commitment to develop a range of measures which will deliver 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 (PHOF), to provide levers to maintain drug treatment penetration and the quality of treatment and achieve reductions in drug-related deaths.
The quality and effectiveness of drug misuse treatment is being compromised by under-resourcing.
Recommendations 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 and ineffective services.
The Government’s new Drug Strategy Implementation Board should ask PHE and the Care Quality Commission to lead or commission a national review of the drug misuse treatment workforce. This should 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 the situation in England against other comparable EU countries.
There is an increasing disconnection between drug misuse treatment and other health structures, resulting in fragmentation of drug treatment pathways (particularly for those with more complex needs).
Recommendation Local and national government should consider strengthening links between local health systems and drug misuse treatment. In particular, drug misuse treatment should be included in clinical commissioning group commissioning and planning initiatives, such as local Sustainability and Transformation Plans (STPs).
Frequent re-procurement of drug misuse treatment is costly, disruptive and mitigates drug treatment recovery outcomes.
Recommendation Commissioners should ensure that recommissioning drug misuse treatment services is normally undertaken in cycles of five to ten years, with longer contracts (longer than three years) and careful consideration of the unintended consequences of recommissioning. PHE and the Local Government Association should consider the mechanisms by which they can enable local authorities to avoid re-procurement before contracts end in systems that are meeting quality and performance indicators.
The ACMD is concerned that the current commissioning practice is having a negative impact on clinical research into drug misuse treatment across NHS and third (voluntary) sector providers. Many treatment providers are third sector and current research structures are not designed to recognise them. System churn due to recommissioning and reduced resources mitigates the stability and infrastructure required for research.
Recommendation 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.
Last revised 11 March 2018. First uploaded 29 January 2018
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