This is a slightly longer post than usual, as it’s (almost) the words I spoke at the recent New Directions conference in Weston-super-Mare. For those who haven’t been to New Directions before, I strongly recommend it. There’s always an excellent line up of speakers, this year including Marc Lewis, Nick Heather and Lucy Rocca to name just a few. One of my favourites, who I hadn't seen before, was Marcantonio Spada, from London South Bank University, talking about how our beliefs about how we think and how our brains work actually affect the reality of how we think and what we do: metacognition.
I was asked to speak in a session called ‘Can we have traditional alcohol services?’, under the title ‘Who can buy an alcohol service?’ So here goes…
Morning everyone. I feel like I should start this talk with something of a disclaimer, maybe get my apology in first. In fact, three apologies. First, I'm going to talk to this title of ‘Who can buy an alcohol service’, but I’m not entirely sure what it means, so I'm going to use it an opportunity to present some kind of ‘state of the nation’ reflections from my job as a commissioner of substance misuse services in Dorset
Second, I'm worried about the length of this. But I shouldn't be much more than 20 minutes.
Finally, I don't explain too much of the nuts and bolts of commissioning, or who does what - it's part of my shtick that it's complicated, so maybe I don't want to destroy the mystique. But equally, please stick your hand up or shout out if I'm talking about something you'd like explaining. In my job, it's an extremely unfunny running joke that we talk in acronyms we can't actually spell, left alone explain. Fundamentally, I'm a commissioner, which means my employer - Dorset County Council or Public Health Dorset - pays the NHS or charities to provide treatment for what, despite Wulf's powerful and persuasive points yesterday*, I'm going to simply call 'substance misuse'. And that should really be a fourth apology, before I've really started.
Oh, and a fifth: I'm talking only about my experience, which I'm aware is very English. It's not even British. The systems in Wales and Scotland - not to mention Northern Ireland - are notably different.
But back to that title. The simple answer to this title question is: loads of people. I think it’s a truth universally acknowledged that at the moment commissioning responsibilities are hugely fractured within the public sector.
This diagram, which I showed when I spoke at New Directions last year, is meant to be a helpful explanation of the NHS in light of the Coalition Government’s reforms – which included the transfer of all commissioning funds for substance misuse treatment to local authorities. I don’t find this helpful – apart from to illustrate the mind-boggling complexity of the current arrangements. And it doesn’t even cover some crucial elements that potentially relate to substance misuse, such as housing, or employment.
And this is where we might think we could run into problems.
I’ve written and spoken before about how the shift of responsibilities for drug and alcohol treatment from the National Treatment Agency to Public Health England wasn’t just semantic; there is potentially a genuinely different worldview associated with these different organisations. And the different commissioners might have very different ideas of what the ‘problem’ with alcohol is, who the relevant potential ‘clients’ are, and what a positive ‘outcome’ would be.
But my comment last year was that we shouldn’t see this chaos or complexity as necessarily a bad thing. Perhaps it would be neater and easier for commissioners and providers if we had straightforward, simple structures for ‘alcohol’ services, but of course life – including addiction, or dependence, or problematic use – is more complicated than that. I’m going to stick my neck out and say that it doesn’t make much sense to look at alcohol use, or addiction, as separate from other elements of a person’s life.
Once we’re thinking about a person’s life as a whole, are the problems, the clients, or outcomes really that different for different organisations?
And I’m not going to deny that this is an issue, particularly when resources feel scarce. There are arguments about who should be funding alcohol liaison nurses in hospitals, for example. The acute trust or CCG might state that this is surely about public health, but the local authority Public Health team is likely to reply by saying that it’s the hospital that will save money by having fewer admissions, so shouldn’t they be the ones investing to save?
But my point is to ask whether we’re really as far apart as it might seem. Whenever I sit down with commissioners or providers – be it in relation to the police, housing, or mental health – it’s immediately clear that even if we’re not talking about exactly the same people (and we often are), then we’re talking about many of the same causes, symptoms and solutions: stable housing, strong personal relationships, stable employment, and so on. All these things boost people’s chances of turning their lives around.
That is, when it gets down to serious discussion, we're actually pretty agreed about what a positive outcome is, and how to get it.
This is the attraction of a programme and slogan like ‘Jobs,Friends, Houses’ and the idea that addiction is simply an absence of social connection – an idea recently popularised by Johann Hari, citing the research of Bruce Alexander, who spoke at this conference last year.
And this is why I’m sometimes sceptical of the idea that there should be ‘alcohol’ services, or that we should think of ourselves as part of an ‘alcohol’ sector – or even a ‘substance misuse’ sector. We need to make sure services are linked together and think about the ‘whole’ person, or the ‘whole family', to use the buzzwords of the moment. As Nick Heather put it last year when discussing this, ‘addiction is a problem of living’. You can’t separate it out from other aspects of life; it is part of life, part of living.
But one of the problems with that approach is that there isn’t a neat distinction between cause and effect, or symptom and disease, as there would be in an ideal medical/scientific model. What I mean is: substance misuse can be both a cause of and caused by unstable housing, relationships and employment. These are potentially part of a complex cycle (which may be vicious or virtuous). So it might be that for some people, a housing first approach, or ensuring stable accommodation, starts them on the road to recovery. But for someone else, this would be at best a harm reduction strategy, and no real change can be brought about without addressing alcohol use head on, and the primary problem. Without being flippant, there isn’t one definition of an alcohol problem; there are myriad (in fact infinite) problems where alcohol is implicated.
All I’m trying to say here is that although different people and organisations might agree on outcomes, on a broad definition of what the ‘good life’ might be, this doesn’t mean that services can just be reduced to generic ‘life’ support. There is a need for something alcohol specific.
So if there’s a need for alcohol services, that brings us back to that question of who can (or should) be buying them.
As I said at the beginning, there’s loads of organisations that can buy something that could be badged as an alcohol service. And I’m not really precious about this.
But I want to make two critical observations or suggestions about the way things work at the moment.
First, I think debates about the perfect place to house budgets or responsibilities in relation to alcohol are a waste of time. (Though I still often engage in them!)
I might have a view that local authorities aren’t the best place to house commissioning of structured treatment that involves prescribing, but there it is, and to be honest it doesn’t make a great deal of difference what building I have to work in. The politics and debates will be different, and the pressures and priorities might change, but they won’t go away.
I could complain about how it’s difficult to harmonise or integrate local authority commissioning with the CCG, or NHS England, or the Police, but fundamentally these barriers will always exist - and they even exist within organisations. Even though Public Health is now nominally part of local authorities, this doesn’t mean that there is wonderful integrated commissioning with housing and homelessness support, or social care, or children’s services. These things are pot luck, perhaps a ‘postcode lottery’.
And that’s the crucial bit. They’re down to local decisions and working relationships. That is, the fundamental issue isn’t the structure, but the people. We know this in treatment: that potentially the single most important thing in your treatment is the therapeutic relationship with staff.
But we don’t talk about it so much in broader policy terms. Politicians and broader policymakers and influencers such as think tanks seem to think that we’re justone grand reform away from having the perfect structure to address a problem. If only we had truly ‘joint’ commissioning, or ‘integrated’ budgets.
But this is a fight with an imaginary enemy – or at least an eternal, elusive enemy.
We’re talking about substance misuse, or as I mentioned earlier, all aspects of life. And that means that there can never be a single, perfect way to cut the cake, and equally you can’t just commission ‘life’ support services (if you’ll pardon the pun). To take a simple example: first aid, x-rays, possibly surgery, casts, check ups and physiotherapy might all be part of healing a broken bone – but they’re not delivered or managed by the same person, or the same service, or in the same place. The key is to make sure the different organisations and people talk to each other and work together, for the good of the patient.
And the same is true for commissioning or providing alcohol services. The organisational boundaries will never be perfect; it’s about working to ensure whatever system is in place is as efficient and effective as possible.
So that’s the first point: let’s not imagine that there’s a perfect solution that we just have to reform for in terms of organisational boundaries or responsibilities. In my experience, the reality is that pooling budgets and joint commissioning are a pipe dream in any case, even for relatively small areas or themes. Any form of ‘joined up services’ is best implemented by simply getting on with it at the coal face and coordinating front line services in practice.
So there we go, that’s the first word of the title out of the way: the ‘who’. The answer (or dodge) being that I don’t really mind, but at the moment there’s loads of people.
I promise I’ll get onto the other words.
And to be honest, I’ve already covered ‘alcohol service’. It’s too narrow, but equally some type of service that’s specific to alcohol (or at least substance misuse) is necessary.
So what are we left with?
The key bit is that word ‘buy’. There’s no doubt that we currently do ‘buy’ services from either the NHS or third sector organisations – or in fact in some cases, as in Bath and North East Somerset just up the road, from private providers like Virgin. But I want to suggest that the word ‘buy’ in this context is misleading about what’s happening, or what perhaps could or should happen.
We think of commissioning as buying, and of buying as being something to do with this mythical idea of a ‘market’, or at the very least ‘competition’. But the reality is nothing like buying breakfast cereal in a supermarket.
My job isn’t really about procurement or purchasing. In fact, there’s a procurement team within the council who deal with the actual purchasing and contracting – which only happens every few years in any case. My job is to help design services and work with managers to ensure the right sort of things are being done and we’re getting the outcomes we all want. In fact, you’d probably best describe it as being either some kind of manager or a service design and development officer. But I suppose we call it commissioner because that’s the popular or fashionable language. And in reality, my actual official job title is the meaningless ‘Senior Health Programme Advisor’.
Commissioning, as defined by government, academics and think tanks, is about much more than buying, purchasing or procuring – however you want to label it.
If you look at the model of commissioning from the Institute of Public Care at Oxford Brookes (where I did my commissioning qualification), you’ll see that the actions of ‘analyse, plan, do, review’ could equally apply to any form of service delivery. Maybe that inner circle wouldn’t apply, but if you just look at the outer ring relating to commissioning, it’s hard to imagine any sensible service not operating something along these lines: think about what you might do; do it; see how well it went.
So in some ways, this model of ‘commissioning’, where we emphasise procurement, isn’t actually that important. In itself, it shouldn’t really change the assessment of need in the local community, or the design of services. (I’m not making any comment here about how those things are shaped by local or organisational priorities, and the fickleness of politics in funding decisions.) And as anyone who’s been through one of these processes knows, there’s a lot of discussion about transfer of staff from one provider to another, and you can often end up with much the same people doing much the same job, but perhaps under a different organisational banner.
But, based on a procurement process I’m in the middle of at the moment – and so can’t say too much about – I think there are potentially significant effects of this approach. Fundamentally, a huge amount of my time over the past year has been spent:
- writing reports for committees to approve certain budgets and processes;
- writing service specifications for new contracts;
- writing evaluation questions for prospective providers; and then
- conducting evaluations;
- organising and marking interviews; and
- writing feedback.
There are positives to this: it means we can re-shape services, and we’re planning carefully for that. But it comes at a cost – even if that cost is simply that we have to spend less time on the usual quality assurance or service development work.
And this is where the market analogy breaks down. That just isn’t the same as any market I’ve ever shopped in. You don’t buy years’ worth of Weetabix, find you don’t really like it or it’s leaving you hungry by mid-morning, and then just say: “well, I’ll just have to stick with it for another year or 18 months till I can buy something else”.
I know this is a flippant example, but it is actually relevant. Within this model of procurement and commissioning, there is undoubtedly waste and miscommunication. Some people have suggested to me that there would be much less stress and miscommunication if the whole process was less formalised. In fact, if it was simply an ongoing conversation as it is outside of procurement periods. And rather than setting up evaluations as a kind of exam, or jumping through hoops (“we’re not going to specify who our key partners are; it’s a test to see if they know”) commissioners and providers could just have a direct conversation.
And in fact we can run procurement more in that way. There are ways we can do this whole thing called ‘commissioning’ better. For example, the idea that local authorities must go out to tender every three years is a myth. Commissioners can be more creative – particularly in the current climate where all bets are off about the future of local government funding and NHS commissioning practices. The current regulatory framework allows for decision to be postponed in exceptional circumstances, and if the circumstances today in terms of changing budgets, shifting commissioning responsibilities, local government reform in many areas, and so on aren’t exceptional, I’m not sure what would be.
Moreover, decisions don't have to be made on the basis of price. We've set a budget, and we’re judging providers on how they're planning to spend that money (how much goes on ‘front line’ service delivery, for example), and how credible those plans are.
And this is my plea, then, to finish this rambling presentation. Or rather, my two pleas.
First, we all need to campaign to make the system better, by which I simply mean ‘more efficient’ – which is ironic, given that commissioning and the supposed ‘market’ model is meant to be efficient by definition.
But as I said earlier, changing the system isn’t terribly useful in itself. Usually the most efficient thing is to work within whatever is in place in the most sensible way possible – particularly given that what really matters is the people involved. If you’ve got the right people, and they’re motivated, they can make good things happen.
And that’s the second plea. We all – whether providers, commissioners, or interested observers – need to work in ways that make that system as close to optimal as it can be. Let’s be pragmatic, canny, and calculating. For example, why drive some charities out of business by competing in a zero-sum way? Providers should be working in partnership, and not simply seeking to hoover up additional market share. I know that’s easy for me to say, as I’m not a ‘business development’ officer whose salary is dependent on bringing in new contracts. And I know commissioners have been guilty of setting up these conditions in which that kind of competition happens. But both commissioners and providers can work differently.
And that brings me onto my final point, which I think the organisers of the conference were wanting to get at with this session, entitled: ‘Can we have traditional alcohol services?’ I think it’s getting harder to imagine, with the financial pressures as they are, that it would make sense to commission or provide a standalone alcohol service. Increasingly, there are pressures to reduce transaction costs, which means commissioning one contract across an area, and let’s not forget that ‘joint commissioning’ is the flavour of the month.
But that doesn’t have to mean having just one agency. It’s very possible that partnerships can exist, whereby a specific service or organisation with something to add provides the bit of the treatment system where they have expertise – say in club drugs, or perhaps alcohol, or even a specific element of alcohol – for example engaging increasing risk drinkers, rather than fully fledged dependent drinkers. They might have specific expertise, or a local profile and reputation. That could be what makes them particularly good at doing this on a relatively small, specialised scale. And actually that specificity and expertise could be provided under a different banner or service, but by the same overarching organisation. Wouldn’t that still be a dedicated ‘alcohol service’? It’s not inevitable that specific or local expertise will be wiped out by ‘the market’.
So in conclusion, let’s not paint commissioning in simplistic terms as a form of magic market, or the devil’s work. It’s just a word, and a broad set of principles that are reliant on people doing sensible things.
Of course, the context is the reduction of public sector budgets, and the idea that local authorities will be self-sufficient and fund all public health services (including substance misuse and sexual health) through business rates in a couple of years. But that’s a tale for another day. For the moment, I’d just answer the question: ‘can we have traditional alcohol services’ by saying, ‘Yes, if you actually want them enough.’ Whether we should – well, that’s a question for someone else.
* We talk about substance misuse, but not all substances are drugs, and the word ‘drugs’ is pretty meaningless, as Toby Seddon (amongst others) has pointed out. And what about that word ‘misuse’? Is it misuse to use substances that are narcotic, psychoactive or in some way affect one’s brain, for precisely that reason: to alter one’s mental state?