Wednesday, 18 July 2018

Why service user choice might frighten commissioners

I wrote down some thoughts a couple of weeks ago, prompted by the EXCO conference hosted by the Expert Faculty on Commissioning.  The Faculty has since posted a summary of the conference on their own website, along with videos from the day.  (I can’t stress how valuable this is, and how unfortunate it is that our sector seems to have lost FEAD.)

Reading this again has reminded me of the core debate I had on the day, which I found very difficult.

I’ve talked on this blog before about the idea of ‘tailoring’ services to local areas, or personalised commissioning.  I had planned to talk (which I did) about the same sorts of problems, but I was extremely nervous about doing this after there had been such strong presentations on the value of service user involvement and choice in treatment earlier in the day, particularly from Kerrie Hudson.

What I’m going to do here is just post the ‘abstract’ I’d written to prepare for my presentation.  I would strongly recommend you watch the video of Kerrie’s talk as well.  You’ll find that she’s more positive about choice than I am.  That might in part be a personality thing, but it’s also about our roles: the idea of service user choice in small villages in Dorset fills me with dread – not because I’m frightened of choice or service user autonomy, but because I worry we can’t offer all parts of the county truly equitable choices.  Will they really be able to choose from the same menu of options that would be available if they lived in a more densely populated area like Poole or Bournemouth?

This isn’t an easily resolved question.  In fact, I’m not sure it can ever be resolved once and for all.  The idea of equity of service isn’t a unique problem for substance misuse services, and it’s not something that’s ever going away.  Looking at the programme for the conference, for all the optimism about new technologies and tailored treatment driving improved outcomes and greater efficiency, I just felt we needed a dose of pessimistic realism about what that might mean for commissioners.

And, to the great credit of the conference organisers and all the attendees, my fears were largely unfounded: there was a very reasonable, realistic discussion of what the future of treatment might look like, as opposed to the soundbites some of us have become inured to.

So here it is, my contribution to that necessary, never-ending debate.

Individualised treatment planning: what are the goals and the reality
It’s common to hear how ‘individualised’, ‘personalised’ or ‘tailored’ treatment are best practice, and indeed the future.  It’s virtually impossible to think that tailored treatment could be a bad thing: shouldn’t a care plan by definition take account of the individual service user’s strengths and weaknesses, needs and assets?  More than this, tailored treatment is often presented as a solution to tightening budgets: it would mean we would target resources better, therefore getting more bang for our buck.  Individualised treatment is not only more effective, but more efficient.

But is this a false dawn?  As I say, care plans should already be a collaboration between the service user and a professional, taking account of the unique circumstances that person finds themselves in.  And if tailor-made things are really more efficient than off-the-peg versions, why don’t people buy tailored suits and custom-made furniture when they’re on a tight budget?

This is, like most issues, a question of balance.  We do need to take account of individual circumstances, but we also need to think about economies of scale and planning activity.  Choices in most aspects of life are more nuanced than this.  We do not have to choose between the Fordist mantra of ‘any colour as long as it’s black’ and custom-made cars; most choices are between different options on a menu.

My particular concern is that those ‘menu choices’ won’t be the same for everyone, depending on where they live.  This isn’t just about a postcode lottery of variation between different commissioners; it’s particularly about how any form of choice can realistically be offered for people who live in small towns or villages where there simply can’t be multiple options available.  This means tailored plans need to be developed not just for individual service users but more broadly for different geographical areas and local populations.

So let’s welcome service user choice and individualised treatment, but let’s not present this as a false choice between ‘one size fits all’ and ‘personal budgets’.  It’s more difficult and complicated than that.  Individualised treatment might seem attractive for if we aim to make treatment more effective, but thinking about the other ‘e’s of commissioning, even if it delivers efficiency, will it compromise equity?

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