Friday, 15 March 2019

Can we build a more trusting, collaborative substance misuse treatment sector?


I spent Friday in Manchester, at EXCO2019 – the annual conference of the Expert Faculty on Commissioning.  There were lots of fascinating discussions throughout the day, and I’d recommend catching up by looking at the hashtag on Twitter: #EXCO2019.

One of the key issues revolved around balancing ‘dusting off the old vinyl’ and doing the basics well on the one hand, with the bright shiny disco ball of ‘innovation’ on the other.  Pete Burkinshaw from PHE kicked us off with this metaphor, but pretty much everyone else used it thereafter – in fact Kate Hall had already independently written it into her presentation!

As Tony Mercer from PHE suggested (echoed by Paul Musgrave later, who hadn’t heard Tony), we might sit down at home and listen to vinyl, but it doesn’t work everywhere: you might play CDs in your car and listen to MP3s on the train.

And this was the other key theme of the conference: tailored, or personalised treatment.  There’s an idea that I’ve written about before that although we hope tailored, segmented, personalised treatment will be efficient as well as effective and fair, but we shouldn’t take this for granted.  Fordism, where every colour is available so long as it’s black, sometimes has its place.  The devil, as ever, is in the detail, and the risk with this conference (as with most others) is that it becomes a sequence of platitudes, soundbites and metaphors without taking us forward in practice.

There was much discussion of ‘optimal’ dosing, defined as 60mls-120mls of methadone per day, or equivalent.  But Kerrie Hudson had earlier noted that, for her, being able to deal with cravings in the morning with a relatively low dose of methadone (say 30mls) and then use at other times, was a stabilising factor, meaning she could carry on working.  It was appropriate for her particular situation at that particular time.

The sensible way through this is to point out that (a) the patterns of prescribing in our system don’t suggest that most people on 30mls are ‘optimised’ even by their own definition, and the actual dosage of medication someone receives shouldn’t be imposed (whether that’s through an increase or reduction); it should be a joint decision between clinician and patient to achieve a jointly agreed aim.

And that kind of approach, along with all sorts of other initiatives that could be badged as ‘innovative’ or involving ‘segmentation’ were discussed on the day.  But they remain that: isolated examples of good practice.  We don’t (yet) have a tool for segmentation that could structure these kinds of conversations that keyworkers need to have.

In the session I participated in, I had been asked to introduce a discussion of depot buprenorphine – a fact possibly not unrelated to the fact the conference was made possible by funding from Camurus, who make these devices.

I don’t object to this, though the Faculty needs to be careful not to become reliant on one source of funding, and I think local authority contributions would be more appropriate.  I saw my role as being to ask some challenging questions and bring the conversation back to those practical considerations, rather than thinking the innovation will be useful in itself.  Who will this form of medication benefit?  Where could it be implemented effectively and efficiently, given we’re living in tough times financially?

I’m not sure I got my point across, but it didn’t matter anyway, because the discussion, thanks to much more eloquent and passionate commissioners than me, took a turn to be about commissioning and the ‘sector’ in general.

This was where the conversation got interesting.  We talked about how certain metrics and processes, previously centrally imposed (like TOPs and ‘successful completions’) don’t have to be at the heart of local authority commissioning, but the point was made that this doesn’t mean agencies and staff can disregard them even if they wanted to.

As a provider, you can’t be sure that if your successful completions are low in one area because you’re being honest and retaining people in treatment, that you won’t be judged unfavourably when you tender for a contract in another area.  Not all commissioners take this view.

And as a member of staff, if you stop recording people (sometimes optimistically) as successfully completed, or don’t note that they have apparently stopped using on top or committing crime on their latest TOP form, then perhaps you’ll lose a sense of a job well done.  And how will the service user themselves be able to identify that they’re making progress?

It’s not as straightforward as a commissioner just telling a provider to relax about metrics.

And what about length of contracts?  There was agreement that long contracts were a good idea, and local authorities seem to be increasingly open to these.  But it’s not the case everywhere, and the sector still feels competitive.

Nurses leave to work elsewhere in the NHS because there just isn’t (felt to be) the same security in substance misuse.  Locally, in each of the three acute hospitals across Dorset there’s at least one nurse in the alcohol liaison/care team that used to work in the Dorset substance misuse service, and we can’t seem to recruit replacements.

Organisations feel they can’t reveal their ‘trade secrets’ (and if anyone has indeed got the ‘solution’ to ‘addiction’ there certainly keeping it secret), and the spectre of tendering can lead to tensions, fear and anger on the ground.  It’s hard to believe that doesn’t then seep into consultations, affecting service user care.

And this isn’t the fault of those frontline staff or the organisations that employ them.  It’s central and local government that have created and maintained these competitive structures.  And while some people in the room could be congratulated on creating different approaches in their area, this doesn’t change the overall picture or culture as being one of competition and sometimes open confrontation.

So I started to think about how, in practice we could make this change.  And all the themes we’d been discussing seemed to coalesce.  We don’t have clear segmentation tools.  Guidance on ‘good practice’ tends to be relatively abstract (NICE, Orange Book) or just a set of examples designed to show that local government is brilliant (the Local Government Association).  Approaches to performance management vary considerably.  Contract lengths vary wildly from 3 years to 10 or more.

This lack of consistency makes life difficult for providers, who can’t tailor their approach to one commissioner, and commissioners, who end up reinventing the wheel.

Last year, I wrote about how I could see a role for the Expert Faculty as a repository for genuine, practical examples of ‘good practice’, but this would need to be distinct from the work of PHE or the LGA.  Some of the work that could improve the situation is being coordinated by PHE through their review of opiate substitution treatment, which I’m hoping will produce some practical guidance on segmentation, enabling frontline workers to put the ‘phasing and layering’ of treatment proposed by the Medications in Recovery report into real-life practice in a straightforward way.

But there’s more that needs to be done to reshape the sector and build trust.  One thing I wondered aloud about in the session of the conference I was directly involved in was something like a charter or a kitemark for commissioning.

Providers want to feel confident they’re entering into an arrangement with someone who’s reasonable, flexible and constructive, and where they don’t have to worry about misleading metrics.

And commissioners, I’m sure, would embrace a set of principles – particularly if they could take these to elected members or senior management and explain that these (for example not re-procuring every 3 years) are considered good (or even standard) practice in the field.

I’m not going to talk much more about this here, as it’s only the most embryonic of ideas (and I wouldn’t claim that it’s original) but I wonder if it’s worth exploring further.  It would surely give both commissioners and providers the confidence to break free from the shackles of successful completion metrics and 3-year tendering cycles that occupied so much time and prompted so many sighs over the course of the day.

I often ask for comments on this blog, and rarely get any, despite hundreds of people reading it, supposedly, so I’m not expecting a great debate in the comments.  What I hope, though, is that by EXCO2020 we’ll have a clearer sense of the practical, tangible contribution of the Faculty, and whether this sort of initiative is what it should be championing.

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