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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