effective strategies to commission drug and alcohol services
TRANSCRIPT
Taking Steps Towards Effective Strategies to Commission Drug and Alcohol Services
Delivering Excellence in Drug and Alcohol Services: Improving Treatment and Recovery 18th March 2015
Jim McManus, ADPH Co-LeadDPH, Hertfordshire County Council
Coverage
• Lessons from the 2014 Review of Drug and Alcohol Commissioning by Public Health England and the Association of Directors of Public Health
• Analysing successes and challenges in putting community-based prevention and recovery at the heart of substance abuse treatment strategy
• Understanding the impact of the localisation of drug and alcohol service provision
• Encouraging innovation in service provision and prevention initiatives
• Sustaining support measures throughout periods of service and agency restructuring
The Major Changes
• Public Health into Local Government
• Drugs and Alcohol services within PH Portfolio
• Move to Recovery and evidential challenges
• Care Act 2014
• New Probation arrangements
2014 Review Key Themes• except where retendering exercises underway or recently
introduced, 2013-14 has steady state • 2014-15 and 2015-16 will see a focus on reassessing current
service provision with the view to recommissioning• over 70% of respondents indicated that they were not planning to
reduce funding in 2014-15. Of the 70%, over 50% reported no change, nearly 10% an increase in funding, while the remainder indicated uncertainty as to future plans
• there were planned realignments of resources between alcohol and drug services – with alcohol assessed as the greater need
• there was a focus on improving outcomes, continuing the move to a recovery model
• improved delivery and performance by providers a clear aim in all recommissioning, with a focus on improving treatment completions
Key Issues• many areas are exploring the integration of services –with alcohol
services, wider services such as housing, criminal justice, and local health delivery
• involvement of public health and PHE welcomed, particularly the advice on commissioning.
• DrugScope, representing service providers, similar to views expressed locally. focus on the volatility of funding, the continuous drive to reassess and retender, the need for commissioners to understand the impact frequent tendering processes have on providers
• Association of Chief Police Officers (ACPO) emphasised the value it places on the importance of effective drug treatment services to the criminal justice agenda, ensure any reductions or changes do not reduce the effectiveness of services, as this could prejudice crime-reduction benefits of the current approach
Key Opportunities
• the majority of commissioners want to transform and make services more efficient
• local authorities are adopting a variety of approaches but overwhelmingly want to make services more effective.
• there is a close scrutiny on current commissioning arrangements and this includes funding.
• However, there is a clear desire to ensure that services continue to improve, and that while value for money is a key driver, so is quality of service
• the review shows that there is little intention to simply disinvest in services, but to bring a rigour to commissioning focused on needs of the population and on outcomes for the services
• ADPH and PHE believe these needs can be best met as part of the sector-led improvement process.
Key Opportunities 2
• massive opportunities for whole system approaches and integration once commissioners have got through the initial transfer
• Directors of public health have an important leadership role in bringing partners and stakeholders together and in looking across the whole system to further their shared aspirations of integration
Key Opportunities
• Integration – Drug and Alcohol Boards
• Health and Wellbeing Board
• Whole System Approach – Boards, Governance (eg Herts Board)
• Localism -
• Innovation– Recovery social enterprise– Recovery models– Integrating services
Steps to a commissioning approach – much done in
parallel
Step 2: Building the Commissioning Landscape
• Bring partnerships together – Formation of DASB as overarching
partnership– Elected member led
• Public Health led commissioning cycle and approach from County
• Working with every other agency (Sports Partnerships)
Monitor/ Evaluate
Plan
Review Need for Service and
Effectiveness of existing services
Public Health Input into the Commissioning Cycle. Can be throughout or can be on
specific areas playing to the PH strengths
Community Engagement
Support in establishing meaningful indicators of delivery and outcome
Model whether need willBe met by proposed volume
Check whether plans equateTo evidence and need andTest for equity / inequity
Support and advise onEvaluation and conductBits of it if enough resource
Needs AssessmentsEquity AuditingEvidence of EffectivenessHealth Impact Assessment
Triangle of critical influence – where public health should be most visible
Contract/Deliver
Triangle of critical influence
Triangle of critical influence
The principles of our commissioning approach in Herts: building the house while living in the foundations
1. Build a system from the best we have, don’t reinvent2. Transformation through phases and staged redesign3. See potentials, not problems4. See Potentials not Problems, assets as well as needs5. Subsidiarity 6. Co-production7. Behavioural Sciences8. Pathwayed
Working out who does whatLead Enforcement and
ControlPrevention Support,
Treatment and Care
Community Safety
County Community Safety Unit
County Community Safety Unit?
Probation, NHS, Public Health
Domestic Violence
County Community Safety Unit
Domestic Violence partnership
?Childrens Services
Drugs and Alcohol
County Community Safety Unit
Both working together
Public Health
Alcohol related violence
County Community Safety Unit
Multi agency NHS Acute Trusts
People with learning disabilities who are victims
County Community Safety Unit
Multi agency LD Partnership
Innovation Example: DIP Pilot
• Commissioned icpr at Birkbeck to evaluate the project
• Currently trying to rework criminal justice aspect of drugs services
• Challenge in that PI says drug testing and treatment responsibility of DPH. No funding for this
• Compulsory drug testing – at least as practised during the first year of the pilot – did not result in a higher proportion of criminally involved drug users entering and being retained (for 12 weeks) in treatment.
• There were no significant changes in levels of self-reported substance use, health and social functioning following exposure to compulsory drug testing.
• Exposure to compulsory drug testing did not significantly reduce the rate and volume of re-offending across Herts, or increase the time taken to re-offend.
• More adaptive/responsive forms of intervention needed for those with more extensive offending histories, and involved in income-generating property crime (versus drug possession offenders).
• Recovery & desistance outcomes being achieved?– Perception that IOM an effective form of crime reduction (but no
counterfactual e.g. in quarterly reporting)– But greater clarity of intervention objectives needed around substance
use (including NPS) and responses to continued use (e.g. DRRs).
• Strategic fit, future commissioning & governance structures– Custody data indicates potential demand for test on arrest elsewhere– But tighter performance framework & scrutiny needed (“what get
measured gets done”)– More broadly, formal governance structures around drugs and work
with DUOs considered as 'a work in progress'
Key Challenges
• Effectiveness
• Austerity
• Population Trends – Chemsex, Offending
• Probation Instructions say DsPH have responsibility for testing. DsPH don’t have money
• Localism
• The rehab sector
Systems thinking
The wider determinants of Health and Local Government functions (Must adopt a Lifecourse approach!)
The Lives people lead and whether LA functions help or hinder healthy lifestyles (policy, service quality, access, behavioural economics, behavioural sciences)
The services people access such as primary care (high quality, easy access, good follow up, behavioural and lifestyle pathways wrap around)
•Our health and our offending occurs in a system•Criminology and public health/epidemiology share some concerns in the literature
A plea..• Page 11 for the figs on spend.•
http://www.local.gov.uk/documents/10180/6869714/L14-794+100+Days+Alcohol+Misuse_v10.pdf/e3b71f8f-9bb5-4b6d-8ac4-041bdc215c95
• The LGA has called for a clear commitment from the department of health for an increase in resources to a level that will maximise the value for money available from well targeted investment in public health.
• Need to make the the case for public health and show how it saves lives but also saves money.
• The elected members should be your ally. Meet them, introduce them to people, share their thoughts, look for opportunities to raise their profile in your policy area.
A plea 2
• There was never a “golden age of public health” in the NHS so let’s not pretend that there was.
– You had local variation, raids on budgets and executive indifference to prevention in the NHS too. Local accountability and transparency in public health is now very real. Was there ever such a degree of transparency of both inputs and outcomes prior to the transition within PCTs
– Public health was often seen as the 'Cinderella service' of the NHS, operating as an add-on to their main business of treating sickness and constantly pushed to the back of their priority list. Too many organisations at a national and local level confused rather than clarified matters.
• Councils deliver over 800 services that will to a greater of lesser degree impact on the health of our communities. Have you made the connections and truly realised the synergies?
Final thoughts
• Prior to transition there was too much reliance on top-down targets that sapped local initiative, the result, was a system which did not deliver the step change in public health outcomes that the country needs or secure the common understanding that health is about much more than just healthcare.
• There is a case to be made that public health spend has historically been too low to achieve a significant and sustained positive impact on health outcomes and on health inequalities. Looking forward it will be important to ensure that the total resources available for public health are sufficient to meet needs.
• Councils in some areas have serious and well-founded concerns that the future public health investment in their communities could fall well behind likely need.
