ACMD warns about consequences of funding cuts

Last week (6 September 2017), the Advisory Council on the Misuse of Drugs (ACMD) published a new report (with one of the longest sub-titles you will see):

Commissioning impact on drug treatment: The extent to which commissioning structures, the financial environment and wider changes to health and social welfare impact on drug misuse treatment and recovery.

ACMD reports have a quaint tradition of being sent to the relevant Home Office minister (Sarah Newton in this case) with an introductory letter which forms the introduction to the report. In this case, Dr Owen Bowden-Jones, the Chair of the ACMD, doesn’t mince his words:

In brief, the ACMD has concluded that drug and alcohol treatment appears to be facing disproportionate decrease in resources, likely to reduce treatment penetration and the quality of treatment in England.

He also goes on to say how this situation is aggravated by constant repeat commissioning:

This situation is compounded by frequent re-procurement of services that is using vital resources, creating unnecessary ‘churn’ and disruption and resulting in poorer recovery outcomes – at least in the short term.

Context

The ACMD starts by reflecting on the significant recent changes in the commissioning of drug treatment with local commissioning moving from health to local authorities (overseen by Health and Wellbeing Boards); stating the changes had strengths and weaknesses. On the positive side, drug treatment was easier to align with other local authority and public health-related issues. However, there also appeared to be negative aspects, including “challenges” to local authority budgets. Another downside was an increasing disconnect with wider health commissioning and provision.

Resources

The ACMD found themselves in the frustrating position of being fairly certain that there had been a substantial reduction in drug treatment funding but being unable to substantiate this from official data:

The majority of evidence from providers and commissioners described a level of reduction in funding, which was not apparent in published local authority financial returns.

The report also highlights evidence from the King’s Fund which stated that cuts in public health services were planned up to 2020–21, particularly for drug misuse (and alcohol) treatment.

Re-procurement

The report pays lengthy attention to the English habit (I would use the word “disease”) of frequent re-commissioning. Interestingly, many commissioners and some providers saw the merits of re-procurement, mainly in terms of system change and “efficiency savings”. However, the ACMD also recorded a number of negative impacts:

‘churn in the system’ causing instability, disruption of local system performance and negative impacts on treatment outcomes in the short term.

An ACMD survey of commissioners found:

• 71 per cent (20 out of 28 who responded to the question) reported a negative impact in the 3 months prior to the start of a contract;
• 66 per cent reported a negative impact in the 3 months after the start of a contract;
• 62 per cent reported a negative impact up to 6 months after contract start;
• 44 per cent reported a negative impact a year after contract start; and
• 23 per cent were still reporting a negative impact after 2 years.

Re-procurement was also reported to be an expensive process for commissioners and providers. Some commissioners reported having to ‘fight’ for contract lengths of more than three years; others were frustrated by delays in local decision-making processes, which led to rushed processes and poor transitions.

Conclusions

The ACMD expresses in direct terms its concern that reduced funding may be doing serious damage to the treatment system:

A system that has been seen nationally and internationally as highly successful is at risk of being undermined. The ACMD is concerned that loss of funding will result in the dismantling of a drug misuse treatment system that has brought huge improvement to the lives of people with drug and alcohol problems.

The report also highlights concerns that reduced funding will lead to increased levels of blood-borne viruses, drug-related deaths and drug-driven crime in communities.

Recommendations

The ACMD makes five recommendations to protect drug treatment services which I paraphrase below:

1. Government should consider mandating drug and alcohol misuse services within local authority budgets and/or placing the commissioning of drug and alcohol treatment within NHS commissioning structures.
2. National bodies should develop clear standards, setting out benchmarks for service costs and staffing to prevent a ‘drive to the bottom’ and potentially under-resourced and ineffective services.
3. Government should consider strengthening links between local health systems and drug misuse treatment. In particular, drug misuse treatment should be included in clinical commissioning group commissioning and planning initiatives, such as local Sustainability and Transformation Plans (STPs).
4. Commissioners should ensure that recommissioning drug misuse treatment services is normally undertaken in cycles of five to ten years.
5. The Government’s new Drug Strategy Implementation Board should address research infrastructure and capacity within the drugs misuse field.

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