NATIONAL TREATMENT AGENCY: the beginning
This article was published in March 2001. It is still relevant today.
Its expert recommendations were ignored – leading, seven years later, to the predicted inconsistent practice and resultant disillusion with NTA and purchasing/ commissioning procedures
What is the scope of the NTA? What reaction did providers give during the consultation process? Deirdre Boyd gives details.
As a result of the government’s cross-cutting review of drugs expenditure last year, Home Secretary Jack Straw revealed in June that it would set up a National Treatment Agency for substance misuse. Its aim is to raise standards and ensure consistency of drug treatment across the country.
A draft list of functions for the NTA was discussed at a forum in September with over 50 representatives – providers and purchasers, from statutory and non-statutory bodies – from the drug-treatment field.
Officials from the Department of Health, the Home Office and the UK Anti-Drugs Coordination Unit worked since then on a consultation document . The end of last January saw a day of workshops with treatment providers and representatives from the NTA team to analyse this.
The workshops came to their conclusions independently – but all had two key recommendations in common. The first was about the inclusion of alcohol. The unanimous view was that “drugs” and “substance misuse” should be defined to include alcohol. And alcohol should be included in its entirety, not piecemeal.
The second was that urgent action is needed to make Drug Action Teams effective. The NTA is depending on Dats for its plan to work – but the overwhelming and unanimous view was that, while a tiny minority of Dats were good, the vast majority just did not work. They were not trusted.
The other findings in this article were reached by the workgroup I attended, headed by Kevin White, who has been seconded from the Drugs Prevention & Advisory Service to the Youth Justice Board. But before moving on to these, let’s look at the NTA’s guiding principles and functions.
Neil Townley, head of the NTA team in the DoH, states that “The contribution which substance-misuse treatment makes to the government’s drugs strategy and its treatment and crime-reduction targets can by improved by (i) increasing the numbers of clients treated and (ii) raising the effectiveness of their treatment”.
Effective treatment stems from effective assessment. So one workshop suggestion was that this last sentence be extended to include “…starting from accurate, accessible assessment”.
The proposed remit is in four sections: performance management and development, commissioning, development of the knowledge base, and policy management and development.
One immediate recommendation is that such a centralised unit must be appropriately funded. And these funds must not be money hijacked from other effective treatment areas.
PERFORMANCE MANAGEMENT & DEVELOPMENT
This encompasses treatment and purchasing standards and consistency of performance. NTA goals are to:
provide national guidance on model treatment services and patient critical-care pathways, amendable in the light of evolving research
provide regular, detailed guidance on treatment provision to Dats and local agencies, to align plans
provide Dats with guidance on needs assessment protocols, so resources are optimised
local consultancy to Dats
set minimum national standards for treatment quality and outcomes, both for improvements and as the base for a possible accreditation system
work through regional performance management agencies and systems – NHS regional offices, social care and government office regions and regional Drugs Prevention Advisory Service teams – to monitor each Dat against national standards, and to track treatment expenditure in each area
a human-resources strategy to guide Dats so that delivery of services is not compromised by skills shortages.
It is suggested here that the funds/infrastructure be delivered through Dats – but quality of Dats is hugely variable and not trusted across the board.
One suggestion was that there could be a shifting hierarchy in the Dats for this specific purpose. The role of Dat coordinator could be reviewed, for example, so that s/he guides the Dat, has a sound knowledge base, and has power to ensure compliance. The NTA could draw up a job specification for this.
This led into a debate about neither joint commissioning groups nor Dat coordinators actually doing the purchasing of treatment. The situation has not been helped by growing numbers of Dats, nor new Dat boundaries being set (aligning to local authorities).
There was agreement that Dats need guidance. There is a high level of "unawareness". The NTA needs a carrot-and-stick approach, the stick to include sanctions if performance is not satisfactory.
But if one area or Dat is doing badly, what can the NTA do? Take an inspection role? Sanctions? If so, what form? It was agreed that sanctions must never be at the expense of the patient/clients. And, at the end of the day, the aim is to work through difficulties.
There is a need for the NTA to advise Dats on needs assessment. Finally, it was suggested that a “roving” centralised pool of “inspectors” be created to improve Dat performance and standards.
To reduce variations in access to treatment services, not only does the NTA envisage performance improvements but also the possibility of taking on a more practical role. It could, for example, establish collaborations for regional joint commissioning “based on the good progress that Dats have made and continue to make in this area”(!). The NTA particularly wants to ensure treatment provision for Drug Treatment and Testing Orders.
Most providers felt that a local or national purchasing structure works, but that a regional structure does not. They also agreed that there must be a balance between statutory and non-statutory purchasing, a level playing field.
And, due to their paucity, is there a case for residential-care contracts to be handled nationally rather than locally? And should halfway houses and home-less units be included in this category?
“One standard assessment by one centralised body,” was offered by White. “But we must look at the mechanisms. This will free up part of LAs' budgets rather than being taken from them.”
Should the NTA contract-out assessment? Should it contract-out contracts? Then Social Services and the like would have to compete with others.
Guidance was also recommended as to level of manpower in the commissioning team. Comparing geographic areas in the group, levels of manpower have had noticeable effects on commissioning – the higher the manpower, the more effective and balanced the commissioning.
ASSESSMENT IS KEY
But it is hugely volatile across the country. Richard Ward of Broadreach House referred to some LAs consistently getting above-average results from the patients they send, others getting consistently below-average results from their patients. So some commissioners are getting assessment right, while others cannot manage this.
There needs to be a defined continuum of care from assessment onward up to/including resettlement. “And this continuum of care needs to be managed,” White advocated. It was also noted that departments can be driven by individuals prejudiced for or against certain treatments and this can be more powerful than any formal system. Can this be addressed?
There are wide variations in standards between organisations. Centralised purchasing must not be used to drive down costs and thus quality of care. But perhaps there could be a pricing infrastructure, such as bandwidths of prices?
At the moment, charities bear the financial costs/shortfall but “we cannot keep running at a deficit," said one provider. It was stated that funding had become increasingly difficult and worrying rather than improving or even staying stable. This is particularly ironic against a backdrop of DTTOs and the treatment needed to fulfill them.
We need transparency and perhaps ring-fencing – this incurred much debate – in pooled budgets.
“The NTA and funders should fund outcome research. And providers should build this outcome research cost into bids,” added White.
Generally, it was agreed that there must be parity in pay scales between drug and alcohol workers. Non-specialist workers must increase skills. There must be a career structure in the field. And capacity development must go wider than the field.
Human resources strategy must address training. Inspection and performance management exists in the regional infrastructures – but they they lack the specialist advisory knowledge. The NTA hoped that DPAS could provide this – but the DPAS people themselves need specialist training in treatment as they specialise mainly in prevention work.
In fact, should the NTA be involved in pushing medical schools to include a necessary quantity and quality of substance-abuse training?
Finally, having assessed best practice and the best knowledge base, how do we disseminate the results? How can the NTA get people to pay attention? Its workshops and this article are a start – what are your views?