WHAT CHALLENGES MUST RECOVERY PROVIDERS PREPARE FOR IN 2013?
High hopes raised by the Drug Policy 2010 have been dashed in implementation, rehabs are closing – and commissioning is changing with localism, Public Health England, Health & Wellbeing Boards, GP commissioning, Police & Crime Commissioners, Payment by Results… Starting with Nick Barton, we identify issues so you can defuse them.
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The US TV and film writer, director and comedian Mel Brooks and his pal Carl Reiner produced a (vinyl) record titled The 2013 Year Old Man, on which Reiner interviewed Brooks as a man who lived since the year dot/0. Looking over his long life, he provided the audience with an “insight” as to how things were different back then. I wonder if we are all about to be linked to that number and what our perspective will be on what is likely to prove a significant milestone in the commissioning, procurement and provision of alcohol- and drug-treatment services.
We are certainly going to be looking back on how things changed with the advent of localism, Public Health England, Health and Wellbeing Boards, Clinical Commissioning Groups, GP commissioning, Police and Crime Commissioners, the recovery agenda, Payment By Results, new NDTMS data sets and no doubt more besides. Perhaps we will be wishing it was a single lightning bolt, which changed thinking of ancestors on the vinyl record, rather than such a veritable hailstorm of changes.
I have been asked to consider the world of 2013 and beyond as it will relate to rehabilitation and offer some thoughts about possible approaches to adopt.
Traditionally rehabilitation has been provided on a residential basis and the received wisdom is that it must always be so. In fact, rehabilitation programmes do not have to be delivered solely in residential settings. Every element, except beds, food and the residence itself can be transferred to a non-residential setting as our own Sharp programmes demonstrate. People who have a home can return to it daily, practising what they have learned in programme. We are experiencing increasing interest in this model.
Below under various headings are some things which providers of residential rehabilitation programmes will need to think about as they navigate the choppy waters of localism.
Operating in the world as it is. Much as we might not like the world in which we find ourselves having to operate, there are some things we can do little to change. I am not encouraging passivity but realism. This is precisely what good programmes do for their clients, is it not? We must understand the world, or at least the important parts that relate directly to delivery of viable services. We might take a cue from Darwin who said it is not the strongest who survive but those most able to adapt to change.
How does a service that provides for people who have generally been referred out of area manage in the era of localism? Broadly speaking, localism means responding to the needs of local people in a way that sits well with the local voters and their political representatives. It does not mean everything must be provided locally – but there could be reluctance to see funds spent outside local boundaries, especially given the political nature of Local Authorities under whose control commissioning such services will now fall. So we need to arm ourselves with sound arguments about the value of our offerings to meet the local Public Health England priorities.
This is quite a challenge for small standalone providers without large marketing budgets.
The point is that it makes little sense to stuff patients into local services just because of geography: ensuring that they can access the most appropriate treatment for their presenting need and choice is likely to increase chances of a good outcome and thus more cost effective in the long run. Getting our services included in local treatment system frameworks or on provider lists is vital. It might be necessary for residential services to attach as subcontractors to providers contracted to deliver those frameworks.
Understand and articulate in a rational way. If we want purchasers and referrers to respond positively to us, we must be sure to understand their world and its realities and particular pressures. We are then in a position to offer them something to help with their problems and their residents’ needs.
Many people who work in this sector believe passionately in what they do. No bad thing in itself, but it is important not to argue for a service based simply on a belief that it is the best thing since therapeutic sliced bread. We need to lay our hands on some organised, credible evidence of its value (one of the best things we did was submit Clouds House to external independent evaluation). Now the evidence should be cast in the language and metrics of health and wellbeing because that will be the perspective of Public Health England. Understanding the intersection of alcohol and drug problems with other health and social issues is essential because they will now be only one of many competing priorities without any of the protection provided by ring fencing.
There will be much reflection on the costs of services and of treatment episodes. We must encourage budget holders suffering from acute and possibly chronic Budget Anxiety Disorder to consider the cost to them and their local services of not treating a patient appropriately.
Expectations: exit from the treatment system, completions. Where we used to have targets for numbers in treatment, we now have at least some intention to commission with an eye on outcomes related to recovery. Residential programmes, with their usually intensive focus on achieving a sustainable recovery based on abstinence and facilitating proactive links to recovery networks, will be viewed more and more as a potential exit-from-treatment system, allowing commissioners to rack up performance points. But we must not fall into the trap of presenting residential rehabilitation as the magic bullet of recovery. It is a more or less intensive episode in an extended process of change in which many influences pay their part.
Alcohol. Many alcohol problems can be successfully treated in the community, even if an inpatient detox episode is required for safety’s sake. But alcohol dependency, especially when complicated by other problems, can indicate the need for a residential stay. There are many health issues related to excessive alcohol consumption, so communicating the all-round health gain of an intensive programme, including those of the economic variety, is important where this appears to be insufficiently well understood.
Proliferation of detox services not delivered by the NHS. We are supposed to be living in the age of evidence-based services. But the tendency to separate detox from psychosocial programmes which are the real agents of recovery, seems as intractable as ever, despite the evidence of the ineffectiveness, even, on occasion, harmfulness of this.
If it means a chance to offer some recovery-oriented help rather than none at all, it is worth seeing what can be achieved in the management of this necessary but inadequate process. It will be important to ensure that transfer to recovery-oriented community-based programmes has been be pre-arranged to avoid clients immediately falling down a large – unwarranted – gap and soon re-presenting.
For people with more complex profiles: need for deeper expertise. Given the greater cost of residential services, it is likely that purchasers will reserve them for clients with more complex and unstable profiles. This will require a greater level of expertise among the treatment and care staff to minimise risks. We need to press for funding to secure the resources needed for this.
Quality. This is really about culture but formal quality management provides reassurance to commissioners, general public, service users and their families. I recommend showing that we are prepared to go beyond what CQC requires. We need to familiarise ourselves with standards such as Nice.
One great failing in services is the lack of effective supervision of therapeutic practice and programme delivery as opposed to general management. It is vital to find someone who can provide supervision appropriate to the service being delivered.
Workforce development: qualifications and supervision, reflective practice. It is a statement of the obvious, but effective help depends on people who know what they are doing and are realistic about their degree of competence and need for ongoing professional development. It is critical to quality. Practitioners should work according to the principle of “sophisticated understanding but simple application”. Practitioners should always be willing learners, too.
Engage with families. I can’t believe I left this until the end. That in itself is a reflection of how far we still have to go in involving the most important people in a client’s life. Even out-of-area rehabs must ensure a thorough understanding of those hugely affecting interpersonal relationships and their positive and negative impacts. The family is, or should be, at the heart of any health and wellbeing public health agenda. That many clients will be parents of young children must not be ignored. It is vital to have a response when distance is presented as a bar to family work. It does not have to be.
As long as it is clear that some people benefit significantly from residential rehabilitation, I am prepared to continue working for it – even if not quite as long as the 2013-year old man.