Only Millionaires Need Apply!

As a freelance consultant I am registered with several on-line procurement portals and I recently got a notification to say that, as part of the ‘Payment by Results Pilot’, Bracknell Forest DAAT was advertising its Drug and Alcohol Recovery Services (DARS) for tender and was looking for a “Prime Provider” to take on this contract - see www.businessportal.southeastiep.gov.uk 

I know Bracknell Forest reasonably well as I was its first DAAT Coordinator; I managed it on a part time basis along with The Royal Borough of Windsor and Maidenhead DAAT. 

I wasn’t there long, maybe 6-9months between 2000/01.  Just long enough to set up both the DAATs following the disbanding of the Berkshire County DAAT, and I did the first DAAT treatment plans for them both before moving on to manage the Slough DAAT full time until 2003.

Anyway, reading through the Bracknell DARS documentation, one line caught my attention:

“There is a minimum requirement of an annual turnover of £1,000,000 or ability to provide a parent company guarantee.  Organisations submitting a tender must also be registered with the Care Quality Commission.”

I found this line intriguing on several levels not least because it seemed to be passing up a chance to really localise service provision given the popular understanding of a prime providers role is not just to provide a service per se but to provide an outcome or set of outcomes either directly or via a set of other service providers (some prime providers are management companies, ‘dating services’ that link the client with the right help - whether provided in-house or contracted out)

I also wasn’t sure what additional security the turnover of the prime provider company gave the commissioner.  I agree any provider must be in sound financial shape, and in the case of prime providers, so must all the sub-contracted providers down the line.  However, turnover as an entry requirement is not the best indicator of financial stability.  There are a lot of £1m+ companies, or charities for that matter, that are unstable, or are over reliant on a single commissioner / client

Depending on the final specification the prime provider effectively becomes a quasi-commissioner, making me wonder if this usurps the commissioning function of the DAAT itself as Prime provider, in essence means the handing over of a sum of money against a desired set of outcomes and leaves the prime provider free, within set limits, to meet the outcomes in any way they deem appropriate.  

Performance management is via outcome not process monitoring

It also made me think that Payment by Results was going in the direction that some smaller providers and key commentators feared it would.  In the current climate of high turnover super-charities like,  CRI (£56m in 2010, up from £17m in 2006), Turning Point (£69m in 2010, up from £15m in 2006), Addaction (£37m in 2010, up from £25m in 2006), Phoenix Futures (£22m in 2010, up from £14m in 2006),  £1m may not seem that much but believe me, it is.  The £1m ‘floor’ will exclude some excellent but small service providers – I’m not saying the big boys aren’t good in their own way, but you need a mixed economy, corner shops and town centres not just out of town superstores.

  

I decided to follow the money, to see if the recovery rhetoric was being backed with the finances it needed to flourish.  Focussing on the 8 PBR Pilots (rather than just on Bracknell alone) I looked on the NTA website for the DAAT treatment planning documents that DAATs must file with the NTA annually.  There was no data for 2011/12 so I looked at the ‘Part4s’ for 2009/10 and 2010/11.  Below is a table that outlines 4 key areas of DAAT spend i.e. The Commissioning System, Structured Community Based Treatment, In Patient Detox and Residential Rehabilitation (there are other areas of spend, go to nta.nhs.uk and search for your DAAT area)

	2009/10			2010/11
PBR Sites	CommSys	SCBT	INPD + RR	CommSys	SCBT	INPD	RR
Bracknell Forest	45,611	302,950	68,568	127,208	319,119	60,464	0
Enfield	337,832	2,160,997	231,789	374,619	1,893,330	260,500	55,000
Kent	711,317	6,415,771	1,530,873	750,248	6,296,555	796,365	615,132
N.Lincolnshire	170,252	1,492,136	20,000	184,000	1,577,557	20,000	0
Oxfordshire	377,620	2,573,370	2,650,051	541,339	4,336,394	469,221	890,176
Stockport	187,219	1,824,270	258,797	184,295	1,868,360	138,883	369,846
Wakefield	259,370	2,868,198	114,400	239,353	3,168,027	10,000	114,400
Wigan	288,101	407,123	348,000	244,000	1,161,409	246,963	180,000
Totals	2,377,322	18,044,815	5,222,478	2,645,062	20,620,751	2,002,396	2,224,554

Key to Abbreviations

CommSys           Commissioning System (staff to run the system)

SCBT                  Structured Community Based Treatment (e.g. presc, or day services)

INPD                   In Patient Detox

RR                      Residential Rehab (classified usually as a place away from home)

PBR Sites            Payment by Results Sites (DAATs)

Whatever we think recovery means, most reasonable people would accept that it often involves some sort of a stint in a rehab; a place away from home, a ‘dry dock’ in which to try and confront and fix the things in our lives dragging us down the wrong path.  Rehab is usually residential and is part of a process or as some would describe it, a journey.  Therefore, looking at the table above I am alarmed that 2 of the PBR Pilot DAATs have £0 in that section in 2010/11 - lets hope becoming a PbR pilot changes that

NB: in 2009/10 rehab and in-patient detox spend was listed jointly so is difficult to disaggregate

Mitch Winehouse recently said that he had a "gratifying" meeting with Drugs Minister James Brokenshire in which he also requested more funding for drug rehabilitation.

Mitch is absolutely right to ask for more money, and yet what we have to realise is that there are millions of pounds already out there that could be allocated to appropriate rehab placements. 

Again, looking at the table above, more was being spent on the commissioning system in 2010/11 as a total amount than on rehab placements across the 8 PBR DAATs.  I’m not asking for commissioners to get paid less, but I am asking for them to prioritise treatments that help people get better – more rehab please.

PBR was supposed to be, from a meeting I attended in 2010 with Oliver Letwin, James Brokenshire and other key stakeholders and some smaller charities, a chance to get more money into treatments that help people get better, a reason for DAATs to re-balance the treatment system, a chance to shift resources away from the over inflated methadone prescribing budgets and into rehab (residential and community based) so that people get better, like I and many many others have done.

We need to ensure commissioners allocate resources in line with need, and in line with treatments that get people better.  We need to adopt an urgency that is lacking in the system currently.  We know rehab works, there are enough studies that show this, there is the proof of peoples lives and there is common sense.

We need to use the money we have and start spending it on getting people better.  Even the £1m set aside by the Dept. of Health to evaluate the PBR pilots could get between 71 and 119 people started on the road recovery, depending on which rehab you were to send them to.

Maybe a top sliced, national budget administered by a small central team could do so much more in promoting recovery, than the current system which risks re-branding what we already have and calling that recovery!