during the many discussions I had at the SMMGP conference last week a number of people mentioned the letter in the recent edition of SCANbites in which a open letter was published to the NTA. The response from Annette DAle-Perera, which is being printed in the next edition, is as follows

Dear Keron,

The NTA does recognize the unique and valuable contribution of addiction psychiatrists. The success we have all achieved in doubling the numbers in drug treatment has been matched by a massive expansion in addiction psychiatrists, from 74 in 2004 to 453 in the NHS in England today, according to SCAN. This represents a massive endorsement of the contribution that addiction psychiatrists make to drug treatment, which was explicitly recognised in Models of Care for Drug Misuse (2006).

Having said that, I do think there is a lack of understanding about the contributions of different doctors working in addiction. More could be done to promote awareness among commissioners and providers of the potential contribution of addiction psychiatry. The NTA sees the College and SCAN as playing key roles in this. Historically, some areas have not had addiction psychiatrists, and unfortunately so far our data has not allowed us to say whether this made a difference to treatment outcomes, although the forthcoming outcome-focused data of TOP may change this.

You raise increasing reports of commissioning hostility to addiction psychiatrists. Other providers have made similar complaints, so this may not be particular to addiction psychiatry. There will always be some tension between commissioners and providers, but we need them to work together in mature relationships to design and operate local treatment systems that meet client needs. Some practice falls short of this aspiration, and we all need to guard against any “dumbing down” in specialist skills. It is not in our clients’ interests to sacrifice quality to a false economy of services with poor clinical governance and low competence.

There is also variability in the competence of commissioners. The NTA works hard to promote competent commissioning, through the provision of guidance, national training with Oxford Brookes University, delivery assurance of local treatment plans, and the NTA/Healthcare Commission improvement reviews. We should also acknowledge variability in the competence of all professional groups - including addiction psychiatrists - and accept that some instances, criticism of colleagues may be justified as along as it leads to improvements in practice.

However I do not agree that targets and re-tendering are all bad. Without the accountability of targets, drug treatment would not have received additional resources or continued priority status. Re-tendering is also appropriate in many circumstances, for example, where a local system needs re-engineering to better meet local needs, or when efforts to improve a poorly performing service have failed, It is also sometimes required by European and local authority tendering directives, though I agree that all cases should be handled with due care. If providers do have concerns about tendering process or service specifications, they can contact the NTA.

Finally, you make some helpful suggestions as how the NTA can help, and we would welcome the opportunity to discuss this with you, SCAN and the College. The NTA is working with key stakeholders to develop new commissioning guidance, and you represent the College on that group. In addition the NTA will look at how it can promote the role of the profession in its workstreams on enhancing the workforce and promoting better clinical governance. We also hope to continue and strengthen the joint work between the college regional representatives and the NTA regional teams that has been very beneficial to both sides.

Yours sincerely,


Annette Dale-Perera
Director of Quality
National Treatment Agency for Substance Misuse

Thanks for posting this Hugo I think its a very good letter. Stephen Willot I think it was, who spoke eloquently at the SMMGP conference about our need as primary care addiction specialists for psychs in treatment systems. If there are really 453 of them it should surely be possible to have one in every DAT area! I wonder why this hasn't happened?

Does anyone have the original letter to post?
It seems Annette has posted a comprehensive reply but it's hard to understand without seeing the letter.

its still not on the SCAN website!

Here are a cooule of cut and pastes:

A commentary by Colin Drummond,
The future of addiction psychiatry,
highlights the disruption of addiction services
in England caused by incautious re-tendering
by commissioners. Page 7.
The issues and solutions are
detailed in aletter from
Keron Fletcher (left)to the
NTA pointing out the
expertise being lost in a rush
to meet politically-motivated targets.

For example SCAN recently became
aware of a psychiatry training scheme in
South West England advising Specialist
Registrars against a career in addiction
psychiatry in view of the increasing
hostile commissioning environment.
This is a matter of national concern.
Following this meeting Dr Keron
Fletcher, Chairman of the Addictions
Faculty UK Regional Representatives of
the Royal College of Psychiatrists, and
Honorary Secretary of the Addictions
Faculty, wrote to the National
Treatment Agency for Substance Misuse
raising these concerns on behalf of
addiction specialists in England. His
letter is printed on the following pages
for dissemination to a wider audience.
We at SCAN believe that the future of
addiction psychiatry, and with it the
capacity of the treatment field to
deliver high quality services to drug and
alcohol misusers, is at risk in this
headlong rush to achieve politically
motivated targets. We do not believe
this is in the best interests of service
users who have little real say in
determining the commissioning
agenda. If this destabilisation of the
treatment system through re-tendering
becomes more widespread it is likely to
cause long term damage which will be
difficult to rectify should the agenda
shift to a more quality- rather than
quantity-orientated model of care for
this group.
We also believe that the National
Treatment Agency has an important role
to play in safeguarding the future of
addiction treatment by issuing guidance
to commissioners on the importance of
addiction psychiatry in the overall
provision of care for drug and alcohol
misusers.
As will be seen from Keron’s letter it is
acknowledged that many other
disciplines and agencies have a crucial
role to play in providing care for this
group. So this is not a case of ‘special
pleading’ on the part of one
professional group to the exclusion of all
others. Rather his letter clearly lays out
the unique and essential role addiction
psychiatrists have in promoting a high
quality, comprehensive and seamless
system of care. Many of these functions
appear to be overlooked in re-tendering
exercises, leading to stripped-down
prescribing services, creating serious
gaps in the system especially for drug
and alcohol misusers with more complex
needs, and their families.
While the aim of getting as many
people as possible into treatment is
appropriate, this should not be at the
expense of the quality of care provided.
With increasing political emphasis on
promoting recovery from addiction
rather than over-reliance on substitute
opiate maintenance therapy - as
signalled in the updated Drugs Strategy
- this will require a much higher level of
skill and organisation of the treatment
workforce to achieve.
Addiction psychiatrists have had, and
continue to have, a key strategic role in
achieving that. We therefore trust that
due consideration will be given to the
leading role addiction psychiatry has
within the treatment system in ensuring
effective clinical governance and high
quality service delivery which should be
reflected in national guidance to
commissioners and in local
commissioning decisions.
Considerable concern was raised by addiction specialists at the Royal College of Psychiatrists Annual
Addictions Faculty Residential Meeting about the widespread disruption of addiction services in several areas
across England caused by re-tendering. This threatens the future quality of addiction treatment services.
The meeting in Amsterdam, May 2008,
heard that in many cases the service
specifications and tenders awarded did
not include an appropriate level of
consultant addiction psychiatry or
clinical psychology input. The
commissioning environment is becoming
increasingly hostile to addiction
psychiatrists, having previously
benefited from more collaborative
working arrangements.
This new approach to commissioning ran
counter to national guidance in the new
Orange Guidelines on clinical
management and the joint Royal
College of Psychiatrists’ and Royal
College of General Practitioners’ report
as it relates to the role of specialists in
the delivery of addiction treatment. The
latter document highlights the
differences in competencies and roles of
addiction psychiatrists and general
practitioners in providing addiction
treatment, and the complementarity
and need for both within a
comprehensive treatment system. Also
the new Darzi review emphasises the
need for greater quality in the
NHS, clinical leadership and a move
away from nationally set performance
targets.
Concern was raised about the impact
that some of the re-tendering decisions
will have on the quality and
comprehensiveness of care offered to
drug and alcohol misusers. There was
also concern about the long-term impact
that this would have nationally on
training, recruitment and retention not
only in addiction psychiatry, but also the
wider specialist field, including loss of
the key role addiction psychiatrists play
in training and supporting doctors in
primary care and other professionals
involved in treating drug misusers.
Comment
The future of addiction psychiatry: a cause for concernProfessor Colin Drummond, SCAN lead
A HEADLONG RUSH TO ACHIEVE
POLITICALLY-MOTIVATED TARGETS
8| Supporting specialists, promoting consensus
Dear NTA,
It was a pleasure to meet up with you at
the Addictions Faculty Residential
Conference last week. I am grateful to
you for listening carefully to some of my
concerns and for suggesting that I put
pen to paper and forward my comments
to you.
Although the problems I described to
you were anecdotal and applied to my
own recent experiences, the points made
in this letter reflect the opinions of other
Royal College Regional Representatives
and addictions psychiatry consultants
across England. You will have heard
some of these views when you attended
the Addictions Faculty Business Meeting
at the Conference.
I would like to cover the following points
that have a direct effect on service
quality:
1 That addictions psychiatry makes
unique, essential and important
contributions to the overall treatment
of individuals with drug and alcohol
dependence;
2 That there are increasing reports of
commissioning hostility towards
addictions psychiatry;
3 That the NTA could provide more
support for addictions psychiatry.
It is very clear that the NTA understands
that addictions psychiatry has an
important role to play in the delivery of
high quality services for the treatment of
drug and alcohol dependence (from the
commissioning guidance for tier 3
community prescribing for example).
However, given the current pressures on
commissioners and competing, quite
intense demands, I’m not entirely sure
this message has got through at a local
level.
Here then, is an amplification of the
comments I would like to make:
1 Addictions psychiatrists make unique
and valuable contributions to substance
misuse services:
a. Addictions psychiatrists provide a safe
and secure treatment setting that
supports the functioning of other
services by:
• taking difficult cases from primary care
• providing services in areas not covered
by primary care
• seeing patients in a range of settings -
general hospitals, psychiatric wards,
community bases, at home, in GP
surgeries
• offering comprehensive telephone
support and advice to GPs, substance
misuse workers, pharmacists etc
• providing a range of specialist services
for individuals with alcohol problems
• being the final repository for
“insoluble” problems
b. Addictions psychiatrists provide high
level skills for:
• dual diagnosis and other severe
complex needs
• support to the Courts with child care
cases, offending related to dependence
etc
• teaching/training
i GP trainees, psychiatric trainees
ii GPs, general medical colleagues
iii MRCPsych, MRCGP, MRCP, MSc
course contributions
• treatment and care of sick doctors on
behalf of the GMC
• leading on clinical governance
• supporting service developments
• developing innovative practice
• conducting research
• contributing to Royal College work –
support for national policy
development
c. Addictions psychiatrists bring high
quality standards to routine clinical
care of individuals with alcohol and
drug problems:
• through clinical leadership
• by establishing/running Shared Care
Monitoring Groups
• through detailed knowledge of NICE
guidelines/Clinical guidelines
• by identifying and addressing poor
practice
2. There are growing concerns that
the commissioning environment is
becoming hostile, counter-productive
and threatens the development and
progress of addiction psychiatry:
a. There are examples of current
commissioning practice that places the
achievement of certain performance
targets (possibly real measures of
systems quality, but only partial or
proxy measures of clinical quality)
above the provision of effective
interventions and treatments. In this
environment there is a risk that clinical
services with good standards of care
can be forfeited in order to develop
services that can meet performance
targets:
• treatment services outside large cities
or teaching hospitals are often manned
by small numbers of doctors.
Providing the number of clinics
necessary to meet stringent in-patient
and community treatment waiting
times consistently can prove
impossible (sick leave, annual leave,
vacancies etc)
• failure to meet tight targets has led in
several areas to re-tendering/re-
commissioning or threats of re-
tendering/re-commissioning
• in this commissioning environment
pressures can develop that may lead to
dubious, potentially dangerous or
destructive practices, for example:
imaginative data recording; risky
clinical procedures; abandonment of
valuable clinical activity in order to
achieve performance targets of little or
no demonstrable clinical value
• this is counterproductive
b. This current emphasis risks
jeopardising collaborative working
relationships between commissioners
and providers and generating critical,
confrontational and hostile working
relationships:
• I have enjoyed excellent working
relationships with previous
commissioners with whom it has been
a pleasure to explore innovative ways
of making the most of the resources
available. This has also been the
experience of other Addictions
Consultants in the past, and it has been
a highly productive partnership
• I have recently had a very different
experience in one of the areas I cover.
Other consultants have also
complained that commissioners are
dismissive of the pressures on their
services, ignorant of the achievements
of their services over the last few years,
disinterested in learning about the full
benefits of the type of service
Dr Keron
Fletcher
Chairman, Royal
College of
Psychiatrists UK
Regional
Representatives
A letter from Dr Keron Fletcher,Chairman of Addictions Faculty UK Regional Representatives oftheRoyal College
COMMISSIONING
What’s special about addiction specialists?
SCANbites, summer 2008 | 9
addictions psychiatrists provide, and
threatening to re-tender services if
they cannot guarantee to hit the
targets demanded. You heard
consultants from various parts of
England report these sorts of
experiences at the Addictions Faculty
Business Meeting
• to be engaged in such confrontational
relationships during service planning
discussions is unhelpful and
unnecessary. As I work across a
number of commissioning areas I am
able to reflect on the extent to which
some commissioners hold
unreasonable expectations of the
resources available. It clearly varies
from commissioner to commissioner,
and provider/commissioner
relationships vary from area to area (I
am probably in the unique position of
working with 4 commissioners)
3. The National Treatment Agency can
help improve the situation:
a. By clearly signalling the need to
preserve and develop addictions
psychiatry skills and posts to Regional
Managers and local commissioners:
• by educating commissioners about the
value, nature and breadth of addictions
psychiatry (as in part 1 above)
• by comparing the range of services
offered by addictions psychiatrists with
those offered by GPs. Relatively small
differences in competencies do not
adequately reflect the large differences
in roles between GP services and
addictions psychiatry services. Such a
comparison might illustrate clearly the
value of addictions psychiatry
• by asking Regional Managers to take up
this topic with Royal College Regional
Representatives
b. By recognising that, in the pursuit of
performance targets, quantity has
sometimes been achieved at the expense
of quality:
• although the large scale contribution
of Primary Care to the management of
substance misuse has been welcome,
the de-commissioning of addiction
psychiatry posts has led to the loss of
some essential and basic ingredients of
high quality, safe service delivery and
loss of expertise in the management of
severe and complex cases
c. By recognising that, in the pursuit of
quality, further erosion of addiction
psychiatry posts should be strongly
resisted:
• Addictions psychiatry consultants are,
by virtue of their role and training, in a
position to offer clinical leadership
around the clinical governance agenda
• small specialist services can, and do,
treat large numbers of patients in a
cost-effective manner, including dual
diagnosis and combined drug and
alcohol dependence, and need not be
de-commissioned simply to reduce
costs. Continuing to shift more
patients into Primary Care settings may
now be associated with greater costs
and a reduction in quality of addictions
treatments
• addictions psychiatrists have a deep
interest in making systems work and
providing clinical excellence. Other
practitioner groups may deliver exactly
what is specified and no more
• the teaching and training functions of
Addictions Psychiatrists are an
important investment for the future
• since a Primary Care setting for
service delivery is preferable
(because of the advantages of
meeting other primary care needs in
a local setting and because of the
preference of most users to be
treated in Primary Care), some
consideration should be given to
deploying addictions psychiatry
specialists in proposed new
polyclinics
d. By recognising that the complaints of
a hostile commissioning environment,
for whatever reason, are becoming
more frequent:
• hostile relationships between
commissioners and providers cannot
be beneficial to the process of
developing good services
• re-tendering/re-commissioning should
not be used as a threat in early service
development discussions
• re-tendering/re-commissioning should
only be a last resort when all other
measures to improve properly
resourced services have failed
• re-tendering/re-commissioning is
destructive and wasteful of time and
effort when it is not justified
• re-commissioning does not guarantee
improved service delivery
SUMMARY:
It is the view of addictions psychiatrists that we
possess many attributes that bring real benefits
for substance misusers. There is no doubt that
Primary Care services can deliver competent
treatments dealing with a proportion of the
overall needs of drug and alcohol misusers.
However, addictions psychiatrists offer
valuable additional skills that improve service
delivery across a range of settings and
management complexities, and secure a future
for the field through teaching and training.
Services are subject to stringent targets which
must be met and which dominate discussions
with commissioners. It is our view that many
of the benefits of addictions psychiatry are
currently being ignored or sacrificed in order
to meet performance targets which are only
partial or proxy measures of treatment quality.
There are increasing reports of deteriorating
relationships between addictions psychiatrists
and commissioners. This is counterproductive
and destructive and we would like the NTA to
do all in its power to prevent it.
Personally, I have had the pleasure of working
over the last seven or eight years with an
excellent commissioner and two supportive
NTA Regional Managers. It is discouraging to
report my own recent experience of a change
in commissioning atmosphere in one of the
DAT areas I cover. In the past it has been
possible to achieve an enormous amount of
positive service development within the
context of a collaborative partnership between
the commissioner and the service provider,
but I fear the future may bring with it conflict
and, ultimately, the loss of the good working
relationships and effective services that have
been built up carefully over many years.
I am fully aware that the NTA has a positive
view of addictions psychiatry and has
intervened helpfully on a number of occasions
to support this specialty. I would sincerely
request that the contents of this letter are
discussed within the NTA Executive, and I
would be delighted if you would let me know
your opinion on the points made.
Yours sincerely,
Keron Fletcher
ofPsychiatrists,totheNational Treatment Agency for Substance Misuse

I think its a real shame that the addiction psychiatrists are being so 'closed'. I for one can see an important role for them but I feel Keron's letter is so exclusive and pompous it hinders their cause rather than improves it?

Speaking as an advocate these sort of letters say an awful lot and sometimes make sense.
Though i agree Chris that there is indeed a place for consultants in our treatment and i have a lot of resepect for them.
The letter is interesting and reflects a 'regional' picture (imho) maybe???.
The important facts for me though is that if the 'charasmatic', vocal and 'listened to'(Champions) clinicians in our field could only work together then i feel we all could make huge strides and begin to treat the real problems in drug and alcohol treatment.
I try to remember that this comes in the context of a system where consultants do not always support GP prescribing, in theory or practice or GPs criticise secondary services and go 'off the song sheet' without support when offered.
If these two crucial care systems (primary and secondary) do not work together it is the service user that suffers and spectacularly so.
Please get it right guys, share and play nice or NICE
My Best
TonyB

I agree with Chris Fords comments about the tone of the letter. Don't we all bring skills to our work over and above the ability to work in the drug and alcohol field. Psychiatric training would be a useful skill to bring into a CDT. But then, so are the skills a GP brings in. Rather than the us & them approach, how much better the integrated teamwork would work with everyone bringing thier skill to the table. Shame that in 12 years working in our CDT I haven't once seen any of the psychiatrists!

Sorry not to have posted on this or the GP/specialist roles stuff for a while. Have had a lot of stuff going on. I found SCAN really helpful in sending stuff out and I have a pdf copy of the newsletter. If anyone would like one, please email me at sara.mcgrail@btinternet.com and I'll happily send it over.

S

PS Those interested in the role of the GP should take a look at the new NTA consultation on Increasing Value in the treatment system where they explicitly exclude GPs!!

Just a small point of order Sara - we're not excluding GPs from anything in the current consultation. We're looking at the cost of specialised prescribing (among other treatment pathways) wherever it is provided, which is congruent with the models of care update, orange book, and NICE guidelines.

but thanks for drawing attention to it - would welcome responses. The full consultation doscumsnts can be found

here http://www.nta.nhs.uk/areas/value_improvement/default.aspx

That's really interesting Hugo as the consultation claims to reflect the whole treatment system yet states:

"Interventions and costs that fall outside the drug treatment system such as brief interventions provided by generic health and social care services, such as GPs and A&E, and alcohol treatment are not included in the model."

I wonder if I'm the only one who'll be confused by this rather peculiar document in which of the 114 assumptions made, 55 are only based on estimates.

Anyway I wouldn't have thought the announcements thread was the proper place for this discussion - maybe we should move it over to the discussion forum.

Glad to see you back on the board Hugo.

Sara

PS will have a whole blog up covering this later today/tomorrow. www.saramcgrail.co.uk

erm... I'm not sure that means "explicitly excludes GPs". It just means the usual GP services for which the drug treatment system doesn't pay.

would be happy to discuss the programme if you have any enquiries.

I can confirm that Sara's blog is well worth a look at.

Just did, (when I should be working - oops) - what alot there is in there, no time to comment on it all. First thing to say is its really well written and an enjoyable read, and it will get me to look properly at the real thing. Sara I think there are two things I would challenge you on initially:
1. My reading of the sentence apparently excluding GPs is about excluding the generic and brief interventions (ie tier 1) not GP treatment at tier 2/3 level. As I understand it, funding for primary care treatment can vary across parnerships though, some is fully through the PCT, some is supported by PTB - somebody please confirm or refute this.
2. From all I have heard Paul Hayes saying in the last few years, I am reasonably sure that this piece of work is NOT borne of the abstinence vs maintenance debate as you suggest, but of the 8-fold differential in treatment costs across partnerships (the point is made that its not always the obvious places that are the most expensive, there's no apparent correlation between needs and costs). So this is about moving the unit costs work on a stage. What is your view of why there is such a big difference in costs?

Hi Susi - Perseverance

The inclusion of specialist services is explicit, however while I can see that GPs working in the role of a specialist within a clinical services is undoubtedly covered, I can't see how it in any way covers either shared care or other GP interventions. I can't see how GP treatment at tier two could be included. The restrictions of the model - specialist interventions, ptb funded makes its a hugely distorted picture of the treatment system.

My main point is that if this only provides us with costings for what has been described as an ossified specialist dominated treatment system I do not see how it can possibly be helpful in terms of reducing cost differentials. the model is rigid and doctrinaire. IMO it will actually restrict the development of systems focussed on community rather than specialist treatment and so will maintain high costs.

As for the treatment cost differential - well I think a lot of its down to piss poor administration centrally and locally, greedy providers, poor recording and an over reliance on models like this. The perverse incentives of the current funding formula - and how allocations sit against actual mainstream contributions also distorts the picture of cost differential. When you say there is no clear correlation between needs and costs I agree with you, but then there is no real attempt being made to make that comparison - and this exercise, sloppy and ambiguous as it is, based on fag packet estimates and unreliable data, is not likely to make that job any easier.

So the truth is we don't actually know what the cost differentials are, why they occur or even if they are as reported. The exclusion of key services, the lack of a patient rather than services focus, the lack of any accomodation of complexity, area cost differential, care pathway design and usage, the reliance on the average rather than the ideal, in my opinion render this model worse than useless in prosecuting this issue. Your mileage may vary

I'm afraid I'm going to be away for the next few days - please don't take my absence from any ensuing debate as an unwillingness to join the fray!

All the best

Sara

This is all very fascinating. I have had to resort to printing out the "improving the value" document.. all 29 pages, as too much to take in on screen, and will read it though later...

I'm not sure what kind of primary crack users other people come across, but :

"It is assumed that 30 per cent of primary crack users attend intensive day programmes (estimate)
Is this a reasonable assumption?......................................................."

seems to be describing a different planet?
I don't want to be negative about the exercise, because it is very interesting and I can see that it is a necessary process in planning for the future. Hopefully the picture will become more clear. I don't think there are many primary crack users in birmingham attending structured day programmes.

Before we get too carried away...from the very first page of the document (my bold)

"The tool will notenable areas to calculate their global drug treatment system costs as the benchmarks are not indicative or reference costs and will not necesssarily describe all possible treatment options and priorities arising from comprehensive local needs analysis....the development of this model is not a step towards the standardisation of treatment and care, and does not replace any existing means of estimating and responding to unmet need. It is the role of local partnerships - working with service commissioners, providers, users, carers and other local stakeholders - to plan, deliver, and monitor services for the communities in which they are based....It is not intended to be used centrally to determine local need and the appropriate treatment responses."

I'm not sure how we could be much clearer. It's a tool to assist treatment planning, as the harm reduction and primary care self adutis, the needs assessment mechanism, performance reports and so on. Nothing more, nothing less.

As for some of the assumptions not ringing true...isn't that the point of consultation?

Hi Hugo

Yes, I did read that affirmation on the front page, but frankly I don't think it rings quite true. Sorry to be so blunt, but I cannot see given the new formula for distribution of the PTB and the new conditions imposed upon it how this information won't be used to distribute funding. lets just refresh our memories. Areas have been told that they can increase the amount of funding they get in their PTB if they increase their efficiency. Given that what we have is a fixed pot of funding nationally, this means some areas will need to lose money for others to gain. What's needed to do this is a tariff that enables people to demonstrate value for money in a standardised way such that central reallocations can be managed. Unless we're planning a bran-tub ...

To provide a model and say this is what you should compare your provision against, this is who it should be provided for, where and at what cost is either about standardisation of a tariff for core teratment or its a pointless exercise. So it doesn't quite make sense to me. Maybe you can explain exactly how you expect commissioners to use this and what the benefits of this will be? Maybe you could also set out how the tool will be distributed and shared , and maybe how the new distribution formula for the PTB will operate in islotaion from this piece of work. But you see that the sort of thing one might have expected to find in the consultation.

When you ask what consultation is about, well, I always believed consultation was about asking for views about the direction and content of policy. So a consultation should explian WHY an approach is being suggested, HOW it will be used, WHAT the alternatives to that approach may be, WHAT the impact of an approach may be. Its meant to be open - so not simply laying out a series of assumptions, but actually asking people what they think about the issues, purpose, proposed use and consequneces and impacts. I don't think its the purpose of a consultation of this kind to ask people to approve or disapprove a long series of unfounded assumptions about complex issues of treatment usage for which there is no evidence. But then I always understood the intention was to base policy on evidence, not make assumptions about evidence to support policy.

All the best

Sara

Sara

I'm not sure how to respond to your first point. You say it's about standardising treatment and cutting funding, we say it isn't. Where do we go from there?

I think there are some wider issues here.

1) Whatever documentation is put out, be it NTA guidelines, NICE, orange book, Darzi etc. there is always the potential for it to be misinterpreted locally by commissioners and providers, so no, we can't guarantee this won't happen. You allude above to “piss poor administration centrally and locally, greedy providers”. A lot of my job, both in the regions and centrally, has been challenging these practices and it helps to have a framework with which to do it. If one doesn’t have some idea of what one expects provision to cost, how does one start to challenge it? From my own experience, when using the unit costs material (certainly not controversial to the 80 per cent of providers who contributed) in the south east we were able to challenge both to (whisper it quietly) improve services for users. I’m sure like me you’ve been exasperated by often large providers who put in the lowest bid for services and receive the tender, only to not be able to run the service effectively – therefore giving commissioners some idea of what a service should cost can help with planning and avoid a pile it high sell it cheap mentality. Maybe this is over optimistic, but as I say – sometimes tools are used for the right reasons as well as wrong.

2) There really isn't some grand master plan to attack treatment provision funding. (of course, once again we enter "oh no there isn't, he's behind you" territory) But I don't think even the most diehard standard bearer for the treatment sector would argue that all the money is used as efficiently as possible given the increases (and yes, there have been increases in recent years). The fact is that I've challenged both providers and commissioners over the years about costs and their response has often been along the lines of "expensive compared to what?". Conspiracy theories seem to abound more in this sector than any other, but I would suggest that if commissioners at the start of the year don't start with at least some estimation of local need and what they are likely to need to spend (and what on) to meet some or all of it then they are not doing their job.

3) I'd be interested to know what you mean by "an over reliance on models like this" - apart from the average based payment by results and some audit commission models of in-patient provision I'm not actually sure what large scale models there are. In my opinion (and this is my view, not necessarily the NTAs) funding allocations and how they are spent locally have largely evolved to fit the funding envelope than in recognition of need.

4) Even if we were about to set tariffs (which again, we’re not, though NICE already have for Methadone, Buprenorphine, and every other technology appraisal they have ever done), I’m not sure how me could, given Darzi and the declared ‘no target’ environment in which DH now operates. And I think here is the rub. The VfM doesn’t stand alone. It is (as is woven into the document) designed to be used in conjunction with local and national data, an area’s own perceptions of need and throughput, and the local aspirations as to where the treatment system needs to change and/or strengthen current provision. If commissioners want to use it, they will. If they don’t, they won’t. The NTA certainly can’t enforce upon anyone what they should be spending.

Maybe this sounds over defensive, but it isn’t meant to be. I’m not naïve enough to think that all central policy is set up and implemented for the right reasons, nor do I think that whatever the NTA produces will welcomed with open arms.. What I am keen to do, as someone involved in this piece of work, is encourage as much debate as possible.

I did offer the other day to speak with you about this – happy to do so or meet in person at any time.