I'd like to thank everyone who came to Barnsley today for the conference.
I've throughly enjoyed today and the enthusiasm of all involved. It was great to see my boss Dr.Kakoty speak as he never has time to come to conferences.
Some memories that will stick were Lucy Rees being a great chair in the morning, but she'd no chance of keeping people like Jenny Keen to time
Jenny did a fanatastic talk on the prescribing service we do with a needle exchange at BADAS which has had excellent retention rates.
It it always enlightening to see how people in other areas have overcome problems - or not!
Again it seems primary care shines through but maintains excellent links with secondary care services such as our consultant Fleur Ashby, who is one of the most flexible and helpful Consultants i've ever met.
It was great to hear what work is happening in other areas treating Hep C and a lively debate occurred in that session.
It was really nice to see the PCT finance director attend and he was really pleased about the amount of work we have done with Non-medical prescribing, NICE guidelines namely Buprenorphine, Naltrexone, Methadone, Hepatitis C to name a few, plus of course the Orange book - he was amazed how much work had gone on and he'd no idea.
It was also saddenning to promote our achievements knowing that we have all been put out to tender and Chris Ford remarked on this and how many services just need a bit of a 'Tweek' and not necessarily re-tendered. I'm really sad to see how many Nurses have already left Barnsley, fortunately none have from our service - Yet. I think I work with the best team that i've ever worked in and i'd be devastated if this got split up.
I stayed with a few colleagues and a service user rep and had a drink in the bar afterwards, when everyone had left.I'm left with a certain feeling of impending doom knowing what re-tendering has caused in other areas and I've not heard anyone tell a positive story about this.
I may of course be wrong but after so many years in this area I tend to get the right feelings.
I wonder how many organisations win bids and cream off a lot of money from these things and then cut staff to the bone. I'm always careful with public money - maybe others are not so careful.
I feel soon many services will be put back 10 years and the abstinance agenda seems to be looming in a sinister fashion.

Gordon Gibbons closed after a rather nervous service-user Paul gave a frank view of his treatment in Barnsley, which was mostly positive.
Gordon gave a great presentation summed up key-points about communication and key points of the day.
It's was so good to hear so many clinicians putting patients first and a great day.
I hope soon we don't have the usual baby gone with the bath water.
Many thanks to all concerned and I hope i'll still be around to attend next year.

Simon,

Could you say a bit more about your concerns that "the abstinance agenda seems to be looming in a sinister fashion?"

Yes I'm worried that subtle changes in wording and the increasing targets for people exiting drug free. I imagine it's in preparation for a new govt. but I've no evidence of that.
There was rumblings on the Methadone alliance site some time ago and I didn't see it at the time.
http://www.nta.nhs.uk/publicat...siness_plan_0910.pdf
Page 8 may be of interest.

Hi Simon - Glad to hear the conference went well - really sorry I couldn't be there, it woudl have been great to meet and also to hear Jenny Keen speak. As you know we're interested in developing a low threshold model, and our Kirklees Nurse Prescribers will be in touch.
Also, try to help your managers to put a good bid in - delivering the service already must have an advantage - your managers will know what commissioners value and have a feel for what they would look for, and astute managers can use that knowledge well. Good luck.
I will email you on your NHS mail to liaise about protocols
Best wishes
Gill R

Hi Gill,
I did get a mail, just been too busy to reply.
Our bid wasn't sucessful which is a bit tough really having being involved in almost every NICE guideline relating to substance misuse. Also myself and Jenny being involved with the new Orange book.
It does seem rather unfair.

Simon,
Sorry to hear that. It does make one wonder what commissioners are looking for that doesn't include experience and demonstrated expertise. Could it be merely the bottom line, as the above don't come cheap.

And to whom are commissioners accountable exactly?

In my experience it is usually the commissioners who 'cut the budget to the bone' rather than the incoming provider. Its the new mantra in commissioning 'more for less'

Sorry to hear that, who did win the contract?

Jim its a good question about who commissioners are accountable to - I think they possibly kind of fall between the SHA and the NTA, neither of which seems to have any serious teeth. But perhaps Tony Mercer will help us out here?

Simon, gutted to hear your news. The main unfairness seems to me to be to the patients, and its just plain stupid surely to ignore that quality of clinician that you and Jenny represent - crazy!
Please pass on my gratitude for Dr Kakoty's talk, his historical perspective was absolutely fascinating, its great to see how deeply he thinks about his work and the community he serves.
I was buzzing after the conference,and filled a side of A4 with memorable learning points and ideas for our service - thanks to all

Hi Simon, it was great for me to hear the consulting room side of the service - much better than my usual number-crunching - particularly your workshop with Claire (Prescribing Pharmacist) which I think really demonstrated how far you and the team have moved the boundaries since the clinic has been in existence.

quote:

Originally posted by Perseverance:
Sorry to hear that, who did win the contract?

We don't know the decision has been put back, twice now I think. Maybe we will find out this week.
I guess though when a service wins a tender often they want to make money or they wouldn't do it.
To make a profit you have to provide less of a service.

quote:

Originally posted by susi:
Jim its a good question about who commissioners are accountable to - I think they possibly kind of fall between the SHA and the NTA, neither of which seems to have any serious teeth. But perhaps Tony Mercer will help us out here?

Simon, gutted to hear your news. The main unfairness seems to me to be to the patients, and its just plain stupid surely to ignore that quality of clinician that you and Jenny represent - crazy!
Please pass on my gratitude for Dr Kakoty's talk, his historical perspective was absolutely fascinating, its great to see how deeply he thinks about his work and the community he serves.
I was buzzing after the conference,and filled a side of A4 with memorable learning points and ideas for our service - thanks to all

Hi Susi,
Thanks for your kind words.
You are correct of course it's the patient's that will suffer. I cannot believe commissioners would chance losing Jenny Keen from Barnsley especially when so much positive work has been done. This tender process did not have to happen.
I also find it odd that people think a T.U.P.E. arrangement would be acceptable for NHS staff - why would anyone want to lose out on a pension they'd paid into for years? Crazy.
I've no idea what we can tell our patients when we've no idea what is happening.
I'm glad you enjoyed Dr.Kakoty's introduction he's a big personality and a good heart.
I also learned a lot and most of this is through networking and some services are ahead of the game and others are behind. I love learning and developing.
I'm glad I still have my HGV licence though!

quote:

Originally posted by Marie Hoyle:
Hi Simon, it was great for me to hear the consulting room side of the service - much better than my usual number-crunching - particularly your workshop with Claire (Prescribing Pharmacist) which I think really demonstrated how far you and the team have moved the boundaries since the clinic has been in existence.

Ahh but without the number crunching we wouldn't be paid and that would make going to work much less enjoyable

I'll be glad when this cloud is lifted and it might be sorry to have to say goodbye to our patient's, however we might have no option.
Very sad.

Hope this is helpful:

In the first instance the Joint Commissioning Manager is accountable to the DAT Joint Commissioning Group-the 4 statutory partners (PCT, Local Authority, Police and Probation) should be represented on the DAT JCG-and the JCM functions as the officer to this group-it’s usually chaired by the PCT or LA rep, depending on where the budgets are held. The DAT sits under the local Crime and Disorder Reduction Partnership (usually known as the “Safer Partnership”) and so it’s this partnership’s chair and lead officer (usually from the LA) who are ultimately accountable for the DAT (they have to sign the Treatment Plan along with the JCG chair).

When it comes to tendering and procurement the Standing Financial Instructions of the organisation holding the budgets have to be followed, usually the PCT. Some PCTs’ policy is to re-tender everything every 3 or 5 years, others don’t if existing contracts can demonstrate that local needs are being met, they represent value for money and are achieving outcomes-it usually comes down to local politics and personalities. I think LA policies are much less flexible and contracts have to go out for re-tendering every so many years. Value for money hasn’t really been an issue until the last couple of years but will be from now on after the national unit cost exercise. Some services may have higher unit costs as more intensive and complex interventions are required due to the client group-eg. pregnant drug users, rough sleepers etc but the national unit costs are a useful starting point for local discussions. Anyone can make a Freedom of Information request (and often do) about contract values, performance etc and commissioners have to be able to demonstrate value for money etc. We’ve all battled for drugs treatment to become mainstream healthcare for a few years and shrinking budgets, efficiency savings etc are the reality in mainstream healthcare-so we are into rationing and prioritising.

SHA’s focus is on assessing PCT’s competencies as commissioning organisations but they wouldn’t get involved in commissioning decisions as such. Similarly the NTA’s role is to performance manage DATs rather than become involved in local commissioning decisions—but we are accountable to NTA for our performance. World Class Commissioning sees commissioners as those who invest tax payers money to get the outcomes the public want-so ultimately commissioners are accountable to the local public. This may sound a bit far fetched but now LA “Scrutiny Committees” have a role in scrutinising community safety services and Birmingham DAAT is currently going through a Scrutiny Committee Review-and they’re leaving no stones unturned—meeting with local service users and providers and all of our commissioning functions, processes, decision making etc are well and truly under the spotlight.

For me personally the essence of commissioning is about making sure that there are local services that meet local needs. If in 10 years time most problematic drug use isn’t heroin but more of the “stella, skunk and speed” type then local commissioning will have failed if most of the Pooled Treatment Budget is still invested in substitute prescribing. Similarly with the “abstinence agenda”—I agree that people like Kathy Gwingell and Neil McKegney seem to approach this as a moral issue, but many harm reductionists are equally as blinkered and ideological. More and more service users now want the opportunity to become and sustain abstinence-probably due to increased visibility of people who have become abstinent. Commissioners have a responsibility to ensure that these opportunities exist locally. A good place to start in understanding commissioners’ role and so hold them to account is the 11 world class commissioning competencies.

Tony,

That is indeed very helpful. When under full scrutiny it seems rigorous, however how can you tell if a commissioner made the wrong judgement in deciding who gets the contract? Processess can be clear and stringent, but it usually comes down to judgement in the end. Given the way in which different parts of the country go about this differently, has any evidence been accrued as to which produces the best outcome?

I am still concerned regarding the 'churn' that can take place. Schools are inspected to ensure they meet the standards they are contracted to achieve. If they don't then management is replaced, not the whole workforce, building etc.

With drug treatment services it seems this is not seen as sufficient, and a pseudo-commercial model is put in place. This can result in a reduction in service quality if an existing provider fails the retendering process. The lead up and transition to the new provider is often characterised by low morale and good staff will leave for new jobs as soon as they can. The new provider in turn will take time to get up to speed. The total time can be a year long, with inevitable negative consequences for service users.

It seems to me that this aspect is not recognised sufficiently. Inspection based commissioning and contract renewal might stil produce the same results, without the cost and disruption of re-commissioning.

Take the number you first thought of and double it,I'd say Jim, .. ie not a year, but nearer two: the first year of uncertainty while staff hear rumour upon rumour of how the retendering process is going (and get called to meetings at short notice, cancelling clients' appointments etc etc) and then the second year while new contract holders have a difficult "bedding in" period.
I agree so much that this disruptive period is not recognised, or seen as a major disadvantage of the drive to become more efficient and cost-effective. And I love your comparison with schools - it's a good one and makes the system we are labouring under seem even more crackers.

I understand some of the tender was won by Phoenix who had a joint bid with the PCT and some by addaction. We haven't been told officially by the DAT but we heard through facebook from other service providers, maybe it's the modern way to spread news?

quote:

Originally posted by jimjones:
Tony,

Given the way in which different parts of the country go about this differently, has any evidence been accrued as to which produces the best outcome?
I am still concerned regarding the 'churn' that can take place. Schools are inspected to ensure they meet the standards they are contracted to achieve. If they don't then management is replaced, not the whole workforce, building etc.


Jim I fully agree and if a service was failing things would have been easier understood.

With drug treatment services it seems this is not seen as sufficient, and a pseudo-commercial model is put in place.



I'd argue that for some reason the commercial organisations are favoured, no idea why, they must be taking a fair profit, but who from?



This can result in a reduction in service quality if an existing provider fails the retendering process.


Does any commissioner care about this?


The lead up and transition to the new provider is often characterised by low morale and good staff will leave for new jobs as soon as they can. The new provider in turn will take time to get up to speed. The total time can be a year long, with inevitable negative consequences for service users.

Ahh but who cares about the patient's ? If commissioners don't care about staff they won't care much about patients.

It seems to me that this aspect is not recognised sufficiently. Inspection based commissioning and contract renewal might stil produce the same results, without the cost and disruption of re-commissioning.

I think cost is a big issue here but quality does cost. Myths in substance misuse where do they all come from? Not a quality service. This is public money and i've no idea why these companies are being allowed to profit from our taxes.


My bold above.

The pension point is a very important one indeed.
As suggested staff will quickly head en masse I suspect for the protective cloak of being part of the NHS and in particular its pension arrangements.
It appears that most commissioners enjoy this protection, why in the interests of savings can this function not be hived off to the independent sector.
It is intersting to see the very expensive re branding exercises that charities go through from time to time at I imagine very considerable expense ad for what. Certainly not patient care.
I wonder how vigilant commissioners are in relation to this type of profligacy.
It has been described to me once as "fur coat and no drawers".

Simon - I am so sorry - I can't believe that you and Jenny keen are not running a top notch service ? But I guess you are and some other points were scored by competitors.
Yes, pensions aren't as good in the voluntary sector.
You can ( as a service ) ask for explanation for the decision, and I am sure you could put in an appeal if you feel it warrants it. Freedom of information and all that ?
Also some services do get new tenders but then come in way over budget, and the service is - wait for it - retendered.
It's a real time of uncertainty for you all.
As for fur coat and no drawers ?! Would that have won you the bid ?? Please don't answer that bit
Gill