Commissioner, Prime Provider or The New Gang Masters?

I haven’t written a blog on these pages since mid September and I’m getting withdrawals, I haven’t written on ‘Wired In’ for a while either, so double withdrawals!!

There are several reasons for this (I’m not just lazy!).  Firstly work is hectic, which for a self-employed consultant is a good thing.  I have 3 contracts at present and deadlines galore.  When it gets this bad I start having to pull all nighters because there are literally not enough hours in the day to cram in work and family life.
Also, I have a number of projects on the go: 
  • I’ve been asked to write an article
  • I’ve been asked to include my story in a book of Recovery Stories, which is a huge privilege.
  • Finally, I have a couple of pro-bono jobs which are also busy at the moment
  • Oh, and finally finally I’m prepping for a conference, filling in as a favour for a friend and I’ve committed the cardinal sin (for a consultant that is), I didn’t agreed a fee upfront!! So will probably end up doing it for expenses, boo hoo, woe is me!!

Anyway, all that to one side, I was going to sit tight, meet my deadlines, go to my little committees, and conferences, write my stories and wait till November before musing any more musings.
Sometimes however events just conspire against you (I mean me) and I felt I had to put e-pen to e-paper.  I’ve been seeing quite a lot about service re-design on various DAAT websites, driven as ever by PbR (whether as a full on pilot site or a wannabe early adopter)
I’m all for knocking some walls down and moving the furniture around but some of the stuff being mooted seems a bit beyond the pale and I’m not sure that commissioners and the policy types have really thought things through.  With this in mind and in light of some of the proposed changes I thought I would explore a modality close to my heart, residential rehabilitation aka resi rehab
Getting into rehab can be a complex journey if you don’t have the money and need the state to pay.  There are several starting points on the journey to rehab and several ‘levels’ to negotiate.  If you are already “in treatment” you can see your drug worker and ask for a referral, e.g. at a ‘care plan review meeting’ and if you have a good drug worker they will brief you on how things work where you are (I’m going to be positive and assume there is none of the usual game playing, hoop jumping and gate-keeping that normally goes on and that you get the referral).  
Following referral you’ll need an assessment.  Now different areas do this in different ways, even though they all work to the same set of rules, they just interpret them differently.  Under the NHS and Community Care Act 1990, we all have a right to an assessment of our needs, leading to a care plan and if eligible, access to appropriate care in a residential setting – e.g. resi rehab
After assessment, care planning, etc, a decision about funding comes next and an individual commissioner, or a panel of social care professionals can then make the decision.  Sometimes the panels include local statutory or non-stat service providers e.g. The Probation Service, NHS Trusts, Police, Voluntary Sector Groups and other stakeholders – but always chaired, organized and administered by a statutory body because we are dealing with a member of the publics statutory rights and deciding on the use of public money
Increasingly however DAATs, via PbR, or service re-design, as mentioned above end up, in their innovative zeal, going a bit too far.  For instance, in some areas, it almost seems that the NHS and Community Care Act 1990 doesn’t apply anymore.  Some DAATs are shifting the responsibility for most or all aspects of the resi rehab process to Prime Providers or a series of voluntary sector providers, under a framework agreement.  They are in effect turning a service provider into a type of ‘gang master’ and asking them on the one hand to be a proxy commissioner and the other to be a service (or outcome) provider – surely this poor governance. 
We are in Nick Leeson territory, performing the back office and trading floor functions without proper oversight.  It’s like authorizing your own expenses; it just isn’t done because to do so would open you up to allegations of a conflict of interest, a bit like a news article I saw on the BBC today.  The BBC said that a GP practice in York wrote to its own patients to inform them they had to go private for certain minor ops etc, only to find out that they owned one of the private providers they were referring their patients to. 
Some of these prime providers and proxy commissioners are also resi rehab owners / providers and in effect could be referring clients to their own services, assessing them and judging they are suitable, funding them and then paying themselves for the clients stay and then claiming the money back from the DAAT!!
Don’t splutter into your coffee, you heard me right.  They are asking service providers to effectively commission (no that’s the wrong word) be responsible for finding, assessing, placing and paying the invoices for, resi rehab clients.  In some ways this seems a brilliant strategy, and it means the commissioners’ don’t have to solve the much more difficult and confusing statutory situation surrounding how we get people into rehab (via the community care act and via the paid commissioners whose role it really is).
It’s also brilliant because not only do they shove the problem onto someone else, it sets provider against provider (I know that’s not their aim but its inevitable, and its already started).  The selected providers will decide who gets referred, who gets assessed, who goes to which rehab and who gets paid.  These providers suddenly become very powerful because they suddenly hold the DAAT budget for resi-rehab
What if these service providers (that also have services across the country and which turnover millions of public £s per annum) use this privileged position to further their own ends?  I’m not sure about that.  What if they want to stifle a competitor that is threatening their income stream or their preferred status?  What’s to stop them? And what of the commissioners that have given them this power and responsibility; what of them, will we see a reduction in the number of commissioners due to a reduced workload?
The logic is very much like the rationale behind PbR.  I’ve been told on several occasions by civil servants, in a sometimes boastful manner, that Oliver Letwins Cabinet Office is plastered with flip charts and post it notes as he charts the growth of PbR in every area of government and because of this PbR (or a modified version of it) is here to stay
I’ve been in Oliver Letwins cabinet office (I know, I’ve dined out on this story before, but please be patient and allow me one more crumb).  I witnessed an early version of this rationale, PbR-v1.0, when I met him in September 2010, and where he declared that the government will pay only for what works.  If a particular approach doesn’t work, then we won’t pay and the public purse is protected, if something does work then we will be more than happy to pay because the public benefits, brutal, but brilliant logic, undeniable and impressive, as was he  
However, whilst brutally brilliant, the PbR rationale is critically flawed, and even the more recent versions 2.0 and 2.1 etc are also critically flawed.  First off, somewhere in the discussion about PbR we have forgotten that we are talking about the care of often very vulnerable people and we are treating them as a commodity, slapping a tariff on them and trading them – the promise of payment for a good outcome.  I wonder how long before a provider is enticed to split the winnings with the clients if they pretend to be better.  They are people and not widgets.
Anyone that has been in this field any length of time will tell you, everything and nothing works.  There are so many variables that if we could have solved this problem we would have done it years ago – the truth is we almost did, it was called resi rehab.  
It’s the one people with money and means choose.  No celebrity ever went to a prescribing service for help – they go to rehab. They get stable, they get detoxed, they get hope and they try and put their lives back together. Sometimes it takes a few goes and if you have the means you persevere, if you don’t have the means, you get methadone or Buprenorphine for years and years and the irony is it costs more than rehab ever would.  The costs eventually run into the hundreds of millions, and the legacy is that it hurts for generations and it keeps costing.  You cannot prescribe your way out of addiction in the same way that you cannot borrow your way out of debt.  At some point we have to confront addiction, and yet what do we spend most of our treatment budget on?  Well, 18-months after the new coalition came to power and nearly a year since the new coalition drug strategy and we are still spending most of the budget on prescribing.  A bit like spending all your money on interest payments, eventually you have to pay back the capital, something the loan shark failed to mention!
And yet, lets assume for a moment that the brutal logic is sound, ok then, if it is lets apply across the board, not just to the most fragile part of the system, the bit that only 2% of addicts get a crack at.  Use the logic and apply it to prescribing services that take up 80% of the resources and contribute the least to the Recovery journey of an addict.  In fact these services, over inflated as they currently are, seem to rob the client of the very cognitive skills required to build motivation and hope.  They trap the individual and make it almost impossible to escape, if we are going to apply the brutal logic of PbR lets do it to the whole system and lets have a free for all
I am amazed at how so many genuinely clever people, like Mr. Letwin, top cabinet ministers and the civil servants that advise him (many with an education to die for) can be so clever and so stupid at one and the same time – government strategy, is that what they call a paradox or an oxymoron?
Maybe its like the story about the emperors new clothes, it was fabled that only the clever courtiers could see the fine new cloth, and so because no one wanted to be seen as ‘not clever’ they went along with the deception.  In the end, the emperor was humiliated because a little child pointed out the bleeding obvious, in public, and everyone laughed at the naked King.
Nuff said, rant over
All the best


2 thoughts on “Commissioner, Prime Provider or The New Gang Masters?

  1. I don't know if this is common practice around the country, but in Westminster, London, if you are already in treatment, you have to reduce your methadone dose to a maximum of 30mg/day before you will be given a referral to rehab. I'm sure this is a way of rationing the treatment, as the obvious point is that if you are able to reduce your dose without relapse onto street drugs you probably don't need rehab anyway.I know in the USA, once the decision has been taken to fund a person to enter rehab, they can go into a detox regardless of what they are using, so if they are on 10mg or 100mg methadone it makes no difference. If we could get rid of this arbitrary limit of 30mg before people can go into detox/rehab I'm sure there would be more people willing to go, as plenty would like to find recovery, but can't face that painful slow reduction from 100mgs or more down to 30mg. Once someone gets below 70mg from a 100mg dose, they really begin to notice that the medication is not as effective anymore, and start suffering with insomnia and various other withdrawal symptoms. If I was making recommendations to government it would be to allow those who ask for detox and rehab to access it immediately, and detox them from whatever dose of methadone they are on in-patient.

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