Striking the Balance: providing quality and cost effective services


The NHS SMPA believes strongly that drug and alcohol services that provide methadone, or any pharmacological therapy, for an opiate addiction should do so in a manner that first and foremost enables a service user to be safe. The dose should also be of a level that provides stability and the foundation for balanced decision making with regards to a service user's future aims and ambitions.

This is what clinical guidance says and is best practice; any provider that diverts from this should be able to very clearly justify why they have.

From a NHS SMPA perspective, no provider would stop or reduce a service user’s prescription unless there were sound clinical justifications for doing so, and no commissioner acting as a responsible guardian over the treatment system would pursue this.

In contrast, a recent article in the Stoke Sentinel highlighted concerns about Stoke Council’s new approach to commissioning drug and alcohol services. With a reduction in budget and an emphasis on reducing methadone prescribing costs as a way to offset their £751,000 depletion in funding, the Council has presented the idea that any provider coming in will be ‘incentivised’ to reduce the cost on methadone prescribing.

We suspect that the story behind this incentivised model is more nuanced, and that in reality the local authority is following a direction of travel that is becoming a staple of most tender specifications across England. Existing services must be recovery-focused whilst ensuring safety. Many of these specifications have KPIs, and often penalties related to them if a certain percentage of successful completions are not achieved.

Stoke on Trent’s successful completion rate for opiate users in 2014/15 was 3.62%; year-to-end February 2018 it is 2.04%. This is well below the national average, and whilst there are some who should remain on substitution therapy, to suggest that 98% of opiate users in treatment choose to do so seems unbelievable. By no standard is this positive for service users who may wish to move beyond a methadone prescription, nor does it paint a picture to tax payers and elected officials that drug and alcohol services are effective. All at a time when making that case locally is paramount.  

One could argue we wouldn’t be too far off the current recovery rate if we just prescribed from pharmacies employing the minimum of staff, gave service users an optimum dose and invested the remaining money in residential detox/rehab. Would there be better outcomes and probably less deaths? If a system is failing consistently for a period of time when spending in excess of £5.5 million a year, is it any wonder commissioners consider incentivising an improved system and recovery? However, to be clear, this doesn’t justify inappropriate targets. One can see the frustration from commissioners, but providers should not agree to these targets.

The NHS SMPA believes drug and alcohol services should be provided in a manner that strongly prioritises safety, but that also enables aspiration and ambition. Within this, different individuals will have different measures of success which should be accommodated. Organisations should strive to achieve this balance, ensuring that the relationship they establish with commissioners is a collaboration which, at times, involves challenge, but is underpinned by working in a manner that is evidence based, supports quality and does not create ceilings that thwart service user’s goals.

Danny Hames – Chair of the NHS SMPA