The document discusses strategies for commissioning effective drug and alcohol services. It covers: 1) Lessons from a 2014 review on challenges and successes in prevention and recovery-focused treatment. 2) Understanding the impact of localizing drug and alcohol service provision. 3) Encouraging innovation while sustaining support during restructuring. Key themes included realigning resources between alcohol and drugs, improving outcomes through recovery models, and ensuring quality while prioritizing value. Opportunities exist for whole-system integration and innovative prevention initiatives. Challenges include austerity, population trends like "chemsex," and differing responsibilities between public health and other agencies.

1. Taking Steps Towards Effective
Strategies to Commission Drug and
Alcohol Services
Delivering Excellence in Drug and Alcohol Services:
Improving Treatment and Recovery 18th
March 2015
Jim McManus, ADPH Co-Lead
DPH, Hertfordshire County Council

2. Coverage
• Lessons from the 2014 Review of Drug and Alcohol Commissioning
by Public Health England and the Association of Directors of Public
Health
• Analysing successes and challenges in putting community-based
prevention and recovery at the heart of substance abuse treatment
strategy
• Understanding the impact of the localisation of drug and alcohol
service provision
• Encouraging innovation in service provision and prevention
initiatives
• Sustaining support measures throughout periods of service and
agency restructuring

3. The Major Changes
• Public Health into Local Government
• Drugs and Alcohol services within PH
Portfolio
• Move to Recovery and evidential
challenges
• Care Act 2014
• New Probation arrangements

4. 2014 Review Key Themes
• except where retendering exercises underway or recently
introduced, 2013-14 has steady state
• 2014-15 and 2015-16 will see a focus on reassessing current
service provision with the view to recommissioning
• over 70% of respondents indicated that they were not planning to
reduce funding in 2014-15. Of the 70%, over 50% reported no
change, nearly 10% an increase in funding, while the remainder
indicated uncertainty as to future plans
• there were planned realignments of resources between alcohol and
drug services – with alcohol assessed as the greater need
• there was a focus on improving outcomes, continuing the move to a
recovery model
• improved delivery and performance by providers a clear aim in all
recommissioning, with a focus on improving treatment completions

5. Key Issues
• many areas are exploring the integration of services –with alcohol
services, wider services such as housing, criminal justice, and local
health delivery
• involvement of public health and PHE welcomed, particularly the
advice on commissioning.
• DrugScope, representing service providers, similar to views
expressed locally. focus on the volatility of funding, the continuous
drive to reassess and retender, the need for commissioners to
understand the impact frequent tendering processes have on
providers
• Association of Chief Police Officers (ACPO) emphasised the value it
places on the importance of effective drug treatment services to the
criminal justice agenda, ensure any reductions or changes do not
reduce the effectiveness of services, as this could prejudice crime-
reduction benefits of the current approach

6. Key Opportunities
• the majority of commissioners want to transform and make services
more efficient
• local authorities are adopting a variety of approaches but
overwhelmingly want to make services more effective.
• there is a close scrutiny on current commissioning arrangements
and this includes funding.
• However, there is a clear desire to ensure that services continue to
improve, and that while value for money is a key driver, so is quality
of service
• the review shows that there is little intention to simply disinvest in
services, but to bring a rigour to commissioning focused on needs of
the population and on outcomes for the services
• ADPH and PHE believe these needs can be best met as part of the
sector-led improvement process.

7. Key Opportunities 2
• massive opportunities for whole system
approaches and integration once
commissioners have got through the initial
transfer
• Directors of public health have an
important leadership role in bringing
partners and stakeholders together and in
looking across the whole system to further
their shared aspirations of integration

8. Key Opportunities
• Integration – Drug and Alcohol Boards
• Health and Wellbeing Board
• Whole System Approach – Boards,
Governance (eg Herts Board)
• Localism -
• Innovation
– Recovery social enterprise
– Recovery models
– Integrating services

9. Steps to a commissioning
approach – much done in
parallel

10. Step 2: Building the Commissioning
Landscape
• Bring partnerships together
– Formation of DASB as overarching
partnership
– Elected member led
• Public Health led commissioning cycle
and approach from County
• Working with every other agency (Sports
Partnerships)

11. Monitor/
Evaluate
Plan
Review Need for
Service and
Effectiveness of
existing services
Public Health Input into the Commissioning
Cycle. Can be throughout or can be on
specific areas playing to the PH strengths
Community
Engagement
Support in establishing
meaningful indicators of
delivery and outcome
Model whether need will
Be met by proposed
volume
Check whether plans equate
To evidence and need and
Test for equity / inequity
Support and advise on
Evaluation and conduct
Bits of it if enough resource
Needs Assessments
Equity Auditing
Evidence of Effectiveness
Health Impact Assessment
Triangle of critical
influence – where public
health should be most
visible
Contract/Deliver
Triangle
of critical
influence
Triangle of
critical
influence

12. The principles of our commissioning approach in Herts: building the
house while living in the foundations
1. Build a system from the best we have, don’t reinvent
2. Transformation through phases and staged redesign
3. See potentials, not problems
4. See Potentials not Problems, assets as well as needs
5. Subsidiarity
6. Co-production
7. Behavioural Sciences
8. Pathwayed

13. Working out who does what
Lead Enforcement and
Control
Prevention Support,
Treatment and
Care
Community
Safety
County Community
Safety Unit
County Community
Safety Unit?
Probation, NHS,
Public Health
Domestic
Violence
County Community
Safety Unit
Domestic Violence
partnership
?Childrens Services
Drugs and
Alcohol
County Community
Safety Unit
Both working
together
Public Health
Alcohol related
violence
County Community
Safety Unit
Multi agency NHS Acute Trusts
People with
learning
disabilities
who are
victims
County Community
Safety Unit
Multi agency LD Partnership

14. Innovation Example: DIP Pilot
• Commissioned icpr at Birkbeck to
evaluate the project
• Currently trying to rework criminal justice
aspect of drugs services
• Challenge in that PI says drug testing and
treatment responsibility of DPH. No
funding for this

15. • Compulsory drug testing – at least as practised during the first year of
the pilot – did not result in a higher proportion of criminally involved drug
users entering and being retained (for 12 weeks) in treatment.
• There were no significant changes in levels of self-reported substance
use, health and social functioning following exposure to compulsory drug
testing.
• Exposure to compulsory drug testing did not significantly reduce the rate
and volume of re-offending across Herts, or increase the time taken to
re-offend.
• More adaptive/responsive forms of intervention needed for those with
more extensive offending histories, and involved in income-generating
property crime (versus drug possession offenders).

16. • Recovery & desistance outcomes being achieved?
– Perception that IOM an effective form of crime reduction (but no
counterfactual e.g. in quarterly reporting)
– But greater clarity of intervention objectives needed around substance
use (including NPS) and responses to continued use (e.g. DRRs).
• Strategic fit, future commissioning & governance structures
– Custody data indicates potential demand for test on arrest elsewhere
– But tighter performance framework & scrutiny needed (“what get
measured gets done”)
– More broadly, formal governance structures around drugs and work
with DUOs considered as 'a work in progress'

17. Key Challenges
• Effectiveness
• Austerity
• Population Trends – Chemsex, Offending
• Probation Instructions say DsPH have
responsibility for testing. DsPH don’t have
money
• Localism
• The rehab sector

18. Systems thinking
The wider determinants of Health and Local Government functions
(Must adopt a Lifecourse approach!)
The Lives people lead and whether LA functions help or
hinder healthy lifestyles (policy, service quality, access,
behavioural economics, behavioural sciences)
The services people access such as primary care
(high quality, easy access, good follow up,
behavioural and lifestyle pathways wrap around)
•Our health and our offending occurs in a system
•Criminology and public health/epidemiology share some concerns in
the literature

19. A plea..
• Page 11 for the figs on spend.
•
http://www.local.gov.uk/documents/10180/6869714/L14-794+100+Days+Alcohol+M
• The LGA has called for a clear commitment from the department of health
for an increase in resources to a level that will maximise the value for money
available from well targeted investment in public health.
• Need to make the the case for public health and show how it saves lives but
also saves money.
• The elected members should be your ally. Meet them, introduce them to
people, share their thoughts, look for opportunities to raise their profile in
your policy area.

20. A plea 2
• There was never a “golden age of public health” in the NHS so let’s not
pretend that there was.
– You had local variation, raids on budgets and executive indifference to prevention in the
NHS too. Local accountability and transparency in public health is now very real. Was there
ever such a degree of transparency of both inputs and outcomes prior to the transition within
PCTs
– Public health was often seen as the 'Cinderella service' of the NHS, operating as an add-on
to their main business of treating sickness and constantly pushed to the back of their priority
list. Too many organisations at a national and local level confused rather than clarified
matters.
• Councils deliver over 800 services that will to a greater of lesser degree
impact on the health of our communities. Have you made the connections
and truly realised the synergies?

21. Final thoughts
• Prior to transition there was too much reliance on top-down targets that
sapped local initiative, the result, was a system which did not deliver the
step change in public health outcomes that the country needs or secure the
common understanding that health is about much more than just healthcare.
• There is a case to be made that public health spend has historically been
too low to achieve a significant and sustained positive impact on health
outcomes and on health inequalities. Looking forward it will be important to
ensure that the total resources available for public health are sufficient to
meet needs.
• Councils in some areas have serious and well-founded concerns that the
future public health investment in their communities could fall well behind
likely need.

22. Where next?
Over to you
Thanks
Jim.mcmanus@hertfordshire.gov.uk