Fight for the future of shared care

At the RCGP 20th National alcohol and drugs conference last week there was evidence that a number of shared care schemes are being decommissioned following changes in tenders during the process of re-commissioning services. Guest blogger Paul Roberts suggests we need to be ahead of the game when it comes to preserving shared care services.

It was shocking to hear at the 20th RCGP National Drug and Alcohol Conference of the many areas in the UK where ill-considered commissioning decisions are dismantling shared care services at the very moment that Simon Stevens’ five year forward view is demanding more integration. A conference position statement is part of the solution, but other strategies are needed to counter the prejudices of maverick commissioners. Sadly commissioning is often not as sophisticated as one would want and it is easy to interpret ignorance as enemy action. Most of us feel “got at” at least some of the time but we have to strive to avoid seeing ourselves as passive victims. There are opportunities to avoid further disasters. The value of these contracts is large so they are going to be tendered under current legislation; we cannot change this given the last election result, we have to play by the commercial rules.

This is the start of a list how to play an active role in the commissioning of drug and alcohol services in your area. This is not exhaustive, and I would encourage you to add anything I have missed in the comments section:

Be aware of the commissioning plans for drug and alcohol services in your area. Contracts tend to come up every 3-5 years. Sometimes contracts get extended because of lack of local appetite or resource to support re-tendering.

  • Whilst Clinical Commissioning Groups (CCGs) may not be leading on commissioning of drug and alcohol services they will be aware of them and should have an influence. Pester your responsible officer to keep you informed of the timetable for any re-commissioning so that a stealth approach is not possible.
  • Commissioning specifications should go out to consultation; let the commissioning lead know you are interested and would like to contribute to the development of the specification.
  • Spell out the benefits of shared care to everyone involved in writing the specification. Do this specifically in terms of overall care for long term conditions and normalising individuals’ treatment. Commissioners are mostly completely fixated on avoiding unplanned admissions and stopping local people going to A&E. They probably haven’t stopped to think how shared care contributes to these goals.
  • Help your patients help you to help them. There has to be service user involvement in the process. Speak to the patient representative on the CCG board. Get them to come and talk to some of your patients. If you don’t do this then it is likely that the only view that is obtained will be from clients attending a community clinic provided by the incumbent provider. It is assumed that the commissioning specification will contain lines about being sensitive to the needs of local communities and to be building on existing good practice (because they always do). Once the commissioning process starts you have options, but you have to act quickly (so it is best to have thought about this, and have had discussions before).
  • It is possible for a group of GPs to tender to deliver an entire drug and alcohol service? This is a step that may be beyond most of us.
  • Shared care requires wrap around services; who are the agencies providing this now? Are they any good? Are they bidding?
  • Identify who the likely bidders are going to be; who would you want to work with?
  • Approach them early, explain that you want to sustain shared care and that you want it in the bid. You are unlikely to be rebuffed since a bidder who has a demonstrated, worked out relationship with primary care is likely to appear better at interview. There are a couple of likely outcomes:
    1. Bidder welcomes you with open arms and invites you and your colleagues to form a consortium bid (this has to be decided at a very early stage since NHS procurement traditionally goes through a two stage process). The first stage requires potential bidders to identify themselves in a Pre-Qualification Questionnaire stage (PQQ) during which they are assessed for viability. If a consortium has not been assessed suitable via a PQQ then it will not be allowed to tender.
    2. Bidder indicates that they do not want to form a consortium, but is keen to work with you as a group of subcontractors. This will require commercial negotiation. What are you signing up to do for how many clients/patients? What level of support are you going to get in your surgeries, who is going to be responsible for what? A commissioner is going to want to see some sort of outline contract as part of the tender submission along with a governance structure indicating lines of responsibility. In some areas shared care was funded by a local enhanced service agreement. Financial planning on both sides requires understanding about the proposed continuation (or not) of such schemes. This is the sort of undertaking that a local GP federation may well be in a position to support, if it is brought to their attention.

    Assuming one gets to interview then ensure that you are well prepared.

  • Commissioners want a guarantee that their future service provider has the capacity to do what they say they are going to do in a safe manner.
  • Commissioners will want to deal with one agency not 20 practices.
  • Governance is very important.
  • Use the opportunity to explain, once again, how shared care fits into the wider current NHS England agenda. It is a shining exemplar for multiagency working. If it is done well the relationships developed with housing, social care and other third sector organisations can be positively exploited to provide similar approaches for other marginalised groups. The Five year forward view paper talks of multi-speciality community providers as being a desired end point. At its best shared care is this in embryonic form and it needs to be sold as such.

– Paul Roberts, GP