06 August 2010

be careful what you wish for...

The new NTA business plan was published today and one can see the tensions between the old and new guard being played out between the lines of the document. Though in truth this document is going to be less significant than the changes that it heralds - and the structures in which they will be implemented.

There are three things that leap out at a quick initial reading:
- the priority given to abstinence is very obvious: the word is used twenty times, and most strikingly in the line "New clinical protocols will focus practitioners and clients on abstinence as the desired outcome of treatment." But desired by whom? And what of those people who wish to stop using the drug on which they are dependent, but not other substances? "Harm reduction," by comparison warrants only three mentions, one in the budget, one in relation to young people and a generic mention. "Reducing harm" has gone.

- Payment by results: the Business Plan says "We will continue to drive unit costs down by a combination of matching resource allocation to performance, progressive implementation of
payment by results..."

This throws up two substantial challenges. The first - what is the "result." Given the priority given to "abstinence" one must suspect that payment by result will be tied to abstinence as an outcome.

The second is that payment by results can result in very long timescales for payment. They tend to work in the favour of large corporate bodies who can afford the up-front costs of treatment and can await later payments. They don't work so well for small third sector organisations with limited cash flow and small reserves.

Time-limits on substitute prescribing: The business plan stresses that open-ended prescribing will not be an option most of the time and the presumption is against it. The Plan says "substitute prescribing is planned to be a time limited intervention." What the stated time limits will be are not yet clear and guidance has still to be issued.

There is at least grudging acknowledgement that some people will warrant and benefit from long-term prescribing. The Plan says "Those who need substitute prescribing beyond an initial time limit should, in turn, be reassured that it is only on the basis of a rigorous, multidisciplinary review of their ongoing needs." Reassurance really depends on your perspective. For those who argue that it is too easy for people to be left on methadone without other interventions, this review and reassessment is welcome. But for others, "reassurance" will mean a three-monthly battle to justify ongoing prescribing because they are not yet ready to reduce or stop - irrespective of the other interventions being offered to them.

In a lot of respects the Business Plan will get cautious approval from a lot of people who will see what they want in it: mutual aid groups get a mention and will be more involved; abstinence is reprioritised; there's mention of residential rehab than before though probably not as much as this Sector would have liked. But there'll also be bouquets for the mentions of time-limiting substitute prescribing and some will even cheer for payment by results.

But at the heart of this a couple of unresolved issues still remain, potent and toxic. The first is the remaining tension as to what "recovery" really means. And the Plan doesn't resolve this. On the one hand it says that "treatment gives individuals the opportunity to overcome their dependency and achieve abstinence" suggesting that it's all about abstinence.

The other says "The purpose of treatment is to enable individuals to overcome addiction. This is fully achieved when someone has completed treatment and been rehabilitated back into their community as an economically active contributing citizen." And given that we are entering terrain which will include payment by results, the definitions are all important.

Ultimately it won't be the NTA who ends up resolving these questions: but some of the voices that will be shouting loudest will be the ones who tie it to abstinence for ideological, not evidentiary reasons.

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