The metamorphosis of addiction services

The National Health Service's (NHS) reorganisation that started with the Darzi report ^{Reference Darzi2} is shaping up with the most recent White Paper Liberating the NHS. ³ This is taking place in the light of a constrained financial climate. The interaction between these translates into the ongoing metamorphosis of services, aiming to provide the best care at competitive costs. Over the past couple of years, the working landscape of addiction psychiatry has been witnessing gradual reshaping with an increased risk of extinction. ^{Reference Finch4} This prospect continues to grow and has become even more real with the recent Coalition's announcement ⁵ involving the dissolution of the National Treatment Agency (NTA, an NHS special health authority established to improve the availability, capacity and effectiveness of drug treatment in England) alongside the merging of addiction monies within the ring-fenced public health budget. ⁶ During its lifespan - and in the context of an implicit exclusion of funding for people with alcohol dependency - the ethos of the NTA has been based on raising the involvement of primary care physicians in the provision of services for drug addicts. The model indulged patients in the evidence-based victories of a methadone or buprenorphine prescription as the end-point of their treatment. ^{7-Reference O'Hara9} The emphasis on harm reduction is swiftly shifting towards the broader concept of ‘recovery’ that decentralises the medical model aiming to foster reintegration of addicts in society with abstinence as the prime goal. ^7,10,11

The ‘ownership’ of addiction services has become blurred with decommissioning and retendering being the ruling processes of redesign in a financially drained NHS. ^{Reference Finch4,Reference Wolstenholme12-Reference Pollock, Murphy and Sugarman14} According to an interim report of a survey performed by the Specialist Clinical Addiction Network (SCAN, www.scan.uk.net/) in 2009, 45 services were involved in the process of retendering in England and Wales. ^{Reference Wolstenholme12} In total, 31 of those services completed the retendering process and only 16% were regained by the NHS, 42% went to non-statutory agencies and 13% to a partnership between both. The report also highlighted inconsistencies in the bidding process, lack of clarity when awarding bids and perceived poor rationale in the decommissioning of innovative and well-functioning services. ^{Reference Wolstenholme12}

Driving competition to achieve excellence at lower costs is leading to a combination of partnerships between the NHS, non-statutory services and the private sector that more often than not tend to re-evaluate the need to employ ‘expensive’ consultant psychiatrists, favouring general practitioners (GPs) or senior nurses with a special interest in the area. ^{Reference Finch4} As is the case for many other subspecialists, we now have to redesign our future and ‘charm’ commissioners trying to attract investments. ^{Reference Butterworth15} This is the current cost-effective NHS in which we can only make ourselves financially worthwhile as long as we can differentiate what we do from cheaper options. ^{Reference Butterworth15}

General adult psychiatrists have not been immune to ongoing reshaping of services with functionalisation being the upcoming controversy. ^{Reference Burns16} Furthermore, challenges raised around the model of functionalisation against the status quo ^{Reference Burns16} have resembled those affecting retendering of addiction services, for instance: threats to continuity of care, staff uncertainties, low morale and animosity among providers, with patients falling into precarious interfaces. ^{Reference Finch4,Reference Wolstenholme12,Reference Butterworth15} There is recognition that weaknesses associated with these transitional models will undoubtedly impact on the training of developing professionals ^{Reference Finch4,Reference Drummond13} and there are questions as to whether their objectives will be ultimately achieved (lower costs with better services). ^{Reference Drummond13,Reference Burns16,Reference Drummond17}

Resuscitating old classics and reinventing new ones

Primum non nocere

Although the number of substance misuse consultants in the UK is limited to 361 (Royal College of Psychiatrists’ Addiction Faculty personal communication, 2011), the issues they face are as complex as in any other subspecialty. They lead rich, rounded quality services with a uniquely wide range of high-level skills to manage the most severe cases. ¹⁹ They foster a supportive and therapeutic setting that offers liaison with other professionals from primary and secondary care. They provide training to expand the provision of high-quality services and there is a commitment to research and innovation to improve effectiveness and efficiency. ^{38,Reference Craddock, Kerr and Thapar39}

This combination of leadership and expertise is presently being threatened by the current ethos of the NHS reorganisation. There is a consensus of concern about price competition damaging healthcare quality. ^{Reference Hawkes40} Besides, the monetarisation of the transitional process in which redesign is implemented by the retendering of services is likely to see many casualties among highly qualified professionals. ^{Reference Godlee41} Service providers should be mindful to apply the principle of Primum non nocere to professionals as well as patients, in particular because of the need for personal integrity to be the riding force leading quality, enhancing outcomes and absorbing accountability in a cost-effective and creative way.