1. health and fitness

CABINET
Meeting date:
From:
26th March 2015
Interim Corporate Director - Health and Care
Services
PERMISSION TO PROCURE ADULT SUBSTANCE MISUSE
RECOVERY SERVICES
1.0
EXECUTIVE SUMMARY
1.1
This report sets out the proposed timetable and method of
procurement of Adult Substance Misuse Recovery Services, with the
intention to have a new contract in place by 1st October 2015. The
current annual funding associated with this activity is approximately
£5.9m per annum. However, due to a combination of service redesign
(to meet current need) and some changes in commissioning
responsibilities at national level, the future value for this new contract
will be reduced to £4.235m per annum. This forms the upper limit of the
planned financial commitment for the new contract in regard to the
budget consultation.
1.2
The report builds upon the report to Cabinet in December 2013 and the
further development of an Integrated Wellbeing Service.
1.3
The proposals within this report recognise that efficiencies can be
realised, in part due to the changing nature and profile of substance
misuse. Although opiate use is still significant, the opiate using
population is declining as the current service receives fewer
presentations and recovery becomes a stronger element of the service
offer. Increasingly the response to substance misuse in Cumbria is
less clinically focused and structured around psycho social
interventions. These interventions tend to be more cost effective than
traditional substitute medications which necessarily require greater
levels of clinical input and supervision
1.4
Cabinet approval is sought to commence procurement of Adult
Substance Misuse Services for a period of 48 months, beginning from
1st October 2015 for an initial period ending 30th September 2019, with
the option to extend for up to a further 12 months.
1.5
In line with Cumbria County Council Contract Procedure Rules and EU
procurement legislation, the Council is obliged to procure these
services through a competitive process.
2.0
STRATEGIC PLANNING AND EQUALITY IMPLICATIONS
2.1
Adult Substance Misuse Recovery Services support the delivery of a
range of Public Health outcomes which are consistent with those set
out in the Health and Social Care Act 2012.
2.2
It is well understood in public health that costs associated with
recovery from substance misuse are far exceeded by the benefits
realised through a reduction in need for continuing and acute health
care, social care, care in later life and income maximisation. Guidance
issued by the National Institute for Clinical Excellence (NICE)
highlights a range of interventions with modelled financial benefits
associated with substance misuse recovery. This service is NICE
compliant and therefore these modelled benefits could reasonably be
expected within the system in Cumbria.
2.3
Currently the Council has one contract for a Substance Misuse service.
This contract has been inherited by Cumbria County Council following
the transition of Public Health Services into the Council. Opportunities
continue to be presented by aligning contracts for service provision
across Public Health and the potential realisation of the benefits from
an integrated Health and Social Wellbeing System, it is proposed to
scope the procurement process to enable such services to be
incorporated. Such an approach leads to better outcomes for service
users while reducing the costs of procurement and contract
management for the Council.
2.4
Commissioning a single service for Cumbria is more cost effective
than having multiple providers; it enables more consistency in
delivery, service improvement and performance management and
enables a viable service within a manageable cost envelope.
2.5
The procurement of Adult Substance Misuse Recovery Services
supports the delivery of the Council Plan ambitions, which include: To promote health and wellbeing, and tackle poverty.
 To support older and vulnerable people to live independent and
healthy lives.
2.6
Public consultation and engagement is critical to the strategic planning process to
shape future service provision. Appropriate engagement with the service user
population is ongoing.
2.7
Substance misuse services are of critical importance to the local health service, in
particular to primary care and the Clinical Commissioning Group. Discussions
are therefore underway with the CCG and with GPs involved with provision of
shared recovery services to ensure that the future model of service is appropriate
for Cumbria.
2.8
An Equality Impact Assessment of this proposal has been built into the
development process. This is a universal service with open access to
anyone in Cumbria suffering from the effects of substance misuse and
seeking recovery. Therefore as a matter of principle the whole
population has equality of access to these services.
3.0
RECOMMENDATION
3.1
It is recommended that Cabinet Members approve the procurement of
Substance Misuse Recovery Services for Cumbria in April 2015, as set
out under paragraph 5.2 below (Option 1 – a single integrated provider
for Cumbria). It is recommended that a contract commences on 1st
October 2015 until 30th September 2019, with the option to extend by
up to 12 months.
4.0
BACKGROUND
4.1
Substance misuse services are primarily focused on tackling illicit drug
misuse and alcohol misuse. The ultimate focus of the service is to enable
recovery for service users. This is sometimes, as in the case of addiction to
opiates, assisted by substitute medication, or as in the case of other
substances assisted by talking therapies. Substance misuse treatment can
often follow a legal order made by a Court under Sections 209 and 212 of the
Criminal Justice Act 2003, a prison release back into the Cumbrian
community and Cumbria Constabulary police station cell sweeps.
4.2
There is an important harm reduction element to services especially for those
clients, such as steroid users, who use drugs intravenously. Needle
exchange and harm reduction advice services are available to ensure that
blood borne viruses do not proliferate.
4.3
Substance misuse is a key driver of health inequalities. The needs of the
population point to a shift in patterns of use away from opiates such as
heroin with increased usage of alcohol, cocaine and legal highs. This means
that the service which has traditionally been structured around opiate
treatment and substitute prescribing can be reviewed as part this process
and hence significant savings can be projected.
4.4
The current recovery focused contract continues to perform exceptionally
well and delivers amongst the best recovery outcomes in the country. A key
factor in this success is that the entire service is integrated into one contract
meaning that one single provider works with the client from entry into the
system until the point of recovery. Recognising opportunities presented by
the developing integrated Health and Social Wellbeing System and aligning
of contracts across Public Health and the additional benefits that can be
derived from working with multi-agency partners, it is proposed to scope the
procurement process to enable such services to be incorporated.
4.5
The costs of the current service are £5.9 million per annum. However, the
proposal for this new contracting period is to seek efficiencies of £1.8 million
per annum. Some of this shall be delivered through changes in
commissioning responsibility for substance misuse services in HMP
Haverigg which are no longer the responsibility of the Council. However, the
major change shall come from reconfiguring the service to respond to our
identified needs.
4.6
The selected provider shall be monitored by the Council to ensure the
service is provided effectively. The specification for the contract would
include a requirement for the provider to demonstrate knowledge of
delivering this type of service to a diverse range of users and communities
(both urban and rural), including innovative approaches to provide a range of
ways that users can access the service including clearly accessible local
delivery points. The budget for the contract may increase dependent upon
future provision of services provided by Public Health services.
4.7
Recent work has been commissioned jointly by Public Health England and
the Association of Directors of Public Health to examine whether or not the
commissioning of Substance Misuse Services should be mandatory. In
responding to this review, Ministers want to ensure that local authorities
continue to give effective drug and alcohol services the priority they require
and for this reason the Department of Health shall use the power in Section
31 of the Local Government Act 2003 to attach a new condition to local
authority public health grants in 2015/16. The new grant condition shall
state that: A local authority must, in using the grant, have regard to the need
to improve the take up of, and outcomes from its drug and alcohol misuse
treatment services.
4.8
An Open Procurement Procedure is being used for this tender and the
stages and timetable are set out below. Open Procedure Key Stages
Timetable
Stage
Date(s)/time
OJEU Notice Advertised
1st April 2015
Issue of Invite to Tender (ITT)
1st April 2015
Deadline for Submission of ITT
23rd May 2015
Evaluation Of ITT
24th May 2015
Cabinet
23rd July 2015
Standstill starts
24th July 2015
Intention To Award + Unsuccessful Letters
27th July 2015
Contract Award
1st October 2015
5.0
OPTIONS
5.1
There are four options for the service:
5.2
Option 1. One countywide integrated contract for Substance Misuse
Recovery Services.
5.2.1 This is very much in-line with current arrangements since 2012 which have
worked exceptionally well and have seen performance in Cumbria go from
bottom of the national performance table to top in a very short time frame.
The advantage of the one contract approach is that it provides greater
control over requirements and also consistency of service across the
County.
5.2.2 Furthermore, it would also give efficiencies in overhead costs as a result of
reducing duplication. This gives the Council, as commissioner; greater
control over the outcomes delivered by the provider and enables the Council
to monitor in a more cost effective way. A single contract would reduce the
contract monitoring time by the Council, as outlined in Option 3.
5.3
Option 2. Bring the entire service in-house.
5.3.1 This option may require TUPE transfer of existing staff to the Council. The
advantage would be greater control over the requirements and consistency
of the service across the county. Furthermore, it also affords greater control
over the potential volume of users accessing the service. Service volume
would be controlled via the in-house capacity of the specialist staff to work
with users rather than an open access service.
5.3.3 However, there is potential disadvantage in this option whereby the TUPE
transfer is also likely to cause significant disruption which could reduce the
efficiency of the service being brought in-house, and a period of transition
could also limit the number of service users successfully completing
treatment.
5.3.4 The Council lacks capacity or expertise to oversee healthcare clinical
governance and risk management at a provider level, and would not be able
to offer appropriate supervision without employing a specialist member of
staff. Currently, recovery options are supported through the prescribing of
substitute medication such as methadone and buprenorphine which are
prescribed as part of an abstinence programme. Methadone and
Buprenorphine must be monitored via a trained service clinician who must
have clear lines of clinical supervision and governance. These substitute
medications have contra-indications and the potential for adverse harmful
effects.
5.3.5 Many potential service users are not in contact with Cumbria County
Council. Potential users do not currently associate Cumbria County Council
with Substance Misuse Recovery Services and this association would need
time to develop. There is a risk that users may not come forward for an
intervention and shall not receive the support that they need, and recovery
outcomes could be compromised as a consequence.
5.4
Option 3.
Services.
Six district based contracts for Substance Misuse Recovery
5.4.1 Whilst providing a localised approach, it would reduce the consistency and
would be likely to carry a higher proportion of overhead costs within provider
organisations as a result of duplication, leaving less money for direct user
contact. This would also mean higher level of officer time in monitoring the
six contracts to achieve consistency of service.
5.5
Option 4.
Do not approve the procurement process
implementation of a Substance Misuse Recovery Service.
and
the
5.5.1 This option would mean that people are unable to access the support they
need to recover from substance misuse, via Public Health funded services.
This would have consequences on long term conditions, death rates, levels
of crime disorder and anti–social behaviour, adult social care, and wider
social costs to society.
6.0
RESOURCE AND VALUE FOR MONEY IMPLICATIONS
6.1
There is a revenue budget within the Health and Care service which funds
the expenditure relating to this contract. There is an expectation that
savings will be found through the procurement process.
6.2
Members are recommended to approve Option 1, the procurement of a
single county wide contract for Substance Misuse Recovery Services. It is
anticipated that a single county wide contract will give a consistent service
across the county, create efficiencies in terms of contract monitoring, and
improved control of outcomes delivered by the provider.
6.3
Option 2 to bring the service in house is not recommended due to potential
TUPE implications and because the Authority lacks the capacity or expertise
to oversee healthcare clinical governance.
6.4
Option 3 is to let six district based contracts. This option would reduce the
likelihood of a consistent service across the county, and would also increase
the time needed to monitor the contracts.
6.5
If Members decided to select Option 4 which is to not approve the
procurement of a Substance Misuse Recovery Service, such a service would
not be available via Public Health funded services.
7.0
LEGAL IMPLICATIONS
7.1
Section 12 of the Health & Social Care Act 2012 imposes a duty on Local
Authorities to take such steps as it considers appropriate for improving the
health of the people in its area and addressing behaviour that is detrimental
to health. The provision of the services discussed within this report should
therefore fall within this section.
7.2
The procurement of these services, through the use of an Open procedure
tender in accordance with the Public Contract Regulations 2006, as
proposed, should allow for the contract to be procured in accordance with
EU and UK requirements as well as in compliance with the Contract
Procedure Rules contained within the Constitution.
7.3
This is a proper decision for the Cabinet as under Part 3 of the Constitution
and rule 3.4.3 of the Contract Procedure Rules Cabinet is responsible for
approving the commencement of procurements where expenditure is over
the key decision threshold of £500,000 per year.
8.0
CONCLUSION
8.1
Following the recommendations of this report shall enable the Council to
reduce ill-health by ensuring that there are substance misuse services in
place.
Sally Burton
Interim Corporate Director, Health and Care Services
16 March 2015
APPENDICES
Electoral Division(s):
All
Executive Decision
No
Key Decision
Yes
If a Key Decision, is the proposal published in the current Forward Plan?
Yes
Is the decision exempt from call-in on grounds of urgency?
No
If exempt from call-in, has the agreement of the Chair of the relevant
Overview and Scrutiny Committee been sought or obtained?
Has this matter been considered by Overview and Scrutiny?
If so, give details below.
Has an environmental or sustainability impact assessment been
undertaken?
N/A
No
N/A
Has an equality impact assessment been undertaken?
PREVIOUS RELEVANT COUNCIL OR EXECUTIVE DECISIONS
Contracting and Procurement Changes in Public Health - 19th December 2013
Development of the Medium Term Financial Plan 2015 to 2018 - Budget for
Consultation - 23rd October, 2014
Budget Response – 5th February 2015
CONSIDERATION BY OVERVIEW AND SCRUTINY
Not considered by Overview and Scrutiny
BACKGROUND PAPERS
No background papers
RESPONSIBLE CABINET MEMBER
Cllr Ian Stewart, Cabinet Member for Public Health and Communities
REPORT AUTHOR
Contact: Paul Dobie, Commissioning, Procurement & Contact Management
N/A