Thread by @WilliamHaydock

There's so much in this article to disagree with or be confused by it's hard to know where to start, but here's a few thoughts. 🧵 To start, this isn't about LAs cutting budgets; the public health grant is set by central government & has fallen by c20% 1/?
theguardian.com/society/2021/j…

But why then does the article suggest spend on detox has gone up by 27.5%. Does that sound credible? And how can this be described as a 'race to the bottom', if there's more funding per client in detox? 2/

The answer is that this is really about an approach to procurement and a prioritising of the NHS when all sectors have something to contribute here. And I do mean all - don't forget that GPs & pharmacies are private companies. 3/

This is where the write up gets confused. Is a block purchased bed really better than one spot purchased for people drinking at higher levels? That would mean the person from Dorset gets a worse service from the same NHS unit than the person from Bristol in the next room. 4/

Block purchasing may be better for the sector, but at an individual local authority (or indeed CCG) level it doesn't always make sense. That's why local authorities often club together & coordinate on this (see press release from London this week: gov.uk/government/new…) 5/

The key in that example is that there was more funding, so it became possible. This isn't about sectors; it's about funding & culture. NHS trusts don't feel able to commit to spot purchasing arrangements as the income is uncertain and it doesn't seem worth it. 6/

Dorset's community health trust withdrew not just from providing inpatient detox but any form of substance misuse support. That isn't just an issue with LA commissioning; without funding or enforcement most NHS hospitals didn't develop alcohol support as recommended by NICE. 7/

That brings me back to the weirdest bit: the idea that more is being spent on detox than in 2013-14. That doesn't seem credible. Having been the person responding to these kinds of queries it's because FOI across different LAs over time doesn't generate valid or reliable data. 8/

As the article suggests, commissioning has changed. How do you compare something mainstreamed into a contract with something spot purchased through a separate budget? LA boundaries have changed, staff have changed, you're asking them to find & analyse someone else's budgets. 9/

Also, plenty of NHS provision/funding wasn't transferred as the NHS itself was under pressure ('no, you can't use mental health inpatient beds any more & we're not transferring the funding') so 2013-14 figures are probably underestimates & things have had to be built back up 10/

This does suggest again that competitive commissioning may not be the answer, as the transactional relationship with GPs, pharmacies & now hospitals & community health trusts can be argued to have been counterproductive. 11/

But that won't be news to LA commissioners or academics. Look at the work of people like @tobyjlowe @geerai @benhughes1963 @wearenewlocal. Indeed that's the point of integrated care systems (dare I say it). 12/

The other element to the analysis is the data. Inpatient detox is a pretty short period, generally involving at least two provider organisations - so getting a consistent picture across time & place is a challenge. Which dataset are you looking at, how is it recorded etc. 13/

And this brings me to my overall point. This approach frustrates me. When the primary issues are funding, coordination of care & quality assurance, we should all be working together. FOI with odd assumptions & claims feels like 'gotcha' journalism. 14/

The write up also feels adversarial. LA commissioners know detox provision needs reshaping - a national group is working on that. The NHS isn't better or the only solution; it's part of the picture. This gets people's backs up, which isn't a great way to improve things. 15/

So this is a plea, as someone now slightly distanced from the debate. Please could we try to talk to each other and work together, rather than engaging in what looks like point-scoring & pushing hobby horses? 16/

This isn't to specifically criticise the authors. There's plenty of comparable claims, like LA commissioning is great, or there's not enough spent on 3rd sector rehab. They'll probably be in responses to the article. But I'd prefer to feel like we were all working together. ENDS

Having said 'ENDS', inevitably not. (Note the actual HSJ article.) 1/3 Coordination of care was poor when (some of) treatment was in the NHS. I've had NHS staff lament that they've been discussing dual diagnosis since they started their career in the 80s. hsj.co.uk/service-design…

2. It looks like the analysis might be based on alcohol only clients, who are just one group accessing detox. In fact polydrug use seems to be increasing, & is a key factor that will help determine whether someone accesses the most intensive) inpatient support.

3 The jibe about records from 2013-14 is misleading. NHS will still have held various elements, plenty of LAs have been reorganised etc. If NHS oversight is so good, ask CCGs how many specialist or GP detoxes took place then & now. Expect equally inconsistent & incomplete answers