CAMERON’S DRUG STRATEGY IS NOBBLED AT STARTING GATE

With the Coalition’s first Drug Strategy – Reducing demand, restricting supply, building recovery: supporting people to live a drug-free life – not even a month old, the Department of Health/National Treatment Agency for Substance Misuse rushed to incapacitate prime minister David Cameron’s vision of “Supporting people to live a drug-free life”, indicated in the strategy’s title and which “is at the heart of our recovery ambition”.

Organisations with a track record of getting people drug free have been excluded from recent contracts and from participating in Payment-by-Results pilots which were intended to be templates for the country’s recovery from drugs and all their attendant problems. It is akin to Ascot being run by mules, with race horses disqualified from entry and race dates kept secret from all but a cabal of mule owners.

“Insanity,” Albert Einstein said, “is doing the same thing over and over again and expecting a different result.” Despite the government announcement that the NTA would be abolished – perhaps influenced by the facts that drug deaths rose under its regime, and only 2% of people presenting for treatment were referred to drug-free providers – it was put in charge of the PbR application process.

What happened next was that, instead of its usual expensive taxpayer-funded media hype, the NTA quietly posted the details onto its website. It did so only a few days before Christmas, with a deadline of 20 January when public-sector potential partners did not return to work before 4 January, so there was effectively only about a fortnight to bring together a diverse group of partners for this template for the future... less for providers not made aware of the web page’s existence; it is not even flagged up on the NTA home page.

For the NTA did not inform the residential/quasiresidential/ daycare providers with a track record of getting people into full recovery. Instead, it wrote to the public sector, seeking “innovative” rather than proven delivery by organisations with literally thousands of years’ experience between them. Addiction Today’s queries to all the country’s providers of full recovery elicited that only one had been informed by the NTA (by the exceptional Mark Gilman). Only one had been informed by its local public-sector ‘fund holder’, a moot point as the fund holder “was not interested” in applying.

And here’s another way that Cameron’s recovery runners have been nobbled: even where they were informed (by us and DSDaily), they have been disqualified from entry. The criteria in the “invitation to tender” Pre-Qualification Questionnaire were worded in such a way that only fund holders (of pooled treatment budget, IDTS, Carats, Dip, PCT mainstream budget, local authority community care budget) could qualify. Needless to say, providers of full recovery were not consulted on drafting the invitation. Nor, it seems, will they be part of the co-design scheduled to start in April of the Payment-by-Result pathfinders.

“It is palpably absurd that all the richest reserves of knowledge re the delivery of recovery-oriented treatment are completely ignored,” summed up Nick Barton, CEO of Action on Addiction.

"To not run PbR pilots with services which have been providing for a long time the kind of results which the government wishes to see more widespread, makes poor sense. It is a half measure and does not underpin the vision of the Drug Strategy 2010, inasmuch as we are haunted again by the same old failure,” added Carl Edwards, director of ParkView Projects.

COMMENTS FROM PROVIDERS WITH A TRACK RECORD OF FULL RECOVERY

“We have spoken at length to the local DAT about their plans for a pilot project.  We provided them with information that clearly demonstrated our ability to provide most of the services they say they would like to offer to clients.  However, they have chosen not to include us in their plans.” Jan De Vera Davey, director, Open Minds

“I find it very hard to understand that when the Government wants to focus on recovery, the Department of Heath / NTA bring out a pilot for payment by results that excludes nearly all the smaller organisations with the most experience and proven success of delivering recovery. This will lead to a ‘Ratner’ style treatment field with cheap, poor quality treatment and more people suffering.”  Brian Dudley, CEO, Broadway Lodge and board member of EATA

 “If I hadn't been informed by you, I wouldn't even know it was happening. I got in touch with DH who told me to contact NTA. I phoned NTA south west, they said talk to the DAT, then nothing.” Brendan Georgeson, treatment coordinator, Walsingham House.

“Didn’t realise they were going for pilots until you contacted us.  Typical really, we are never informed about anything by either our local CSDAT or the NTA.  We are never informed about capital monies available or anything that may prove beneficial to our service.”  Amanda Lea, director, Western Counselling

 “We have never been contacted by the NTA about a pbr pilot.  In fact, we do not get contacted by the NTA for anything!!  We have several issues about PbR.  It will perpetuate the continued falsification of outcomes to demonstrate 'success' which has been happening for years.  It thus opens the door further to fraud and corruption.”  Paul Spanjar and Steve Spiegel, CEO, Providence Projects 

 “We have not been approached by anybody. But I am disturbed about PBR as they don’t even seem to agree on what a result is yet. I am particularly worried about the fact that someone been placed on to a methadone script could now be considered a positive result. I have also heard one government spokesperson describe a possible result as being full employment for a year. On that criterion, very few of us will get paid, whatever field we work in.” Chip Somers, CEO, Focus 12 and board member of EATA

 “The principal (perhaps only) result for anyone suffering from dependency must be the end of that dependency.  The acquisition of social capital (education, employment, housing etc.) will contribute to ending dependency but they are not measures of it.  What could be measured are indicators as to what degree there has been a reduction in substance misusing lifestyle.” Nick Barton, CEO of Action on Addiction

“We have not been approached or asked to participate by the NTA or local fund-holder to participate in the PbR pilots, even though the Ley Community has 40 years’ experience in residential rehabilitation. At a briefing event at the House of Commons before Christmas, NTA CEO Paul Hayes talked about the pilot PbR schemes and made it clear this would be an opportunity for providers to apply. But when I downloaded the invitation to participate, I was astonished to see it is a partnership system approach! The timing of the invitation was ridiculous together with the tight turnaround. I rang the two named contacts on the document only to be told they had finished for Christmas and would not be back until 4th Jan – when I asked if anyone else could help I was told no not really. If the Coalition Government is committed to recovery then why is the DoH/NTA excluding small providers? At the end of the day, the people who suffer are our beneficiaries, those most in need of recovery who will struggle with yet another complex navigation around a system.”  Wendy Dawson, CEO, Ley Community and board member of EATA

Comments

[Jon Hibbs]

To clarify any misunderstanding about the process raised by this article, here are the facts. The proposal to develop a system of payment by results for drug recovery was approved by the Government and put in the hands of a steering group of officials from five government departments and the NTA. Ministers made clear they wanted the pilot schemes up and running as soon as possible. The steering group agreed a two-stage process, by which localities would be identified first, and then providers brought in later. The aim of the initiative is to involve a range of providers, and indeed encourage new providers into the market. However, we need to work through local partnerships (because they hold the local budgets and contracts) to ensure that the pilot schemes meet local needs. The next step was therefore to issue a pre-qualification questionnaire to identify expressions of interest from local areas that would have a good likelihood of success. This is accepted practice in tendering exercises and was issued almost immediately after the first steering group meeting in order to build on the momentum of the recently-launched Drug Strategy. Once the pilot sites are identified, the second stage of the process kicks in and providers will be able to take part. In the meantime an expert group including representatives of provider membership bodies like DrugScope and eATA is providing advice and guidance.

[Sara McGrail]

Oh please, a little more fact checking!

PBR is being piloted at a system level rather than a provider level. The NTA/DH are exploring mechanisms for operating PBR across multiple providers. There is no additional money for the pilots - the work is about distribution of existing funds.. Given this it would seem somewhat inappropriate to approach individual providers at this stage. It may be that DATs have included the sector in their plans - and that providers will be contacted in the future.

However this does highlight what will undoubtedly become an even greater problem for this part of the sector over the next few years - that is the apparent isolation from local commissioners - and indeed the whole of the localism agenda - of many providers of residential care. There is role for an effective intermediary body here. Were there such an organisation then possibly they could have led some work during the last 12 months on what was a very predictable development. They could also have worked with individual providers and consortia of providers to break down some of the barriers between local commissioning, local communities and residential services.

Maybe the sector needs to think a little more strategically about this stuff - and grumble just a little bit less?

[Laurence McM]

Hibbs and ex-NTA employee McGrail (should she have declared she was involved with NTA "implementation"?) are stuck in the same old rut of repeating the same thing over and over again even though it led to so much failure and Britain branded in research as the worst country for drugs in Europe (under the NTA).

The timing reminds me of the old government embargo'ing mention of the unpopular move to close post offices - until midnight before christmas. Similar timing to this! (p5 at ftp://ftp.royalmail.com/Downloads/public/ctf/po/Sussex_decision_booklet.pdf)

And why were proven providers of full recovery not on the steering group from the start? Who was on it, because it was certainly not people enabling addicts to get help to recover. How can they predict what McGrail said they should predict when they are excluded from information time and time again by the NTA and others it is funded (by us) to manage?

There are just too many unquestioned assumptions about repeat working. Rehabilitation revolution? Not if Hibbs and McGrail can prevent it.

[Peter Walker]

If as Jon Hibbs say it was necessary to ' work through local partnerships ( because they hold the local budgets and contracts) ' why did the invitation state ' This invitation to,participate is not confined to existing drug partenerhips.' ?

And why then did it further state that applications could be made by the ' third sector,private and statutory sector' provided they were ' legally and functionally capable of coordinating the relevant budgets and comissioning'?

It's not surprsing given this level of ambiguity - if that is what it is rather than any sort of subterfuge designed to mislead -causes confusion and strong feelings given the history of mistrust in the treatment sector.

[Mike Pattinson]

So the new drug strategy has been launched and sets ambitious targets for the delivery of treatment and recovery across England and Wales. The pooled treatment budgets and DIP allocations have been made - and have pretty much been maintained at last years levels. In this age of austerity and deficit reduction the continued investement into treatment and recovery is to be welcomed as a reflection of the hard work of all those involved within the treatment sector.
There are to be 6 PbR pilot sites - meaning that there will be 140+ areas not involved in the pilots.
So why don't we all concentrate our energies on improving our services, implementing the strategy and making sure that as many of our service users as possible leave our systems drug / alcohol free and with the resources in place to sustain this recovery independently.
We can then look to any lessons from the PbR pilots, incorporate the positive elements and compare and contrast these with our local evidence base.

[Treatment provider]

As a provider of full recovery, the situation is such that I cannot risk repurcussions on the charity I work with by publicly identifying it when saying anything the NTA might take exception to (I have given my name and contact details to Addiction Today).

I want to ask, about Jon Hibbs' reply, why and what is behind his comment about wanting new entrants into the field when they have no experience, proven quality and results?
Is it the NTA trying to open the door to the likes of Serco etc?
There are more than enough quality provider, especially in Tier 4, which are struggling to survive because we never get listened to and everything is either decided by the likes of the NTA or the Big4 providers of lesser services which are given more taxpayer money than all the rehab providers put together - something like £200million? (approx £70m+£50m+£35m+£45m)

[Sara McGrail]

Lawrence,

I cannot tell you how much your comments amused me. I only hope the NTA are reading them too ......

Thanks for the best laugh so far of 2011!

Sara (McGrail)

[Matthew]

Lawrence McM, I would suggest that it might be worth understanding a little bit more before making judgements on others. I don't know Sara McGrail personally but am aware of her work and reputation and your comments are clearly wide of the mark.

I'm not sure I understand the principle point of the article. PBR pilots are about analysing the improvements to treatment systems. How could this be done if the money wasn't being held by a commissioning body? If all the money to commission the results were given to an agency providing the (expected) results, how would it be payment by results?

Surely it would just be... payment...?

[Andy Williams]

Actually, McGrail's own website states that "The only rational basis for policy is the reduction of drug related harm" - not exactly supportive of recovery or the drug strategy.

[Sarah Butler]

Jon Hibbs comments almost sound like a script from Yes Minister and in fact the current situation is so comical it could well be. Hibbs states “put in the hands of a steering group of officials and the NTA”, is this not the point that the article is making, this steering group are the same authors of the current system, the architects and builders of the current system, in fact a fine example as to why we are moving to localism and local decisions, to avoid the Central obsession of control and power which stifles innovation or new thinking around the table. Whilst the NTA and officials may appear to publicly approve and defend local decision making, I suspect nothing could be further from the truth and would point to the rolling out of PBR pilots as a prime example, a steering group behind closed doors, a hap hazard rushed approach to consultation and indeed a hint of the old labour tactics of burying bad news or consulting the wider field.
After all officials can then blame Ministers as Jon Hibbs has clearly started to do in his comments “Ministers made clear they wanted the pilot schemes up and running as soon as possible” therefore implying it’s their fault for rushing us! What is actually the fault of Ministers is the fact that they have turned a blind eye and allowed those responsible for our current state of affairs and what amusingly Mr Hayes himself has stated as a “lack of ambition in the field” to drive the new strategy forward. Well Mr Hayes the lack of ambition is due to the over burdened and over controlling measures and culture lead by you and your organisation of the field, the NTA has never inspired anyone to look beyond a script. The NTA has never engaged in healthy debate or opposition, they have presided over the closure of many rehabs, low occupancy level and either refused or maybe it’s that they do not have the expertise to build a fair and balanced ambitious treatment system, so please do not expect us to be jumping with joy that Ministers have been foolish enough to hand over to you the proposed new ambitious system.
Does anyone in the field truly believe that there will be a Rehabilitation Revolution anymore? Has anyone held Ministers to account over the promises they made to this sector pre-election, or David Cameron comments during televised debates on methadone and the numerous statements about his views on abstinence? Iain Duncan Smith in your very magazine and Break Through Britain, David Burrowes and James Brokenshire at UKESAD and in the media, we have a very different watered down version now and as far as I can see they are back tracking
As for Sarah Mc Grail, “Independent Consultant”, well Sarah there is nothing independent there about your comments, after all did you not work for The NTA with responsibility for implementation? You state “A role for an effective intermediary body”, Sarah had you retained independence and gained a wider view of the field, then you would know that the rehabilitation sector has not only as individuals, but also under umbrella organisations such as EATA has had numerous meetings with Ministers, Officials and Commissioners pre & post election to form such a body, the lack of engagement has been appalling and very clear that such a body would not be supported. Whilst you may find this amusing and your previous work for the NTA may have been to a high standard, clearly you do not understand the whole field and to be indepdent you should be unbaised and respect the views of the whole sector, not just those you are familiar and comfortable with.
We know there are no new monies, but there is a wealth of knowledge and infrastructure out there and many examples of locally delivered Recovery networks and communities.
When the NTA needed advice on prescribing they brought in the clinical experts to develop and deliver the system, when they now need advice on building a recovery system they bring in the same group of people who are inexperienced in delivering Recovery, many are opposed to it, but never mind they shout the loudest, so the rationale for doing this can only be the fear of being challenged by true experts in the Recovery sector, a prime example is the response to your article and the fear that this will lead to real system change and true Recovery.
Rehabilitation sector how dare you speak out, after all you only cater for 2% of the treatment population and many intend to keep it that way.
S Butler
Treatment provider

[Ann Stoker]

Is anyone surprised ? The NTA is to be subsumed into the Health Dept. - what is the betting that the same staff will either be moved sideways (or upwards) with different titles, or will become 'independent consultants' - and they will take their existing attitudes towards recovery and
their understanding of 'treatment' with them.
I am currently waiting for an alcohol dependent young man to be accepted on to a structured day programme - and felt sick at heart when I heard them say 'if our funders will allow it'.....
We cannot trust any politicians with their fine promises and this latest fiasco is
utterly sickening, of course existing providers of treatment leading to recovery should have been involved in PbR pilots. Come on Mr. Cameron - let's have another six contracts awarded to some of the smaller
providers - how about three to structured day programmes and three to residential rehabs ?

[Professor Neil McKeganey]

In honeyed tones Jon Hibbs, National Treatment Agency Director of Communications, provides an account of the first stage of the payment by results pilot. Who could object to the process as he describes it? Only a fair proportion of the UK residential rehabilitation sector it seems who, it turns out, have been largely excluded from the process so far. For Hibbs the exclusion seems entirely understandable: a combination of ministerial impatience and the need to access existing budgets held by major service commissioners and providers. A reasonable person might assume that a shift in UK drug treatment practice of the scale envisaged in our new drug strategy would have necessitated the involvement in all stages of the payment by results process of those agencies who know most about recovery. Not so, according to the NTA, who turn for guidance to the very same agencies that have presided over the marginalisation of the recovery process for the last fifteen years. If the exclusion of the residential rehab sector from the pilot process continues then it will take a lot more than the dark art of the spin doctor to avoid the conclusion that the NTA are not capable of managing the shift into payment by results.

Professor Neil McKeganey
Centre for Drug Misuse Research

[Chris Knight]

Below a copy of an email which was sent one month ago, still no responses from NTA Social services or Government:

“Hi Chris,

I was going to telephone you but thought it might be best to send you this email to inform you that Kieran died yesterday.

Since the last time we spoke, after Kieran was discharged from hospital, his situation took the usual pattern. With Kieran trying to control his drinking consumption, last Thursday he told me he was unable to "stop himself". During the 3 weeks period he had been to see his GP for help but yet again, hit the brick-wall of "I'll refer to", of course we both know that this response would never work in Kieran's case. Over the last 3 weeks I continued desperately to find help for Kieran and being told the same rhetoric - "It's up to your brother not you". In fact ironically yesterday afternoon I rang his GP for help and was told "I've done what I can, so why are you telephoning me again", I also rang the duty mental health team and was told, "I'll get someone to call you back", nobody did call me back and in the meantime my brother Tom had called in on Kieran and found him dead.

You are the first person in many years who understood our situation, who showed genuine concern for Kieran and tried like I have to get Kieran the help he needed so desparetlely. I would like to thank you and Mark for all the help, support and understanding you shown to Kieran and his family. Especially to me, it meant a lot to talk to a true professional who understood and acted on it.

I wish you all the very best and once again thank you for your help and support.

Bev ******”

This person did not have the mental capacity to make a decision about his welfare, he had a brain related injury, below is an email to the director of social services Manchester Joanne Colley sent 26 Nov

“Hello Joanne,

Thank you for speaking to me earlier.

I have pleasure in attaching information as discussed. I do apologise for having to ask for Directorate intervention here, but as I said on the phone, in 13 years I have only felt the need to this level of recourse twice before.

I appreciate that some people make a choice to drink and even a choice to die and of course many a choice to live – Kieran cannot make any of those choices. The bottom line here is that if the Coroner’s Office rang me next week to enquire about the treatment this man has received I really feel that he has not had access to the services and social support that a man in his condition of mental state and illness should have received.

This is definitely a case where the State has a responsibility and I hope that you are able to facilitate access to that help.

Thank you for your assistance.

Kindest regards”

We and Kieran’s family tried every avenue possible to get Kieran help he deserved, local alcohol teams, doctors, hospital and social services. An application was made on my behalf to report Kieran as a venerable adult and looking at getting a mental capacity order of sorts. Please see attached.

I remember as a child a dog walking on a railway track stepped on the live rail to receive a shock and then turned and bit it, the dog didn’t know any different and melted before my eyes.

I have to say that Kieran was treated no different than a dog in this case.

What is going to be done about this NTA?

Rest in peace Kieran.

How many have to die eh!

[Lisa Davis]

It is sad that a society has come to this, another needless death. there are special rehabs that could have at least gave this man a fighting chance.

I totally get the above post now, payment by results mmnnn, NTA have less need to put their hands into their pockets, not that they could reach the bottom of them anyway...

[Matthew]

The article and some of these comments still seem to miss the point!
PbR pilots are being delivered through GEOGRAPHICAL AREAS. Someone in the area has to hold the money to pay it to the agency, be it residential rehab or day programme or even methadone clinic, that delivers the results. No provider agency is going to be applying to be a pilot area as this makes no sense. CSP / DAAT s are commissioning bodies that exist for just this purpose - to commission services. Therefore they make the most sense to hold the money. But if they didn't, another body such as the Local Authority or local NHS commissioning bosy would have to. PbR doesn't work by giving the money to a particular agency or group of agencies that are going to deliver the service to produce the results.
The results are clearly going to be benefits from treatment and abstinence from drugs, so more money is likely to go to residential rehabs if they deliver this.
This is a completely misguided discussion!

[BRIAN]

Matthew,

I think you need to understand the facts a little more before making comments. In the DAT area near us for one example, the budget for the whole of the drug service has been handed to a large national provider who can and probably will apply, why because they can dictate the outcomes to suit. Also another large natioanl provider was asked directly by the NTA if they had a PBR model available. Therefore if the large national providers design the PBR to be used it will not benefit anyone other than themselves. Commissioners in some areas have no Tier 4 budgets and others do not refer to Tier 4. Most of the smaller longest established treatment centres - 26 that I know of, have not been approached by commissioners or the NTA and that is why they are speaking out. Finally you do not need to hold any budgets to measure outcomes

[Anthony Massouras]

Jon Hibbs of the NTA gives a useful summation of the background to and process around, the development of the MTA/DoH joint invitation for fund holders to register an interest in participating in the pilot PbR development projects. EATa was not involved in the development of this process although along with others, it did raise a number of questions as to how the system would work. The EATa has been invited to join an expert panel that is supporting this process going forward and it will be doing so as it is fully behind the Government's initiative to reform the addiction treatment sector and to place recovery from addiction at the heart of this process.

Anthony Massouras - Trustee EATA and Chairman
Addiction Recovery Foundation

[Kenneth Eckersley]

Neil McKeganey sums up the actions of the NTA in respect of PbR very well, but is too much of a gentleman to accuse them of again trying to con the government in regard to addiction recovery to lasting abstinence.

The NTA's plan to take nearly three years before PbR is rolled out across the rehab community is pure delay tactics to keep them in their present jobs for as long as possible while they find enough excuses to report that PbR doesn't work and to then ask: "anyway what's wrong with the old treatment system?"

Why doesn't the government talk to those organisations who can offer Payment by Results right now, without expensive time wasting "pilots" calculated to maintain the status quo?

CEO Addiction Recovery Training Services

[Beleaguered Residential Provider]

I'm confused about the NTAs role? Initially I welcomed them with open arms, I misguidedly thought they heralded a new era in British drug treatment, an end to postcode funding and the lottery of access to appropriate care to meet individual needs. However I have viewed the residential sector being increasingly marginalised, beds are going and staff morale is at an all time low.
Our service is well recognised, we have been around for a many years and have a wealth of experience of delivering recovery programmes for families and individuals affected by addiction, whether it be drugs, alcohol, gambling, gaming, food etc.
We are never invited to regional NTA events, we are never consulted by our local DAT office. I speak to our DAT when I can get hold of them; the local commissioner has never visited, despite invitation to do so. Apparently our local population dont have a requirement for residential treatment, which is weird because we get many calls and have to refer them to the local non stat provider.
We are never advised when there is capital monies available or when we could provide valuable data for funding purposes.
We arent a large service so we are considered not worthy of consulation, however we are a national resource and are commissioned by a large number of DATS. Who are now telling me that no one is interested in treatment. Not interested in treatment? Are they having a laugh? I visited a service yesterday that told me that they would love to refer clients for residential treatment, but they cant get the funding, its refused with no justification.
I spend my time increasingly perplexed about the way forward. We have reviewed practice and treatment programmes to make allowance for the commissioning practice of only funding 12weeks - we can all remember that comment that 12weeks is "optimum" for treatment. Today I was informed that a DAT were considering no longer funding secondary care, their clients were to be referred to supported accommodation for that aspect of their treatment programme.
Infact, today has been really enlightening, I have also been informed that our only hope of survival as a small provider is to join a consortium and bid for beds with them. I also learned that money is being returned to the Treasury, as much as 83% in some cases as they were only able to spend 17%. 17%, what a joke.
People are dying waiting for treatment. Referrals are increasingly chaotic, vulenrable, unstable mental and physical health with extensive forensic histories. Care Managers are referring for treatment people who really should be admitted to hospital. And yet we work with them, we support them through their issues, we assist them with their Benefits, their medications, their housing, their educational and training needs, we teach them about abstinence, their relapse triggers, we work with their families and assist with poor life skills, communication and social skills, ultimately instilling a sense of pride and purpose into their lives; and all in 12 weeks, our staff arent just drug workers, they are expected and do in some cases work miracles.
Tier 4 is increasingly being asked to justify its existance. I was under the impression, obviously misguidedly, that Models of Care was a system for pathways to treatment and recovery. clients could clearly view the route most appropriate for their assessed needs, however what has really happened is that Tier 4 is considered the last hope.
PbR, will it make a difference? Maybe, I hope so, but right now we are hoping to still be here to view the potential changes.

[Alistair Sinclair]

Quick couple of questions: What exactly is a "Full provider of recovery"? How do you provide 'Recovery? I can see how you can provide abstinence focused (or harm reduction focused)services but I have some difficulty understanding how you "provide recovery". Be interested to hear what exactly people mean when they use this sort of language. Thanks.

[Chris]

Only the 'recoverer' can define recovery and how best to achieve it. Having lived at the sharp end of addiction for over a decade, I know a few people who achieved abstinence-based recovery through rehab but many more who live fulfilled lives assisted by medication. Why can't people who have never actually been addicted (to opiates) stop pretending that they know what is best for those who have. At the end of the day, making money is the primary goal; what works best for individual service users is rarely considered.