From their inception in 1995, Drug Action Teams have always faced stiff challenges in bringing local agencies together. The problem is not so much with the structure of the DAT system as with how it works in practice.

The commissioning of drug treatment services provides a good example of the range of problems to be overcome in achieving a coordinated strategy. In theory, each member of a Joint Commissioning Group should be a budget-holder, in a position to commit funds to the integrated treatment plan that the DAT has devised. In practice, however, not all Joint Commissioning Managers now have shared budgets at their disposal, as it is quite common for individual agencies to default on their commitments to drug services. This is at least partly because the commissioning managers’ influence on the commissioning strategy itself may be limited. A study carried out jointly by the Healthcare Commission and National Treatment Agency, as a pilot for the recent large-scale survey of commissioning standards within Drug Action Teams, reported that ‘substance misuse commissioning posts were usually poorly resourced and isolated from strategic management’.

Where a Joint Commissioning Group is weak, the DAT itself is not in a position to exert any extra authority. Some agencies are prone to commission services ad hoc and independently while others adopt an historic approach, commissioning what they have always commissioned, regardless of changing needs. Commissioning for the Home Office’s Drug Interventions Programme for drug-using offenders, which is separately funded, may cut across other plans and take priority over them. There is also some confusion as to the effect that the reorganization of the NHS in England is likely to have on the DATs’ commissioning system. What will happen, for example, as a result of the merging in 2006 of 300-odd Primary Care Trusts into 150 ? What will be the effect of the creation of the ten over-arching Strategic Health Authorities? And how will the DATs be affected by the large-scale introduction of practice-based commissioning, which gives GPs far more say in the health services that are provided for their areas?

At the moment the bulk of NHS money is allocated to Primary Care Trusts which commission and reimburse hospitals (and other health care providers) for the services used by their local populations and pay GP practices for the services they deliver to patients. Under practice-based commissioning, GP practices are to be given their own ‘notional’ budgets with which to ‘buy’ health services for their patients, like attendances at Accident & Emergency departments, all referrals to hospital for outpatient and inpatient treatments, and drugs. The GP practices are accountable to their PCTs, which draft the contracts with hospitals and other providers and remain legally responsible for the funds. The idea is that GPs should come up with new ways of using the money, individually or in groups, to design services better suited to their particular circumstances. GPs who take up the scheme get payments and are allowed to keep any ‘surpluses’ they generate by better management of budgets. Practice-based commissioning will start in earnest in 2008.