The payment by results drug recovery pilots failed

PbR drug and alcohol recovery pilots evaluation finally published

The Department of Health has published the final report of the £1million evaluation of the eight drug and alcohol payment by results recovery pilots, originally due in April 2015. The report includes findings from the process, impact and economic evaluations and compared the outcomes of the eight pilot sites with every other drug and alcohol treatment service in England.

Below, I reproduce the key findings organised by the main themes of the evaluation.

Funding Models

Funding models adopted by individual pilot sites varied markedly, in terms of the proportion of the total contract value subject to PbR and the number of providers commissioned to deliver services. Stakeholders credited the funding models with incentivising priority and relevant outcomes and improving joint working but criticised them for inherent uncertainty; difficulty in forecasting and planning operations; being risky, deterring some providers from entering the market and, possibly, stifling the innovation of existing services.

Local Area Single Assessment and Referral System (LASARS)

LASARS were introduced in PbR pilots to establish independent assessment of in-treatment and new users and to set payment tariffs, in effect to prevent providers gaming the outcomes payment system. There were three main LASAR models across the 8 pilot sites: independent (from both providers & commissioners); run by dedicated staff within provider settings and by dedicated staff managed by the DAT. The main findings were:

  • In some sites, LASARS were perceived as contributing to greater integration of treatment services and improved data collection
  • In some sites, LASARS were perceived as restricting providers’ ability to establish relationships with service users
  • LASARS were broadly perceived as prolonging time taken for users to access treatment
  • Duplication of work between LASARS and treatment providers was reported

Impact of PbR on Treatment Outcomes

Pilot sites performed worse than Non-Pilot Sites in terms of:

  • Proportion of primary drug clients assessed but failing to start treatment (better for primary alcohol clients)
  • Proportion of primary drug clients waiting over three weeks to start treatment (better for primary alcohol clients)
  • Proportion of clients (both primary drug and primary alcohol) successfully completing treatment (including completion without subsequent re-presentation)
  • Proportion of clients (both primary drug and alcohol) with an unplanned discharge from treatment

Pilot sites performed better than Non-Pilot Sites in terms of:

  • Proportion of primary drug clients reporting becoming abstinent while in treatment
  • Proportion of primary drug clients injecting while in treatment
  • Proportion of those primary drug clients successfully completing treatment who did not subsequently re-present
  • Possibly better re: proportion of primary drug clients recorded as committing acquisitive offences (but this finding was not robust)

Pilot sites showed:

  • Significantly increased treatment costs per client
  • Increased number of hospital admissions for substance-related behavioural problems
  • Decrease in the estimated costs associated with A&E attendances for poisonings
  • No difference re: improving service users’ housing problems; retaining service users in treatment over the first 12 months (primary drug clients); occurrence of premature mortality


Implementing and delivering a PbR recovery-orientated treatment system

The main findings were:

  • PbR provided a clear framework for implementing a recovery-orientated treatment system, although most sites reported that recovery focus pre-dated introduction of PbR
  • Recovery focus led to some services developing new approaches and improving areas of service delivery
  • In pilot sites a greater emphasis was placed on reducing prescription levels for opiate substitution, for both new and on-going service users
  • In pilot sites there was a desire to deliver more psychosocial support and holistic interventions, encompassing wider health and well-being needs
  • Potential for conflict between treatment goals and the focus on abstinence and non-re-presentation
  • Sites offered a greater range of services than before pilot introduction
  • Alcohol treatment showed considerable change from pre-pilot provision

Intended and unintended consequences

Stakeholders reported that:

  • Treatment throughputs increased after PbR implementation (partially substantiated in quantitative analysis, only for primary alcohol clients)
  • Collaboration between providers improved during piloting
  • Bringing general practitioners into new PbR model of commissioning was a challenge
  • Impact of austerity measures and structural change to public health and criminal justice systems were underestimated
  • The scale of administration, bureaucracy and related costs of the pilots were underestimated
  • Limited time to prepare for the PbR pilots had unintended, negative consequences

Exit Strategies

Most practitioners preferred not to take PbR forward after the pilot but commissioners were keener to do so, albeit with adaptations. All but one area stated their intention to continue PbR as part of local commissioning but only one area was to continue with a 100 per cent PbR funding model.

Conclusions

The introduction of PbR appears to have encouraged a clearer framework for implementing recovery-orientated treatment, although the change of focus may have already been occurring nationally. Implementation was variable, with considerable differences in choice of funding models & LASAR provision. For practitioners the experience of piloting had resulted in a preference not to take PbR forward, but commissioners wanted to continue, subject to some adaptations (dropping offending as an outcome domain, not awarding 100% of the contract value under PbR, re-focusing on process measures, reducing length of follow-up to 6 months).

All had underestimated the scale of administration, bureaucracy and related costs associated with the introduction of PbR, and the limited time to prepare for transition had unintended consequences impacting negatively on waiting times for treatment, client-practitioner relationships, staff morale/ retention, and commissioner-provider relationships.

The evaluation found that the introduction of PbR did not seem to be associated with all the desired effects of outcome-based commissioning of drug and alcohol treatment services. While some outcomes, such as abstinence rates, showed improvements relative to non-pilot sites, others, such as unplanned discharges and successful treatment completion, did not. Furthermore, treatment costs per client increased significantly.

Analysis

Unfortunately, this evaluation has confirmed my original assessment of these pilots as being fundamentally flawed. Although I remain a fan of outcome-driven commissioning systems, the design of the pilots effectively disrupted a critical element of treatment and recovery systems. Most new treatment entrants were not greeted by a skilled practitioner aiming to build motivation and engage them in a recovery journey but by a bureaucrat wishing to decide what payment tariff should be applied in their case.

No wonder, the evaluation findings are so disappointing.

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