Payment by Results and Drug Recovery

Under the radar

The Department of Health’s payment by results drug and alcohol recovery pilots seem to have dropped off the radar over the last year or so.

The pilots, taking place in eight sites, (Bracknell Forest, Enfield, Lincolnshire, Oxfordshire, Stockport, Wakefield, West Kent and Wigan) started in 2012. The final evaluation is due out next month, so I thought it might be helpful to refresh our collective memories by looking at the interim findings published last June.

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Interim findings

Before looking at the findings, I should declare that, despite being an advocate of PbR, I don’t think it’s a natural fit for drug recovery for three main reasons:

1. It is hard to define outcome measures for drug recovery
2. It is even harder to measure them
3. It is hard to set outcomes which need to be measured over several years

However, these are the first drug recovery pilots I am aware of, so my concerns could be confounded by the final report.

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The findings

This interim report focuses on four key themes, each of which are covered below. The report is based on 142 stakeholder interviews, focus groups with 109 service users and 19 carer interviews, in addition to monitoring reports and NDTMS data.

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1. The LASAR system

The Local Area Single Assessment and Referral System (LASARS) was established so that an independent body assessed each service user to decide how complex their needs were and allocated them to a corresponding payment tariff  – a long-term dependent homeless heroin and crack user with mental health problems heavily involved in the criminal justice system obviously requires many more resources than someone who is concerned about their recreational drug use. The LASARs do not provide treatment, they merely undertake a preliminary assessment with the sole purpose of setting the payment tariff, to prevent “gaming” of the payment system. The LASARS operate differently in different pilot sites and the researchers unearthed contradictory views in different areas. Different stakeholders expressed the following opinions:

• LASARs divert resources from treatment.
• They enhance the integration of drug and alcohol treatment services.
• They can fulfil an important user advocacy role.
• They may increase the likelihood of dropout, but may reduce waiting times.
• LASARs may deter people with relatively low needs from accessing or staying in treatment.
• In many areas, treatment services questioned the skills of LASAR assessors.

I think the LASAR system is wrong. For many service users, it requires a significant effort of will and courage to admit you need help and make an initial appointment at a treatment service. After disclosing what for many is a painful, sometimes shameful and embarrassing, life story to a total stranger, most do not want to hear that they need to repeat the process to a totally new worker the following week. We know from our day-to-day lives that our first impressions of an organisation are critical. Indeed most drug treatment agencies provide their staff with sophisticated training on how best to engage service users and build and develop motivation from a first contact. Designing the front door to a treatment system as a porch is surely a mistake which will reduce take-up of services.

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2. Different funding models

The researchers found variable funding models in the different pilot sites. While interviewees generally stated that PbR had helped to ensure a greater focus by both commissioners and providers on the nature and complexity of the needs of local drug and alcohol users, there were a number of different challenges:

• PbR contracts failed to attract some prospective providers (mainly because of the cash flow consequences of not receiving payment in full until outcome measures have been verified).
• Contracts with large PbR components can increase budgeting uncertainties.
• Funding models were not always consistent with the complex nature of dependency and long-term basis of recovery.
• The tariffs set for service users with different levels of complexity were not always set appropriately.

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3. Impact on recovery-oriented treatment systems

The focus on recovery in drug treatment pre-dated the implementation of the pilots. Nevertheless, several pilot sites described a greater emphasis on promoting the staged reduction of methadone or other substitute prescribing to both new and existing service users. There was also a drive to deliver more holistic interventions which address broader needs than just substance misuse – outcome payments are also made for resolving housing issues and improved quality of life.

Set against these positives, researchers found a number of problems including:

• Anxiety and uncertainty for service users and practitioners alike who were concerned about reducing methadone too quickly.
• The chronic, relapsing nature dependency being at odds with the notion of the PbR outcome focused on not re-presenting to services.
• Some established barriers to recovery – including access to stable housing and help tackling offending behaviour – being beyond the influence or control of providers.

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4. Exit strategies

When commissioners and providers were asked about whether they wished to continue a PbR approach to substance misuse treatment beyond the life of the pilots, there were again very mixed views.

Some reported that PbR created opportunities for increased creativity and flexibility in the way in which services were designed and delivered. PbR had also encouraged a greater emphasis on monitoring and reviewing the progress of those in treatment. However the emphasis on measuring progress solely in terms of the PbR outcomes was both extremely costly and time-consuming but also had the potential to alter and distort aspects of practice and risked undermining the responsiveness of services.

Interestingly, despite the many difficulties, interviewees generally expressed the desire to continue with PbR provided that the contract design was modified substantially in light of the learning from the pilots.

Despite this ambivalence, the recent (12 February 2015) DrugScope State of the Sector report found that PbR is becoming increasingly common in the substance misuse field with 12% of non-pilot treatment services being commissioned on a PbR basis with a further 9% anticipating the introduction of PbR before September 2015.

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Conclusion

It will be interesting to see whether next month’s final evaluation encourages or deters the developments of payment by results approach to the commissioning of drug and alcohol treatment.

If you’ve been involved in commissioning or providing substance misuse services under a PbR approach, please share your experiences via the comments section below.