Drug recovery Payment by Results pilots fail in first year

Evaluation pending

The evaluation of the Department of Health’s payment by results drug and alcohol recovery pilots is now two months overdue. I understand that this is not because of any reluctance on the part of the DoH but because the research team was seriously delayed by the difficulties in obtaining reoffending and mortality data.

However, the researchers [Tom Mason, Matthew Sutton, William Whittaker, Tim McSweeney, Tim Millar, Michael Donmall, Andrew Jones and Matthias Pierce] have recently published an article in the Addiction journal which compares the performance of the eight PbR pilots in their first year against the other 141 non-pilot commissioning areas in England. Unfortunately, the article is not freely available, but if you click on the formal title in the blue box below you will have the option of purchasing it:

[button-blue url=”http://onlinelibrary.wiley.com/doi/10.1111/add.12920/pdf” target=”_self” position=”left”]The impact of paying treatment providers for outcomes: difference-in-differences analysis of the ‘payment by results for drugs recovery’ pilot[/button-blue]

The pilots

There were eight pilot sites, (Bracknell Forest, Enfield, Lincolnshire, Oxfordshire, Stockport, Wakefield, West Kent and Wigan) which were launched in 2012.

The interim findings from the evaluation (which were published in June 2014) mainly presented the views of stakeholders and service users and highlighted some advantages but a number of concerns.

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The study

This was a major study with researchers obtaining anonymised individual-level data from the National Drug Treatment Monitoring System (NDTMS) on 182,447 service users who received treatment for primary drug use during 1 April to 31 December 2011, and 178,860 during 2012.

They measured the key outcome of service users who are free from drugs of dependence, with the formal definition of being:

“discharged from treatment successfully (free of drug (s) of dependence) and do not re-present in either the treatment system or in the criminal justice system in the following 12 months”.

It’s clear from this definition that full achievement of the outcome can only be measured 12 months after discharge. However, this research study only considers achievement of successful completion of treatment which is the first stage of the outcome measure and a critical one for the providers in the PbR pilot areas. This is because successful completion of treatment triggers the first payment under the PbR contract. Unsurprisingly, treatment completion is the most significant payment domain, representing the highest proportion of provider income because it is the prime objective of the government drug strategy.

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The outcomes

There were two, rather surprising, negative findings:

1. Service users treated in PbR pilot areas were significantly less likely to complete treatment.
2. Service users treated in PbR pilot areas were significantly more likely to decline to continue with treatment.

The researchers come to the very fair conclusion that PbR is not a straightforward guarantee of improving performance in drug and alcohol recovery. Although previous studies have shown that PbR can drive some limited improvements in quality, this study unambiguously found that:

[alert-warning]”the introduction of payment for outcomes had a significant, negative impact on successful treatment completion.”[/alert-warning]

The DoH recovery pilots have attracted significant criticism and this study adds considerably to existing concerns. Nevertheless, 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.

It will be interesting to see what the final evaluation has to say when it is eventually published.