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Payment by Results: A limited tolerance for error

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The 1972 Munich Olympics launched Olga Korbut on the world stage. Half of Britain fell in love with the diminutive gymnast with the gamine looks and the playful,  definitely anti-Soviet disposition. I too liked Olga, but I loved her compatriot, Ludmilla Tourisheva; with her regal countenance, she had an elegant approach which made you think she had just stepped off stage at the Bolshoi. Tourisheva won 9 Olympic medals in her career but my abiding memory of her is at the 1975 World Championships at Wembley. At the end of a typically graceful routine on the asymmetric bars, as she performed her dismount, the entire apparatus collapsed to the floor behind her. She spotted her landing perfectly, turned and left the stage without even a glance behind her.

Payment by results has a Tourisheva-like focus on outcomes. A central plank of its rationale is that by focusing payments on outcomes without describing how these are achieved, it frees up providers – and the voluntary sector in particular – to work in innovative and exciting ways. It doesn’t matter to the commissioners how outcomes are achieved, just that they are.

However, my recent experience of developing plans for PbR initiatives, specifically when calculating potential payment metrics (using a combination of hard evidence, past performance and many backs of envelopes) is that, sometimes, PbR has a strong gravitational pull towards a safety-first approach. Initial ideas may be ambitious, involving far-reaching partnerships with a wide range of specialist providers. However, once detailed plans are worked up, trustees and Senior Management Teams are honour-bound to consider the risks to an organisation’s survival if it does not deliver the predicted/hoped for results.

The flavour of discussions can often change. How can we make sure that we get the clients who actually want our service and can benefit from it? Can we really trust our partners? What happens if they have recruitment problems in the first six months? Are we sure this approach will work in rural areas too? Confidence and the willingness to experiment can evaporate fast once you start worrying about gambling with an organisation’s future – and the jobs of all its staff.

The whole point of payment by results is its focus on outcomes. For many of us, that is its main attraction. Although all commissioning should be outcome-driven, we know that in practice most projects are much more likely to be measured by targets that are easy to count. We record attendance and action plans rather than long-term changes in behaviour. If we can get the outcomes right and find a relatively inexpensive way of measuring them that allows staff to focus on their work and not bean-counting, then we can make a real difference to thousands of individuals, their families and the local communities where they live.

Perhaps the challenge of PbR is to recreate the spirit of those Russian gymnasts. Commisioners will require a Tourisheva-like focus on outcomes. But it would be great if providers can emulate Korbut’s sense of adventure and innovation. Sometimes, it feels that developing a truly ambitious PbR programme designed to tackle an entrenched social problem like generational unemployment involves the sort of audacity that Korbut showed when she was the first to stand up on the 4cm diameter top bar and perform a back somersault. As the commentator says: ‘imagine the tolerance for error’.



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4 responses

  1. Good post. I have a lot of reservations about PbR working within Mental Health and you’ve covered some of the reasons for my disquiet. I know work we do has to be ‘quantified’ but sometimes it seems so counter-intuitive when you are trying to work with individuals who all have different needs and can’t necessarily have their ‘outcomes’ decided centrally. It is very frustrating. I don’t have a problem with outcome measures per se but feel that sometimes the outcomes that they focus on and the ways that the processes have developed work counter to what we might be trying to achieve. Fitting round pegs into square holes..

  2. Great post Russell. I agree with earlier comments, not one size fits all. I suppose in some respects the risk involved depends on how tried and tested the service actually is. The St Giles Trust pilot is a classic example, thy achieved a 40% reduction in reoffending using their model in London. This has now been transferred to HMP Peterborough on the first PBR pilot, with a significantly smaller target to achieve. So from their point of view the risk is minimal, however this will certainly not be the case for others.

    many thanks


  3. It has to always be remembered that amomgst those who are sentenced in court there is a significantly high and disproprtionate number of neuro – diverse folk whose disabilities are frequently unrecognised, hidden and masked by understandable consequent mental illness and/or addiction.

    I include Dyslexia, ADHD, Dyspraxia, Asperger’s Syndrome and many related conditions that have unique and indivualised features for every person and that the person’s behaviour frequently appears illogical to their talk and apparent intellectaul potential. A frequent aspect of all these hidden disabilities is short term memory problems which are very difficult to recognise and measure and so often go – unmeasured.

    Then also addiction for some is of itself a hidden disability, and that as a person apparently is ‘cured’ or finds a way of managing one addiction, such as an OCD hand washer, or door lock checker, another addiction creeps in from the Internet or the betting shop or the genitals.

    As a ‘sufferer’ myself of a hidden disability and addiction it has taken a life-time, I am 63 which included a thirty year social work career, to begin to appreciate the full force of these conditions on my behaviour, which are as uncontrollable as say a man with one leg who can only hop, to get along. He cannot grow another leg, although adaption is possible, the disability is always present but invisible and therefore misunderstood, including to the actor.

    Design your boxes, with elastic sides and an invisible lid, but many still will not ‘fit’, never mind when they act out we can always put them in prison once they have behaved so that they have had a societal ‘bad’ label attached!

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