The interesting thing about PbR schemes is that they are supposed to be all about finding creative solutions to entrenched social problems which actually work.
But when you look at most of the articles and opinion pieces, you find they are much more preoccupied with how to measure the results accurately and prevent provider organisations from gaming the system.
That’s why the First Commandment of Payment by Results schemes is “thou shall not pay twice”. PbR schemes are carefully designed not to pay for outcomes that would have happened anyway.
Sometimes this preoccupation goes too far and the concern about measuring outcomes accurately interferes with the operation of the project itself.
To my mind the Kent Drug Recovery PbR pilot is a case in point.
The pilot has been thoughtfully designed so that only one quarter of the provider’s income is paid from successful results in the first year (2012/3) with this proportion increasing by stages to a point in 2015/16 when 60% of the contract is on a payment by results basis. The outcome definitions prioritise recovery from drug dependence with a smaller payment for reduction of offending.
Great care has been taken to try to reflect the range and extent of substance misuse problems which new service users will present. Clearly a person with a long term heroin, crack and alcohol dependency exacerbated by mental health problems will require much longer and more intensive treatment than someone concerned about their level of cannabis use.
For this reason, Kent Drug and Alcohol Action Team has designed a five tariff band with accompanying values:
However, in its desire to prevent gaming, Kent DAAT has decided that it cannot trust its service provider to do the initial assessment and allocate new service users to one of these bands – presumably fearing that the temptation to classify someone that needs a brief intervention on the “critical case”” tariff would be too overwhelming.
Therefore the initial assessment of need and tariff is done by a separate agency which is independent of the substance misuse treatment system.
And this is where the payment metrics have been allowed to distort the effective operation of the scheme. My experience, and that of many other drug researchers, is that the number one complaint of drug users trying to access the treatment system is that they are repeatedly offered assessments instead of being provided with treatment.
This fact was formally acknowledged by the National Treatment Agency back in 2002 when it introduced its “Models of Care” guidance aimed at developing treatment systems whose priority was to match service users to the most appropriate service for them as swiftly as possible.
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.
This mistake is not the only one. There is a consensus in the drug treatment field, shared by commissioners, providers and service users, that assessment is not a one-off activity but a continuous process undertaken by worker and service user in collaboration which develops and fine tunes each individual care plan.
What happens when a service user who has been classified as having moderate needs discloses after 6 sessions that they have much more serious problems – can the worker act, or must s/he wait for a re-classification assessment?
It seems to me that the commissioners and designers of PbR schemes need their own version of the Hippocratic Oath which all doctors take:
“I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.”
The Second Commandment of PbR is: First, do no harm.