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Second Commandment of PbR: First do no harm

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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.



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4 Responses

  1. Russell

    Great blog. Essentially PbR is about designing a payment system not a system of care. It seems the coalition govt. want PbR in all aspects of social care and yet are happy to see financial services operate a Payment (regardless of) Results system

    Lets apply PbR to the banking system and to senior civil services bonuses where it might curb the current profligate culture of excess and lets keep the “CARE” in social care

    All the best


  2. Much has already been said about PbR and I admit to being against its introduction into the substance misuse field. In my opinion the application of commissioning targets has led to a decline in the quality and diversity of treatment provision for a number of years. The introduction of PbR doesn`t appear to offer anything to the future of treatment, other than to continue the downward decline. I fail to understand how the regular contract and performance monitoring, by commissioners, has not already been able to achieve the treatment effectiveness that the introduction of PbR is purported to be bringing.

    In the drug treatment field it appears that commissioners got exactly what they wanted. A long- term retention in treatment through substitute prescribing, driven by a criminal justice imperative. Collective amnesia now redefines this as treatment failure.

    Now the trend is to increasing provision from the charitable/ non-statutory sector. Regardless of how these organisations are registered, they operate as businesses and understandably need to ensure that they do no lose significant amounts of money through their PbR contracts. I think this leads to the conclusion that these organisations must plan for the likelihood that they will not gain the full contract value, which in itself is likely to be lower when retendered.

    Given that some of the costs are fixed and unavoidable, then there are only a few ways in which loss limitation could be achieved. Lowering the staffing levels and/or salaries reduces the financial exposure. Even better, don`t pay people at all if you can help it. This may explain the rapid expansion of peer mentors, volunteers, and other agency partnerships into the new treatment pathways, typically aimed at increasing the likelihood of getting the second outcome payment. Undoubtedly using people who have changed their substance using behaviour brings possibility and hope to those who haven`t, but why not reward them with something more tangible.

    It seems that any sensible organisation, (business), will attempt to break even by getting the first treatment payment, and then view the second outcome payment as the profit. PbR is in danger of having the opposite effect on outcome and treatment quality that it is supposed to do. Less staffing, less investment in training, less time stabilising in treatment all contribute to a decline in quality. Combine this with an increased reliance on peers, volunteers, and self-help methods, mixed with a pinch of gaming to keep clients out of structured treatment until the magical second payment time hurdle has been achieved.

    Over the years it seems that any organisational aspiration to raise standards has been stifled by a compulsion to meet targets and thereby avoid penalties, usually financial. There is plenty of evidence of disingenuousness from all sectors in this compulsion to meet targets. PbR outcome achievement is likely to be no different, but in the meantime another opportunity to genuinely raise standards of treatment, and its outcomes, passes by.

  3. Russell

    I always find your Blogs interesting and well written and this is no exception.

    You make your central point really well. But I am left wondering what you think the answer is. It is easy to see why commissioners are tempted to put the sort of “independent initial assessment of need and tariff” in place to prevent gaming. PbR is new. We’ve had the experience of A4e allegedly fabricating performance data. If commissioners are to resist this temptation and be brave then I can’t see the Hippocratic Oath being enough…..

    I think that PbR is here to stay – for the foreseeable future atleast. You clearly want to influence its direction and shape for the better so it would be good to hear more of your thinking on how this might be done.



  4. Love your content Russell, very well-written!

    “Thou shalt not make unto thee any graven image,
    or any likeness of anything that is in heaven above,
    or that is in the earth beneath, or that is in the water under the earth.”
    Exodus 20: 4

    You may also check my blog about The Second Commandment
    Hope this will also help. Thank you.

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