Drugs & Alcohol Recovery
Lessons Learnt from Payment by Results
Ray Smith
October 2013
The 2010 Drug Strategy said the government would
explore if paying by results would incentivise recovery
PbR for Recovery
• The Government wants to test the concept of paying for
successful outcomes
• Eight local areas from across England were chosen to
test PbR for two years
• No new funding was provided, local areas used their
existing budgets
Minister established a co-design group to develop a
pilot programme
PbR for Recovery
• Government officials from:
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Department of Health
National Treatment Agency
Home Office
Ministry of Justice
Department of Work & Pensions
Department for Education
Cabinet Office
• Local area commissioners
• Service provider and service user representatives
• Invited experts (including DrugScope)
The group developed a ‘national’ model based on the
client journey
PbR for Recovery
CJ referral
Independent
service
Assessment &
tariff-setting
Referral to
provider
GP
referral
Confirmation of
outcomes to
trigger payments
Provider
2
Provider
1
Provider
3
Provider
4
Advocacy for
clients
Relapse & re-presentation
Outcomes achieved
Self referral
LASARS
Prime provider/
provider framework
Sustained
recovery
The 8 were able to adapt the model to reflect local
priorities, leading to unique approaches
PbR for Recovery
Pilot
LASARS
Provider
Interesting Fact
Bracknell Forest
DAAT
Prime, end to end
Bracknell Forest have placed the
largest stretch on their providers to
reduce re-offending
Enfield
DAAT
Prime, IOM support
Enfield have included lots of local
outcomes to reflect local needs
Kent
DAAT
Prime, end to end
A holistic view to recovery means
providers only get paid after
progress on the full range of client
needs
Lincolnshire
Providers with audit
2 competing
providers
Strong focus on working with
current providers to deliver a new
service
Oxfordshire
DAAT / IOM
1 Harm reduction & 1
recovery provider
Oxfordshire use a local incentives
aimed at moving people from harm
minimisation to recovery
Stockport
DAAT / IOM
4 providers different
services / clients
Providers will not be in competition
with each other, but will work with
different groups
Wakefield
Providers with audit
Consortium
Wakefield have developed a local
employment metric
Wigan
Providers with audit
New providers in
2013
Wigan are assessing all clients on
a cohort basis for all the outcomes
Payment can be made made against 9 outcomes
across 3 outcome domains
PbR for Recovery
The outcomes
Interim outcome
Final outcome
Free from Drug(s) of
dependence
Reduced
Reoffending
Health and
Wellbeing
Drug and/or alcohol
use significantly
improved
COHORT
Reduction in the
average offending
compared to the
baseline
Ceased injecting
Abstinence from
presenting drug
Successful completion
of treatment
Does not re-present in
either the treatment or
Criminal Justice
System for 12 months
Improved housing
Hepatitis B course
taken (3 injections)
Health and wellbeing
(client achieves a
normative quality of
life)
PbR for Recovery
Lessons Learnt
•
The pilots have been running for 18 months
•
Performance is mixed,
•
•
•
four have improved outcomes
four have seen successful completion rates fall,
some dramatically.
There have been lessons learnt that can be
applied to other local areas contemplating PbR
Significant resources needed
Feedback
Providers will need to realise
that PbR will be resource
intensive and will require
managing a lot of data.
LASARS are still a
new concept and
some models
require a
considerable
amount of resource.
WHAT THE
PILOT
AREAS SAY
It takes a considerable amount of
time and resources to develop
and implement PbR.
Have
management
and monitoring
systems ready
well in advance.
Given that providers’ payments are dependent on reported
outcome achievement, providers need to ensure that data
is robustly recorded and systematically reported, while
commissioners need to be confident that they understand
the outcome data and can answer providers’ queries and
challenges.
It requires even more monitoring
than traditional commissioning
processes because it is data
intensive and new.
Commissioners need to monitor
performance closely to ensure
correct tariff have been set and
that outcome achievement is
correctly recorded and
independently audited.
Deciding outcomes & setting payment structures
Feedback
PbR can be complex. We are glad we
decided to allocate a fairly low proportion of
the overall contract price to outcome
payments. It was big enough to focus
providers attention but small enough to
help build relationships with our provider.
We needed to
change tariffs after
year one. We had to
decide whether to
pay outcomes on
basis of year of
entry to treatment or
year of achievement
of outcome. This is
complex but there
are benefits to
deciding this early
on.
WHAT THE
PILOT
AREAS SAY
Having a large number of
outcomes adds complexity to
the system.
Setting tariffs
takes a long
time. Longer
than you might
think.
We wanted to have a
balance of interim and
final outcome measures.
However this has meant
we have a large number
of outcomes which makes
the process complicated.
Commissioners need to be
clear on how to measure and
contract against outcomes and
how to tender for it.
The ability to change tariffs the value you attach to the
achievement of outcomes by
clients – is necessary and can
be complex.
Providers need to develop
their understanding of which
interventions are likely to
deliver outcomes
LASARS
The LASARS complexity setting function
influences the amount of money a provider can
receive so it is essential that clients are
accurately assessed. Commissioners need to
closely audit the function so that providers don’t
suffer as a result of poor LASARS
performance.
Some pilots have
seen a big increase in
activity but we don’t
know why yet. It could
be due to more focus
on assessments,
chasing appointments
or a clearer pathway
into treatment.
WHAT THE
PILOT
AREAS SAY
Our LASARS
function is
more
resource
intensive than
we had
originally
anticipated.
Feedback
It is essential that LASARS function
effectively as providers of recovery
services rely on this function.
LASARS that focus on a very narrow
assessment role may find it difficult
to recruit sufficiently qualified and
experienced staff, due to the
restricted nature of their job roles.
Some LASARS may be resource
intensive. So design needs to be
carefully considered.
Consider the additional work if you
want to add all your existing clients.
One bit of the pilot system we will definitely
keep when the pilot is over is the LASARS
function.
Contracts
Examine your contract to ensure they
are flexible enough to allow both sides
to exit before it gets to the point where a
provider does not get paid because
outcomes haven’t been met. This
protects the organisations and the
service users.
We worked
closely with our
provider to design
a flexible contract.
WHAT THE
PILOT
AREAS SAY
Feedback
It looks like our
provider may
achieve better
results than we
anticipated so
we are glad we
placed a cap
on our
contract.
Tariffs are based on estimates of
success. If success is greater
budgets need to be protected.
Consider introducing a cap on
payments to be made.
Build in flexibility into the contract
to make changes to payments or to
allow both sides a chance to exit if
things don’t work out.
Good relationships between
commissioners and providers is key.
We forgot to factor in the pension
costs when TUPEing staff across.
This has made the contract more
expensive than initially anticipated.
As in any contract, consider
carefully how you will address
break clauses and TUPE issues, to
ensure continuity of service
provision to a group of highly
vulnerable individuals.
Data
• The success of a PbR system hangs on collecting and interpreting
accurate and robust data.
PbR for Recovery
• You need appropriate resources at a local level to understand what
the data is telling you.
• Government analysts have identified a considerable level of
unexplained variance (chance/luck) in some outcome data, which
cannot be adjusted for. If performance is significantly affected by
chance/luck, the outcome data is unlikely to be a robust reflection
of provider input.
Conclusion
The three key messages that pilots shared are
PbR for Recovery
• PbR appears to be successful in sharpening providers’
focus on achieving outcomes for sustained recovery.
• Implementing PbR appears to be taking up a significant
amount of dedicated time and staff to monitor
performance – both for commissioners and providers.
• Understanding what the data does and does not show
and sharing this information between commissioners
and providers is essential to making the PbR approach
work.