The lessons from the last two years of drug and alcohol payment by results pilots in England

1. Payment by results: bright new
dawn or riding into the sunset?
Andrew Brown
Director of Policy, Influence and
Engagement, Drugscope

2. “Payment by Results (PbR) is a powerful idea – it has
translated a commissioning and procurement
mechanism into a brand that is intuitively appealing,
politically potent and hard to contest in principle.
Developed by New Labour, it has been placed at the
heart of the coalition Government's approach to the
reform of public services.
“It's a very simple idea in theory. Pay organisations
who receive public money for what they achieve for
people, not simply what they do with them: for
outcome, not process.”
Dr. Marcus Roberts, Chief Executive of Drugscope.
Chair of the NCVO PbR Working Group Source: Sheil, F. Payment by Results and the voluntary sector, NCVO (2014)

3. “there can be no
justification for
spending public
money … without
considering the
impact on the
outcomes that
people care about”
Photo by Flickr user Conservatives

4. Drug and Alcohol Recovery Pilots
In its 2010 Drug Strategy, the government announced it
would pilot payment by results in the drug and alcohol
sector.
Service providers would be paid a proportion of their
contract based on specific successful outcomes. Eight
areas took part in the pilot:
- Oxfordshire - West Kent - Wakefield - Wigan
- Stockport - Bracknell Forest - Lincolnshire - Enfield
The pilots started in April 2012 and an independent
evaluation of the pilot programme will report in spring
2015.

5. Issues and Challenges identified by
UKDPC
• Getting the outcomes and tariffs right
• Encouraging cooperation between sectors and
services to meet multiple needs of clients
• Compliance with clinical and evidential standards
• Avoiding perverse incentives and gaming the
system
• How to encourage customer choice without
reducing effectiveness
• Achieving good workforce development
• Balancing recovery ambitions and harm reduction
interventions
Source: Roberts, M. By their fruits… applying payment by results to drugs recovery, UKDPC (2011)

6. One year in…
• 9,663 clients engaged (2/3 drug dependent, 1/3
alcohol dependent)
• Outcomes were mixed
– 5% better than national performance on abstinent from all
presenting substances (but alcohol lower by 2%)
– Significant drop in those successfully completed treatment,
free of dependency (esp alcohol clients 15% lower)
– Alcohol clients more likely to have resolved housing
problems (5%) over national figures
– No difference in those drug clients who stopped injecting
from national picture
– Fewer meeting quality of life outcome than before pilot, but
higher than national average
Source: Performance of Payment by Results pilot areas: April 2012 to February 2013, Department of Health (2013)

7. One year in…
• DrugScope and RSA national providers
summit
– Change takes time (esp. when lots going on eg
Troubled Families, Health and Wellbeing Boards
etc.)
– Trust in the Local Area Single Assessment and
Referral Service (LASARs)
• Therapy or payment, complexity of client needs,
simplicity vs robustness
– Trust in the motivations of providers &
commissioners
• Baseline data, reasons for declining referrals,
performance payments

8. Key messages after year 2
Outcome data
• Noise annoys:
– Noise has been found in the drug and alcohol outcome data,
meaning the data may not necessarily reflect providers’ input –
they could sometimes be paid when their work has not led to
improved user outcomes, and sometimes not be paid when their
work has led to improved outcomes.
– The impact of unexplained variance on providers is largely
determined by the size of the client-base (too small)
– The unexplained variance falls outside the acceptable range for
the outcome data to be a robust reflection of provider input.
• Suggestion
– Allocating a smaller proportion of overall contract value to
specified outcomes (e.g. up to 20%) will reduce the financial
impact of unexplained variance.

9. Key messages after year 2
Process outcomes
1. PbR has sharpened providers’ focus on achieving
sustained recovery for drug and alcohol users and
helped encourage innovation.
2. Commissioner and provider staff have to spend a lot of
time monitoring performance under PbR and it has been
administratively burdensome.
3. Partnership working is essential: understanding what the
data shows, sharing this information and negotiating any
necessary action are all vital if to PbR is to work.

10. Bright new
dawn or riding
into the
sunset?
It may be too soon to draw conclusions, but seven of the
eight areas are saying they will continue with the
approach after the pilots have ended.
Photo by Flickr user Damian Gadal

11. Thank you
Andrew Brown
Director of Policy, Influence and
Engagement
DrugScope
@andrewbrown365
andrewb@drugscope.org.uk
www.drugscope.org.uk