Evaluation of drug and alcohol recovery "payment by results" pilots
Funding public services on a 'payment by results' basis means the government pays for services only if and when they achieve defined outcomes. An independent evaluation of eight drug and alcohol recovery PbR pilots, commissioned by the Department of Health, assessed whether and how this new funding approach encourages the development of not only the market for provision of services in these areas but also more effective recovery programmes.
Substance abuse continues to be a challenging problem to society. While many drug and alcohol recovery programmes exist, some work better than others. The UK Department of Health and the National Health Service Treatment Agency for Substance Misuse were interested in knowing whether market forces could encourage the development of more successful treatment efforts.
RAND Europe was part of a consortium awarded a £1 million contract for an independent evaluation of the Department of Health’s drug and alcohol recovery payment-by-results (PbR) pilots programme.
The overall aim of the evaluation was to investigate whether, how, and to what extent a PbR approach can stimulate the market to provide different schemes, co-ordinated across a range of services, that successfully initiate and sustain the recovery of individuals from drug and alcohol dependence and their successful re-integration into their communities. The pilot schemes were assessed by both process and impact evaluation.
The Consortium was led by the University of Manchester, with RAND Europe collaborating with Birkbeck College London to conduct the process evaluation. This included reviewing existing research, mapping existing service delivery, and describing each PbR model alongside the different approaches developed.
Impact of the introduction of PbR in the pilot sites
Compared to non-pilot sites, the pilot sites performed worse in relation to:
- The proportion of primary drug clients who were assessed but failed to start treatment.
- The proportion of primary drug clients who waited over three weeks to start treatment.
- The proportion of clients (both primary drug and primary alcohol) who successfully completed treatment.
- The proportion of clients (both primary drug and alcohol) with an unplanned discharge from treatment.
Comparatively, the pilot sites were better than non-pilot sites in relation to:
- The proportion of primary drug clients who reported becoming abstinent whilst in treatment.
- The proportion of primary drug clients who injected whilst in treatment.
- The proportion of those primary drug clients who had successfully completed treatment who did not subsequently re-present for treatment.
- The proportion of primary drug clients who were recorded as committing acquisitive offences.
Treatment costs per client also increased significantly in pilot sites, compared to non-pilot sites, while hospital admissions for substance-related behavioural problems also increased in the pilot areas. There was also a decrease in the estimated costs associated with A&E attendances for poisonings.
The funding models adopted by individual pilot sites varied markedly in the extent to which providers were paid on the basis of results. However, stakeholders credited PbR funding models with incentivising outcomes and improving joint working, while criticising them for uncertainty, difficulty in forecasting and planning operations, deterring some providers and possibly stifling innovation in existing services.
Local Area Single Assessment and Referral System
The introduction of PbR required a new approach to assessing service users’ needs. Approaches to assessment varied across the sites. In some, it was felt that the new assessment approach contributed towards greater integration of treatment services and improved data collection, while in others, practitioners felt the assessment restricted providers’ abilities to establish relationships with service users.
Use of PbR after the pilot
- At the end of the pilot, practitioners generally preferred not to take forward PbR. Commissioners, however, were more likely than practitioners to express a desire to continue with the PbR approach, subject to adaptations.
- All but one area stated an intention to continue using PbR as a feature of their local commissioning arrangements.
- Only one area was to continue with a 100 per cent PbR funding model.
- There was an intention to be more selective around measures to be incentivised, with a greater emphasis on process measures.
- The importance of effective joint working and communication between providers and commissioners was identified as being essential to delivering successful outcomes in any type of arrangement.