Drugs & Alcohol Recovery Lessons Learnt from Payment by Results

1. Drugs & Alcohol Recovery Lessons Learnt from Payment by Results Ray Smith October 2013

2. The 2010 Drug Strategy said the government would explore if paying by results would incentivise 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

3. Minister established a co-design group to develop a pilot programme • Government officials from: • 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)

4. The group developed a ‘national’ model based on the client journey Prime provider/ provider framework • LASARS • Assessment & tariff-setting • Referral to provider • Confirmation of outcomes to trigger payments • Advocacy for clients Self referral Independent service Outcomes achieved Provider 2 CJ referral Provider 3 Provider 1 Sustained recovery GP referral Provider 4 Relapse & re-presentation

5. The 8 were able to adapt the model to reflect local priorities, leading to unique approaches

6. Payment can be made made against 9 outcomes across 3 outcome domains The outcomes Interim outcome Final outcome Health and Wellbeing Free from Drug(s) of dependence Reduced Reoffending Drug and/or alcohol use significantly improved COHORT Reduction in the average offending compared to the baseline Ceased injecting Improved housing Abstinence from presenting drug Hepatitis B course taken (3 injections) Successful completion of treatment Health and wellbeing (client achieves a normative quality of life) Does not re-present in either the treatment or Criminal Justice System for 12 months

7. 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

8. Significant resources needed Feedback It takes a considerable amount of time and resources to develop and implement PbR. 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. Providers will need to realise that PbR will be resource intensive and will require managing a lot of data. Have management and monitoring systems ready well in advance. LASARS are still a new concept and some models require a considerable amount of resource. WHAT THE PILOT AREAS SAY 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.

9. Deciding outcomes & setting payment structures Feedback Having a large number of outcomes adds complexity to the system. 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 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. Setting tariffs takes a long time. Longer than you might think. 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 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.

10. 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. 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. 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. Our LASARS function is more resource intensive than we had originally anticipated. WHAT THE PILOT AREAS SAY One bit of the pilot system we will definitely keep when the pilot is over is the LASARS function.

11. 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. Feedback 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. 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. It looks like our provider may achieve better results than we anticipated so we are glad we placed a cap on our contract. WHAT THE PILOT AREAS SAY We worked closely with our provider to design a flexible contract. We forgot to factor in the pension costs when TUPEing staff across. This has made the contract more expensive than initially anticipated.

12. Data • The success of a PbR system hangs on collecting and interpreting accurate and robust data. • 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.

13. Conclusion • The three key messages that pilots shared are • 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.