In a recent meeting of the Drug Sector Partnership we briefly discussed whether a Payment by Results (PbR) approach to drug treatment would increase stigmatisation of service users. At the time I was thinking about some of the discussions the development of PbR, where it seemed that service users were in danger of being traded like sub-prime mortgages. That seemed to indicate that yes, PbR would worsen stigmatisation.
When I thought about it further it seemed to me that it depends, actually, on whose result is the important one and who makes the decision about it. If the decision about whether treatment has “worked” includes a large input from the service users then it could be an enormously empowering process. In that case providers would need to actively engage with the service user in order to discover what will work best for them and to deliver it.
If the decision about “results” is based on a standard assessment carried out by a hard pressed bureaucrat then the result will be very different.
Even more important would be the involvement of the service user in deciding whether the treatment had worked in the long term. Selfishly, when considering this, my thoughts turned to plumbers; in particular the ones who have now claimed twice that they have fixed a leak in our house only for us to discover a dripping pipe the next day. The form that I signed when I paid them said the job was done to my satisfaction – only later I discovered that satisfaction was short lived.
A service user may believe themselves to be in recovery when they leave a service and then discover six/twelve months down the line that nothing has changed for them, other than that they are no longer dependent on intoxicants. Their view as to whether they have received an effective and lasting solution will depend on factors like their state of mind, the resolution of long term problems like family estrangements, debt or health issues as well as the usually quoted housing and jobs. Providers might take a more careful approach to their aftercare and personal need after leaving treatment if it was the service users’ view of the result that unlocked their payment.
Bill Puddicombe – acting Chief Executive eATA
Four national charities – Adfam, DrugScope, eATA and the Alliance – have formed the Drug Sector Partnership to support community and voluntary sector organisations working in the drug and alcohol sector.
Hi Bill
ReplyDeleteVery interesting Point of View. Clearly right in principle but I don't think that is the way the DoH are thinking... I have posted a link to these comments on the PBR forum of www.no-Offence.org - the new independent website and forum, trading as a Community Interest Company, which has been launched for all those working in the criminal justice sphere.
Hi Bill,
ReplyDeleteInteresting post. In any environment careless or ill informed selection of a target can produce poor outcomes for service users. In the case of your plumbers, a delay in paying is likely to have produced a different outcome. In the case of drug treatment, NTA are focussing on 'successful completion'. However, unlike the plumbing example, if the service user represents within a year the 'success' is overwritten, so there is a sort of warrantee system that I hope and expect will be built into the PbR formula. Thus the payment system should focus the provider on working with the service user towards sustainable recovery. I see this as improvement on traditional practice where sustaining recovery was frequently not given an appropriate degree of focus.
The treatment system will need to factor in consideration that only something like one in ten service users reach the measure of 'successful completion’ in any given year. The achievements of the other approximately 90% must not be devalued. In addition, on presentation some people are closer to recovery than others and we must be alert to cherry picking or stigmatisation at assessment.
PbR is just one performance management tool in the wider outcomes debate. The focus on outcomes appears to be creating examples of innovation in the field which lead to greater choice for service users.
Richard Tamlyn. Chair. The Centre for Public Innovation