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In May 2013, the RSA and Drugscope convened a meeting of the providers that deliver the eight national 'Payment by Results' (PbR) substance misuse pilots.  The RSA wore two hats: one reflecting our role as a think tank with a now longstanding concern for substance misuse policy and practice; and one reflecting our role as one of the providers.  (As readers of this blog will know, the RSA is part of a consortium lead by CRI and including Sussex Partnership NHS Foundation Trust, which delivers the West Kent PbR substance misuse pilot.)

The purpose of the summit was to explore the provider experience over the first 12 months of operation from April 2012, and in doing so to highlight good practice and identify practical recommendations for implementing PbR schemes.  You can download a short summary of the themes discussed and the learning points that emerged below:

RSA DrugScope PbR MeetingNote (pdf)

I will not summarise or repeat the main points here, but I want to add a reflection on some conversations I had very recently about these points and what they mean for PbR.  The pilots represent significant system change, that is happening within significant wider system change, that is happening within wider change still.  The move to recovery-oriented systems, delivered through PbR mechanisms in the case of the pilots, is happening in the context of wider health-system change (move to public health, introduction of Clinical Commissioning Groups and Health and Wellbeing Boards, and so on), which is occurring in the context of multiple and complex changes to public services and the welfare system and wider economic stress for many groups and areas (all of which impacts on 'recovery outcomes' to varying degrees).  Levels of public service performance can often dip after major re-organisations, so isolating the effect of PbR specifically appears difficult.

Further, it was interesting to note that when providers spoke at the summit of the 'effect of PbR' in terms of the value-adding change it had made to service delivery and emerging outcomes for service users, it was usually difficult to see how PbR itself had actually brought about this change.  Rather, PbR had acted as a catalyst for change - something to shake up the system; a stimulus or opportunity for new thinking and innovation.  It seemed that changes could have been brought about by some other catalyst (and in most cases, it seemed that these changes would have happened anyway, given local capabilities and concerns, and as the focus on recovery given by the national drugs strategy washes through the sector).  Again, any change measured will be difficult to attribute to the impact of the financial mechanisms and incentives of PbR.  The diversity of PbR designs in the pilot sites (and the corresponding diversity of the responses delivered by the providers), and the wider roll out of PbR into other (non-pilot) sites make comparisons across areas difficult.  Even with a sophisticated realistic evaluation design, it will be difficult to take account of this much noise.  The risk is therefore that we mis-interpret what PbR does (both positively and problematically), and do not consider whether there are better mechanisms for driving transformation, innovation and improved outcomes.  At least the pilots are generating a significant amount of data that can help to unpick the puzzle (this is PbR without the black box in practice).

The RSA will be publishing a report in the Autumn that will explore our experience of delivering under PbR arrangements.  In the meantime, one clear lesson to emerge from the summit is around the speed of the PbR design phase and the turbulence encountered in the early stage of delivery.  Transforming Rehabilitation should take note.


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