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Payment by results and the public sector: worst of all worlds?

    We are in Nick Leeson territory.  This is what Huseyin Djemil warns in his damning review of how the Coaliton’s ‘drugs recovery PbR’ initiative is panning out. The scenario he paints eclipses the pitfalls I identified in my recent CPS publication, Breaking the Habit. The order of concern about PbR ‘corruption’ exceeds those of ‘cherry picking’ and ‘proxy’ outcome measures, even the  inexcusable exclusion of those small in size but big in ‘big society value’, voluntary, private and not for profit bodies, from the PbR pilots.

    Huseyin’s observations from the ‘coal face’ of policy beg some fundamental questions.  Is getting the public sector to implement a ‘competitive’ policy indeed an oxymoron?  They also raise new questions about the National Treatment Agency’s (to whom the policy implementation was delegated) competence for this task. For if ever an agency was an example of Marc Glendening’s Post Modern Authoritarianism and if ever an agency lacked the expertise and drive to ‘stimulate’ this aspect of the nation’s recovery,  it is this body.

    Huseyin describes how unaccountable, subcontracted but self rewarding monopolies (state sponsored super charities in the main) are emerging as a result of this latest attempt to bring market forces and efficiencies into the public sector. He has been tracking the ‘service reorganization’ of England’s 149 multi million budget DAATs (drug and Alcohol Action Teams).  Their response to the administrative opportunities raised by the PbR challenge, has been second to none. But Mr Letwin should not be duped either by their activity or their rebranding.  What is actually happening is that many are now shifting the responsibility for most or all aspects of drug treatment, including residential rehabilitation, to Prime Providers under new ‘framework agreements’.  This, Huseyin argues, is turning such ‘service providers’ into a type of ‘gang master’, contracted on the one hand to be a proxy commissioner, on the other to be the service (or outcome) provider, “…performing the back office and trading floor functions without proper oversight”.  Like authorizing your own expenses, he says.

    Getting into rehab was always challenging he acknowledges - a fraught and complex process of assessments and referrals for those without the money who need the state to pay. Now it looks to be worse. For the NHS and Community Care Act 1990 that established the right, in principle, for an assessment of individual need, leading to a care plan and if eligible, access to residential care, is, effectively, being sidelined.

    With new prime providers/proxy commissioners taking on all these functions, the individual gets no recall. What’s more, if the Prime Provider also happen to be a rehab owner they can refer  clients to their own unit - losing entirely the  competitive discipline which is critical to PbR - assessing them, judging their suitability, funding them, conveniently paying themselves for their  stay, and hey presto, then claiming the money back from the DAAT.

    “ In some ways this seems a brilliant strategy and it means the commissioners’ don’t have to solve the much more difficult and confusing statutory situation surrounding how we get people into rehab (via the community care act and via the paid commissioners whose role it really is)….(but) the selected providers will decide who gets referred, who gets assessed, who goes to which rehab and who gets paid. These providers suddenly become very powerful because they suddenly hold the DAAT budget”.

    And what if they use this privileged position to further their own ends (bearing in mind that they also have services across the country and turnovers of millions of public £s per annum)? What if they stifle a competitor that is threatening their income stream or their preferred status?  What's to stop them? Finally what of the DAAT’s and their commissioners that have downloaded this power and responsibility? Will we see a reduction in their number due to a reduced workload?

    The questions Huseyin poses all need answering. He recounts the story that Oliver Letwin’s Cabinet Office is plastered with flip charts and ‘post it’ notes as the growth of PbR is charted in every area of government.  Aprocryphal or not, who is fooling who? One wonders at what stage Mr. Letwin will put his system to the test and subject PbR to his ultimate penalty – and only pay for what works? Or will he chose to rely on the NTA’s barely disguised but convenient propaganda that, due to the government’s new drug strategy, the number of illegal drug users of the road to recovery has risen significantly in the last year?

    PbR might be brutally simple in theory, but there is little sign that this will be practiced. It was anyway, Huseyin concludes, always a fatally flawed concept:

    “..somewhere in the discussion about PbR we have forgotten that we are talking about the care of often very vulnerable people and we are treating them as a commodity, slapping a tariff on them and trading them - the promise of payment for a good outcome….(so)how long (will it be) before a provider is enticed to split the winnings with the clients if they pretend to be better. ..
    If we could have solved this problem (drug addiction) we would have done it years ago - the truth is we almost did, it was called residential rehab. It’s the one people with money and means choose. No celebrity ever went to a prescribing ‘service’ for help - they go to rehab. They get stable, they get detoxed, they get hope and they try and put their lives back together. …(But for those who) don’t have the means, you get methadone or buprenorphine for years and years and the irony is it costs more than rehab ever would. ….
    ….18-months after the new coalition came to power and nearly a year since the new coalition drug strategy...we are still spending most of the budget on prescribing. You cannot prescribe your way out of addiction in the same way that you cannot borrow your way out of debt.  A bit like spending all your money on interest payments; eventually you have to pay back the capital.”

    Kathy Gyngell has a first class honours degree in social anthropology from Cambridge and an Oxford M.Phil. in sociology. She has worked for the former ITV companies, LWT and TV-am as a producer and senior programme executive. A full time mother after the birth of her second son, she founded the voluntary organization Full Time Mothers.

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