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Making Payment by Results work in 2012

    In the fifteenth of the CPS' 'UK Policy Resolutions for 2012' series, CPS Research Fellow Kathy Gyngell suggests reforms to the Payment by results method of drug rehabilitation. Yesterday, in the fourteenth in the series, Kieron O’Hara suggested some priorities for the Coalition in 2012.

    UK Policy Resolutions for 2012:

    • Offering the choice of a 'breaking free of dependency' treatment programme
    • Payment based on regular tests for absitnence and sobriety 
    • Progessive payments based on legth of absitnence and sobriety 

    The Coalition inherited a disastrous drug policy. Labour had invested heavily, some 10 billion over 12 years, in a ‘treatment war on drugs’. Its priority was to prescribe methadone to drug addicts in the hope of replacing their street drug dependency. Faith in this solution was pinned on a scientific ‘evidence base’ - collated by NICE – which posited the efficacy of substitution treatment.  It would reduce crime and protect public health, cutting these costs from the public purse.  But the mass methadone ‘roll out’ (through community drug services and pharmacies) did not work out this way. There were unintended consequences. Far from solving addicts’ problems, ‘services’ impeded recovery and increased morbidity – as rehab addiction experts had warned the government.  

    Instead of falling, drug deaths rose; methadone deaths sharply.  The number of addicts barely dropped. Rehab, the favoured approach of successfully recovered addicts, was disinvested in. By 2010 referrals were at an all-time low of 3,914. Yet community ‘treatment’ was entrenching welfare dependency at a cost of £1.7 billion in benefits a year. The costs of addicts’ ‘looked after children’ and child welfare was adding a further £1.2 billion a year. The total social and economic burden to the taxpayer of the 300, 000 drug using and ‘treatment’ population was estimated by the Centre for Policy Studies at over £3.6 billion a year.

    Despite this ‘support’ and investment no one was getting better.

    The arrival of the Coalition promised a seismic shift. It put drug free recovery at the heart of its new drugs policy. Addiction at last would be addressed; rather than ‘managed’.  It would be driven and incentivised by payment by results, a guarantor, it was promised, of effective and life changing treatment. What worked would win.  Only when people were drug free and back at work would the treatment programme providers be rewarded. The vision of a big society of faith based and not for profit rehabs moving into the ground once occupied by impersonal, ‘co dependent’ and discontinuous ‘services’ seemed about to materialise. It was not to be.

    Within months rehab experts found themselves excluded from the new policy implementation, falling at the first hurdle of the National Treatment Agency’s ‘prequalification questionnaire’. The Coalition had left  Labour’s drug treatment policy architects (from the DoH downwards through the NTA)  in place. The NTA and its technocrats, far from going up in a bonfire of the quangos, were in charge of translating Drugs Recovery PbR.

    A year and half later NTA approved PbR treatment ‘outcomes’ as confused, convoluted and complicated as previous outcome measures, are being applied across the country’s commissioned drug services. There is no coherent basis for comparison – eliminating the competitive essence of PbR

    The only meaningful ‘treatment outcome measure’ or ‘result’, that of sustained drugs tested abstinence or sobriety - has been avoided. Existing services do not have the skills or the knowledge base.  The only visible change is a process of re branding old practice.  Harm reduction has morphed into the new language of recovery.  


    UK Policy Resolutions in 2012 

    This could be done if the uncompromising model of Transport for London was emulated by Government.

    Transport for London can only afford to invest in treatment that works. Train and tube drivers found to have drug and alcohol problems must get better to keep their jobs. TfL cannot afford them not to. It sends them to a proven rehab where abstinence recovery outcomes, if not guaranteed, operate at 80% of clients.

    The question the Government must ask is, can they afford to do any less? The short answer is they can’t.  They can achieve comparable results through a PbR performance management measure if they apply it intelligently and coherently, as per:

    • Offering the addict the real choice of a) a replacement prescription conditional on regular clean illicit drug use and alcohol tests, or b) a ‘breaking free of dependency’ option.
    • The payment for the former would require regular illicit drug and alcohol testing proof
    • The payment for the latter would be conditional on sustained drugs tested sobriety (abstinence from opiate substitute drugs, all illicit drugs and alcohol). Payments would be progressive - starting at one drug tested month sobriety (25%), a second at three months (25%) and the final payment (50%) at six months

    This prescription payment regime would also reward referral to abstinence programmes.

    Drug testing would be independently commissioned and administered.

    The introduction of these simple disciplines would transform existing drug services into incentivised recovery programmes.  

    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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