Equality analysis - Department of Health

Equality analysis
Payment by Results Pilot Programme for
Drug & Alcohol Recovery
Prepared by the National Treatment Agency for Substance Misuse
Gateway approval ref 16329
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Introduction
The general equality duty that is set out in the Equality Act 2010 requires public authorities, in the
exercise of their functions, to have due regard to the need to:
• Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by
the Act.
• Advance equality of opportunity between people who share a protected characteristic and those
who do not.
• Foster good relations between people who share a protected characteristic and those who do not.
The general equality duty does not specify how public authorities should analyse the effect of their
existing and new policies and practices on equality, but doing so is an important part of complying
with the general equality duty. It is up to each organisation to choose the most effective approach for
them. This standard template is designed to help Department of Health staff members to comply with
the general duty.
Please complete the template by following the instructions in each box. Should you have any queries
or suggestions on this template, please contact the Equality and Inclusion Team on 020 7972 5936 or
aie@dh.gsi.gov.uk
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Equality analysis
Title: Drug & Alcohol Recovery Payment by Results Pilot Programme
Relevant line in DH Business Plan 2011-2015:
2.7 Co-design and establish pilots to provide payments based on outcomes to providers to
help individuals achieve sustained recovery from drug dependency
What are the intended outcomes of this work? Include outline of objectives and function aims
The Department of Health, National Treatment Agency, Home Office, Ministry of Justice,
Department for Work and Pensions and their partners are establishing a project to develop a
‘Payment by Results for Recovery” approach to the treatment of drug and alcohol dependence
with the aim of improving the recovery outcomes of those being treated.
The main objectives of the pilot programme are:
• To pilot models of Payment by Results for drug/alcohol recovery at local partnership
level
• Deliver improved recovery outcomes for drug/alcohol users,their families and
communities
• Deliver more cost-effective services for drug/alcohol recovery
The pilots for PbR for Recovery will aim to provide a transparent funding system for drug
recovery services based on the achievement of high level long-term and interim outcomes.
It is expected that the pilots for PbR will deliver improved recovery outcomes by encouraging
providers to focus more holistically on an individual’s needs and by improving continuity of
service provision.
It is also anticipated that there will be an improved understanding of need and corresponding
resource requirements, which will in turn lead to provision that is more effective.
Who will be affected? e.g. staff, patients, service users etc
At local level
- Drug & alcohol recovery service users
- Drug and alcohol users not accessing treatment
- Their family members
- Local commissioning partnerships including:
• Local authorities
• Primary Care Trusts
• Probation service
• Police
• Prisons
- Public, private & voluntary sector recovery service providers
- The communities in which drug/alcohol users live
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At Government department level:
- Department of Health
- National Treatment Agency
- Ministry of Justice
- Home Office
- Department of Work & Pensions
- Cabinet Office
- Treasury
Evidence The Government’s commitment to transparency requires public bodies to be open about the information on
which they base their decisions and the results. You must understand your responsibilities under the transparency agenda
before completing this section of the assessment. For more information, see the current DH Transparency Plan.
What evidence have you considered? List the main sources of data, research and other sources of evidence
(including full references) reviewed to determine impact on each equality group (protected characteristic). This can include
national research, surveys, reports, research interviews, focus groups, pilot activity evaluations etc. If there are gaps in
evidence, state what you will do to close them in the Action Plan on the last page of this template.
Payment by Results (PbR) is currently being piloted/implemented in a number of key policy
areas.The Drug and Alcohol Recovery PbR Pilot programme has been designed to test the
assumption that commissioning drug and alcohol services on a PbR basis will lead to improved
efficiency and improved recovery outcomes for all those being treated. PbR is also intended to
provide a transparent funding system for drug and alcohol recovery services, based on the
achievement of high level long-term and interim outcomes.
This pilot programme is an international first and therefore relevant sources of data are rather
sparse. The Department of Health has just completed the piloting of Payment by Results for
Specialist Alcohol Services. The scope of this pilot was, however, restricted to the
development of national tools and tariffs, with more of an emphasis on developing nationallyagreed
payments for set packages of care, rather than focusing on the impact of paying for
outcomes. It has therefore not yet produced any evidence of how PbR for drug and alcohol
recovery may impact on different equality groups.
The potential within PbR schemes for creating perverse incentives constitutes the main
possible barrier to providing fair and equal services across all the main equality groups. Some
specific characteristics of people within equality groups can present drug and alcohol recovery
service providers with additional challenges to delivering effective outcomes.
The references below attempt to show :
a) that PbR can lead to perverse incentives, and the "cherry-picking" of those most likely to
achieve desired outcomes;
b) the likelihood that equality groups will be more or less affected by perverse incentives and
"cherry-picking".
This first section contains references that are relevant to all or a number of different equality
groups. Where appropriate, the reference will be repeated under the relevant section below,
with an explanation of how the findings impact on that specific equality group.
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1. The Right Result? Payment by Results 2003-7. Audit Commission. February 2008
It is important to recognise that even the most sophisticated payment system has unintended
consequences and perverse incentives, and they are often best managed through other
mechanisms, such as contract management at the local level, rather than by modifying the
policy nationally. Nevertheless, NHS bodies have raised substantial concerns, such as those
relating to fairness and quality of care, which will need to be addressed.
2.The voluntary and community sector in health Implications of the proposed NHS
reforms. Curry N, Mundle C, Sheil F, Weaks L, The King’s Fund, 2011
The [voluntary & community] sector is known for its diversity and flexibility, and develops
services to meet needs that are not being met by the statutory sector. (p.13)
Another concern centres on the shift from block contracts towards Payment by Results for
many community services. Under this system organisations within the sector, which typically
have few reserves, will be paid for services in arrears, based on achievement of outcomes set
by commissioners in advance. Contracts that pay in arrears restrict organisations’ ability to
manage cash flows effectively as they do not guarantee a minimum income (HM Treasury
2006). Additionally, there is uncertainty over how payments will be made under tariff for
services for complex populations, whose needs span the boundaries of health and social care
and primary, secondary and community care. Furthermore, there is concern that the transition
to the new arrangements would leave organisations vulnerable if there is a gap between grantfunding
and block contracts and the development of new funding mechanisms.
3. The Incentive Effects of Payment by Results. Miraldo M, Goddard M & Smith P C.
Centre for Health Economics, University of York. September 2006.
The key issues on which we have focused are those that economic theory suggests are the
main priorities - because there is potential for prospective payment systems to create perverse
incentives and encourage unwanted behaviours from providers. Thus we would expect that
monitoring efforts are directed accordingly.......for example, investigating whether shifts in
service provision cause access problems.
However,.....there are some design features of the PbR policy that will in principle help to offset
some of the potentially negative impacts, making the achievement of the positive outcomes
more likely.
4 .Effect of financial incentives on inequalities in the delivery of primary clinical care in
England: analysis of clinical activity indicators for the quality and outcomes framework.
Doran T, Fullwood C, Kontopantelis E & Reeves D. The Lancet, 2008, 372: 728-36
Incentive schemes can increase inequalities in the delivery of care if practices in affluent areas
are more able to respond to the incentives than are those in deprived areas.......Our results
suggest that financial incentive schemes have the potential to make a substantial contribution
to the reduction of inequalities in the delivery of clinical care related to area deprivation.
5. Research finding: analysis of baseline treatment data (NTA 2011)
Multivariate analysis has identified some factors that predict greater or lesser likelihood of
achieving the specific outcomes that attract payments in this pilot programme. Where these
factors are directly related to equality groups, they are set out in the relevant section below.
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Disability Consider and detail (including the source of any evidence) on attitudinal, physical and social barriers.
Individuals with serious mental & physical health problems may be discriminated against as
their added complexity reduces chances of outcome achievement and payment, while making
them more expensive to treat.
6. Implementing Dual Diagnosis Services for Clients with Severe Mental Illness.
Drake R E, Essock S M, Shaner A, Carey K B, Minkoff K, Kola L, Lynde D, Osher F C,
Clark R E, and Rickards L. Focus (Journal of the American Psychiatric Association),
Winter 2004; 2: 102 - 110.
Since the problem of dual diagnosis became clinically apparent in the early 1980s, researchers
have established three basic and consistent findings. First, co-occurrence is common; about 50
percent of individuals with severe mental disorders are affected by substance abuse. Second,
dual diagnosis is associated with a variety of negative outcomes, including higher rates of
relapse, hospitalization, violence, incarceration, homelessness, and serious infections such as
HIV and hepatitis.
See reference 5 above:
• Individuals with high self-report scores for physical and psychological health, and
perceived quality of life are more likely to achieve outcomes than those with lower
scores.
7. OFFICIALS’ WORKING GROUP ON DRUG REHABILITATION Proposals to Create a
Payment by Results System for Drug Recovery. October 2010
At a series of stakeholder events, consistent calls were made by providers for an interim health
outcome to both incentivise engagement, particularly in dealing with the most entrenched drug
misusers, and to ensure gains such as reductions in Blood Borne Viruses (BBVs) were
recognised. It is also important to reflect progress on other key areas, such as family and
relationship issues, which are vital to sustaining recovery.
A Health and Wellbeing outcome domain, comprising four initial outcome measures*, has
therefore been developed as part of the co-design process.
* Health & Wellbeing Outcome Measures for D&A Recovery PbR Pilot Programme
1. Ceased injecting within the last 12 months
2. No longer reporting any housing problem within the last 12 months
3. Course of Hepatitis B vaccinations completed within the previous 12 months.
4. Normative quality of life score achieved in the last 12 months
Finally, feedback from practitioners makes it clear that some key issues affecting an
individual’s recovery journey may not be apparent on initial assessment. For example, certain
mental health problems may not be apparent or made explicit on first assessment, while
sensitive issues in an individual’s life history (e.g. parental neglect; physical or sexual abuse)
may have a significant influence on the type and length of intervention, but may not be
discussed by an individual until a trusting relationship has developed with a service provider.
This could lead to the risk of the wrong tariff being assigned, with consequent negative impact
on treatment.
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Sex Consider and detail (including the source of any evidence) on men and women (potential to link to carers below).
Evidence that women are more likely than men to achieve desired outcomes could mean that
PbR providers are more reluctant to take on prospective male clients.
8. Women in Drug Treatment: what the latest figure reveal. National Treatment Agency
for Substance Misuse. March 2010.
• Women are a little more likely to engage with treatment, to stay in longer and to get
better results.
See reference 5 above:
• Males are less likely to achieve outcomes than females
• Pregnancy is a factor that further increases an individual’s likelihood of achieving
outcomes.
Race Consider and detail (including the source of any evidence) on difference ethnic groups, nationalities, Roma gypsies,
Irish travellers, language barriers.
There is a possibility that it may be perceived as more difficult to achieve outcomes for non-
English speakers and therefore they may be discriminated against.
See reference 2 above:
• Services designed to engage with hard-to-reach populations (often specific
racial/cultural groups) may be adversely affected because of the additional difficulties in
achieving outcomes for these clients;
• Such services are usually within the voluntary/community sector and therefore at
increased risk of financial failure under the proposed PbR model.
• This could increase the risk of drug/alcohol-related morbidity and mortality for
marginalised vulnerable drug & alcohol users.
Age Consider and detail (including the source of any evidence) across age ranges on old and younger people. This can
include safeguarding, consent and child welfare.
It is reasonable to assume that the older the service user, the more likely they are to have
undertaken previous treatment episodes.
See reference 5 above:
• The more treatment episodes an individual has undertaken, the less likely they are to
achieve outcomes;
• The more unplanned exits from treatment an individual has, the less likely they are to
achieve outcomes;
This increased likelihood to fail to achieve the outcomes that result in payment may lead to
possible discrimination against older clients.
From 1 January 2012, most single young people aged under 35 are only entitled to housing
benefit at what is called the 'shared accommodation rate' – the same as you can get to help
pay for the cost of a single room in shared accommodation. It is likely that this will (a) increase
the risk of acute housing problems and (b) reduce the ability for local services to address acute
housing problems experienced by this age group. Access to safe and secure accommodation
is essential for effective treatment, and this will be compromised by the reduction in housing
benefit. It is likely that drug and alcohol users will have to resort more frequently to less secure
accommodation (sofa-surfing, squatting, living in open access hostels or on the street), which
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will impact negatively on their ability to achieve treatment outcomes.
This increased likelihood to fail to achieve the outcomes that result in payment may lead to
possible discrimination against clients under the age of 35.
Gender reassignment (including transgender) Consider and detail (including the source of any evidence)
on transgender and transsexual people. This can include issues such as privacy of data and harassment.
There is higher prevalence of problem drug & alcohol use among transgender communities
and there may also be additional problems to address (e.g. stigma). This added complexity
may reduce the likelihood of clients in this group to achieve required outcomes, leading to the
possibility of discrimination in access to treatment.
Sexual orientation Consider and detail (including the source of any evidence) on heterosexual people as well as
lesbian, gay and bi-sexual people.
There is higher prevalence of problem drug & alcohol use among lesbian, gay and bisexual
communities and there may also be additional problems to address (e.g. stigma). This added
complexity may reduce the likelihood of clients in this group to achieve required outcomes,
leading to the possibility of discrimination in access to treatment.
Religion or belief Consider and detail (including the source of any evidence) on people with different religions, beliefs
or no belief.
• Language and cultural issues may add complexity to treatment
• Certain groups (e.g. Rastafarians) may hold libertarian drug-using beliefs, and only wish to
achieve selected outcomes, possibly reducing the payment allocated to them. This may
result in their being denied access to all or certain aspects of recovery services.
Pregnancy and maternity Consider and detail (including the source of any evidence) on working arrangements,
part-time working, infant caring responsibilities.
See reference 5 above:
• Pregnancy is a factor that increases an individual’s likelihood of achieving outcomes
Pregnant women may find it easier than others to access services, as they are more likely to
achieve the outcomes that attract payments.
However, a PbR scheme that incentivises the rapid achievement of abstinence could have a
negative impact on pregnant women, as it is known that rapid detoxification can have harmful
consequences, particularly in the first and third trimesters of pregnancy.
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Other identified groups Consider and detail and include the source of any evidence on different socio-economic
groups, area inequality, income, resident status (migrants) and other groups experiencing disadvantage and barriers to
access.
See reference 5 above:
The following factors predict a reduced likelihood of achieving the specific outcomes that
attract payments in this pilot programme:
• Referrals to treatment that come through the criminal justice system
• Those with no fixed abode;
While the factors below predict an increased likelihood of achieving outcomes:
• Education (i.e. the more formal education an individual has had, the greater the
likelihood that they will achieve the required outcomes);
• Working (i.e. those who are employed are more likely to achieve outcomes)
If discrimination against individuals from any equality group is systematically introduced as a
result of the delivery of the Payment by Results for Drug & Alcohol Recovery Pilot Programme,
there is likely to be an amplified impact on the communities in which these individuals live.
Carers Consider and detail (including the source of any evidence) on part-time working, shift-patterns, general caring
responsibilities.
All the possible impacts outlined above will impact on the carers of those in drug/alcohol
treatment.
Engagement and involvement
Was this work subject to the requirements of the cross-government Code of Practice on
Consultation? Yes
How have you engaged stakeholders in gathering evidence or testing the evidence available?
1. A series of stakeholder consultation events was held prior to pilot site selection, in
September and October 2010, when the high-level model was being developed.
2. Initially, an Expert Group, including service users, academics and practitioners with
knowledge/experience of PbR models, was set up to advise on early model
development.
How have you engaged stakeholders in testing the policy or programme proposals?
3. Once the pilot sites were selected, the Expert Group developed into a Co-design Group,
keeping stakeholders involved through monthly meetings.
4. The Recovery PbR Discussion Forum on the Alcohol Learning Centre website is a
closed forum for all Co-design group members.
5. Key developments are posted onto the public access pages of both the DH and NTA
websites.
6. DH micro site: a sub-site on DH website which provides regular updates on
implementation progress.
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7. Through the pilot process: from 1 April 2011 to 31 March 2014 the eight pilot sites will
work with local stakeholders (professional partners, service users, carers) to design
local delivery models in line with the high-level PbR model, and test these out;
8. All relevant D&A Recovery PbR documentation will be made available on the DH micro
site (e.g. minutes of Steering Group and Co-Design Group meetings; central Equality
Analysis document, etc.) provided it is not of a commercially sensitive nature.
9. An event was held on 27 April 2011 to inform and test out the model with a broad range
of services providers.
10. The draft outcome measures, on which payments would be based, were initially drawn
up by the Co-design Group, based on broad outcome domains set by the crossgovernment
project team and agreed by ministers. The draft outcomes were posted on
the DH website to seek wider stakeholder views, and were modified in accordance with
responses received. After some further negotiation the final outcomes were signed off
by ministers, and remain posted on the DH website.
11. Following final agreement of the Outcome measures, a Gaming Commission was set up
to examine the possible risks of gaming the system (which is likely to have an
inequitable impact on those equality groups who are harder to treat), and to identify
actions that could be taken to reduce or eliminate such risks. Pilot sites have audited
their own Recovery PbR models in light of the findings set out in the Gaming
Commission report (attached at Annex 7), and present to the Co-design group in
January 2012 (a) what risks their audit had identified; and (b) what mitigating actions
they would take to reduce/eliminate these risks.
12. Pilot sites have also been encouraged to make their individual documentation (e.g.
original PbR model proposals) available on their local partnership websites. This will
support other local areas in developing their own PbR schemes, based on similar
models.
13. It is intended to maintain engagement and communication with all key stakeholders –
see attached Communications Strategy (Annex 1). Engagement events that have taken
place include;
a. a second provider event in London in May 2012
b. an event for Local Authority commissioning partnerships in June 2012
c. an article in the trade press to coincide with pilot launch in April/May 2012
d. focused work to support local links between treatment and Work Programme
providers
We also encourage and disseminate feedback from non-pilot sites on the ability of their
schemes to ensure that equality groups are treated fairly and without discrimination
The pilot programme itself will test the programme proposals.
In addition, an independent evaluation of the pilot programme has been commissioned and
funded by the Department of Health’s Policy Research Programme, following a competitive
tendering exercise.
For each engagement activity, please state who was involved, how and when they were
engaged, and the key outputs:
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1. Early Stakeholder Consultation Events
• Who was involved – a wide range of stakeholders, including providers of drug & alcohol
treatment services
• Engagement – three meetings held in September/October 2010 aimed at a range of
stakeholders including commissioners, service providers and service users
• Key outputs: feedback on the developing model.
2. Expert Group
• Who was involved – see attached membership list (Annex 2)
• Engagement – monthly meetings of main group and a number of “task & finish subgroups”
from January to April 2011
• Key outputs: further refinement of the model
3. Co-design Group
• Who was involved – see attached membership list (Annex 3)
• Engagement – monthly meetings from May 2011, ongoing. In early stages a wide range
of stakeholders and experts attended. As the work progressed, pilot site representatives
and provider representative organisations became the majority participants
• Key outputs: agreement of the national outcome definitions; development of the pilot
model as it would be applied in each of the pilot sites
4. Discussion Forum
• Who was involved – a closed discussion forum for Co-design Group only
• Engagement – used regularly as a means of communication by pilot sites and central
Project Team staff; to a lesser extent, by other Co-design Group members
• Key outputs: good communication to ensure local pilot programmes develop as close as
possible to central mode and with adequate support by central Project Team
5. Relevant documentation on Dept of Health website
• Who was involved – the PbR page on the DH website has open access
• Engagement – it has been widely advertised (through NTA publications and through
other stakeholder publications e.g. DrugScope’s Daily News)
• Key outputs – general transparency in development of pilot programme.
6. DH Micro Site
• Who was involved – open public access
• Engagement – currently under construction – to be launched in April 2012
• Key outputs – to be determined
7. Provider Event
• Who was involved – see attached list (Annex 4)
• Engagement –targeted invitations sent out to cross-government provider list, also
advertised in stakeholder publications. Limited places allocated on first come, first
served basis.
• Key outputs – stakeholders made aware of central model and process of co-design;
stakeholders aware of proposed models in each pilot site and where opportunities
existed for tendering for new contracts
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8. Wider stakeholder views sought on proposed outcome measures
• Who was involved – see attached list of consultation respondents (Annex 5)
• Engagement – draft outcomes posted on DH website for consultation purposes, and the
consultation was advertised in trade press and websites.
• Key outputs- outcomes were posted on public page of DH website comments on the
proposed outcomes led to some modification of outcome definitions
9. Gaming Commission
• Who was involved – see Appendix 2 of Annex 6
• Engagement – by targeted invitation to achieve a mix of commissioners and provider of
relevant services, along with representation from a provider organisation, key experts in
the drug/alcohol recovery field, and government officials with PbR experience
• Key outputs - in-depth consideration of some of the possible unintended consequences
of PbR for drug and alcohol recovery, resulting in a Gaming Report, due for publication
on DH’s PbR micro site (Annex 6).
• Annex 7 sets out how seven of the eight pilot sites (remaining pilot site to report to Pilot
Implementation Support Group meeting on 26 June) are addressing the gaming issues
raised in the Gaming Report.
Summary of Analysis Considering the evidence and engagement activity you listed above, please
summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether
adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected
groups in services or expand their participation in public life.
The evidence available suggests that a key risk to be considered in Payment by Results
schemes is the unintended development of perverse incentives. In the context of an Equalities
Impact Assessment, it is important to consider whether perverse incentives may impact
differentially on specific equality groups. This Equality Analysis addresses the possibility that
provider services may discriminate against some equality groups (as summarised below) on
the grounds that they will be more expensive to treat and/or less likely to achieve the outcomes
that attract payments:
1. Sex: possible positive impact on women, with corresponding possible negative impact
on men
2. Disability: possible negative impact on individuals with serious mental & physical health
problems
3. Age: Possible negative impact on both older service users (successful treatment
completion), and those under 35 (improved housing outcome)
4. Gender reassignment: possible negative impact
5. Sexual orientation: possible negative impact
6. Religion/belief: possible negative impact
7. Pregnancy/maternity: possible positive impact, though also a possible negative impact
for pregnant service users if abstinence too strongly incentivised, as rapid detoxification
harmful (in first and third trimesters of pregnancy.
8. Carers: possible negative impact
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9. Communities: possible negative impact
All of the identified possible negative impacts would be introduced as a result of unintended
consequences of the payment by results scheme, and it is integral to the pilot process to
identify, minimise and, where possible, eliminate these.
Each pilot scheme has been required to set up an assessment service, known as the LASARS
(Local Area Single Assessment and Referral System), intended to provide a means by which
tariffs are independently assigned and outcomes independently verified. Tariff-setting involves
complexity level profiling by the LASARS to determine how far the client is from achieving
outcomes. Clients are scored on a number of factors: for example, factors which are
pregnancy and recent time spent in education and/or employment. Factors that reduce the
likelihood of achieving outcomes are daily heroin use, Criminal Justice System referral or
previous drop out from treatment. Once a client is assigned a complexity level they will be
given a tariff and the referred onto the treatment provider.
The model recommends that LASARS providers are financially disinterested in the PbR
process. As the local PbR schemes have developed, different models of LASARS have
emerged, with greater or lesser degrees of independence from the PbR providers receiving
incentive payments. Where there is a close relationship with the PbR provider, an independent
audit function is commissioned to ensure probity in the tariff-setting and outcome payment
process.
A key additional function of the LASARS is to provide client advocacy, where necessary acting
as a contact point for individuals engaged in drug/alcohol recovery PbR schemes, expressing
their views or acting on their behalf to help them secure the most appropriate PbR services.
As a key element of the PbR pilots, the comparative performance of the different LASARS
models will be a matter of close scrutiny, both within the Co-design group, and for the
independent evaluators.
In addition to LASARS, the tariff-setting process, supported by the recommendations of the
Gaming Commission, is seen as a key tool for minimising the kind of “gaming” behaviour that
might result in discriminatory practice.
The independent evaluation of the pilot programme, commissioned through competitive tender
by the Department of Health, will play a key role in identifying the equalities impact of the pilot
schemes.
In relation to assessment, referral and take-up, it will document how many people are being
referred to the services, how many and what types of people are using the services and what
types of eligible people do not use the services, with specific reference to selection issues such
as ‘creaming’, ‘cherry picking’ and ‘parking’. This will include a specific focus on deprivation or
poverty indicators, health inequalities and equity.
An important aspect of the independent evaluation is to understand how service user views
and experiences differ according to user characteristics, for example age, drug (and alcohol)
use, offending, employment, housing, disability, ethnicity and gender. This will include
analyses by user sub-group, and assessment of the equalities impact on groups with protected
characteristics, including impact on differential uptake of / access to services.
Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation,
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advance the equality of opportunity and promote good relations between groups.
Eliminate discrimination, harassment and victimisation Where there is evidence, address each
protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual
orientation).
It will be possible to identify system-wide in-built discrimination by service providers through
comparing current treatment data with baseline data covering the previous two years. As a
pilot programme, the pilot sites themselves will play a key role in identifying discriminatory
behaviour and modifying their local schemes to minimise or where possible eliminate it. To this
end, each pilot site has been encouraged to produce and keep updated, its own Equalities
Impact Assessment.
Advance equality of opportunity Where there is evidence, address each protected characteristic (age, disability,
gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation).
This will be a key function for the LASARS, monitored through treatment data and further
explored through the independent evaluation process. The LASARS’ client advocacy role
serves to make this function quite explicit.
Promote good relations between groups Where there is evidence, address each protected characteristic
(age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation).
See section above – LASARS will play a key role in this.
What is the overall impact? Consider whether there are different levels of access experienced, needs or
experiences, whether there are barriers to engagement, are there regional variations and what is the combined impact?
These pilots have been designed to eliminate or reduce different levels of service access,
engagement and/or delivery to different groups. They will be monitored locally, centrally and
through an independent evaluation process to test out that the different models achieve this.
Implementation of the most effective PbR models will be encouraged across all commissioning
partnerships to ensure good practice is disseminated as widely as possible.
Addressing the impact on equalities Please give an outline of what broad action you or any other bodies are
taking to address any inequalities identified through the evidence.
As set out above, the broad actions we are taking to address possible inequalities are:
• Responding to feedback from stakeholders (e.g. including health and wellbeing
outcomes)
• Development of LASARS
• Tariff-setting process
• Gaming Commission
• Monitoring of treatment data
• Requirement for pilot site areas to produce, and keep updated, their own individual
Equality Analyses
• Independent evaluation
Action planning for improvement Please give an outline of the key actions based on any gaps,
challenges and opportunities you have identified. Actions to improve the policy/programmes need to be summarised (An action
plan template is appended for specific action planning). Include here any general action to address specific equality issues and
data gaps that need to be addressed through consultation or further research.
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Please give an outline of your next steps based on the challenges and opportunities you have
identified. Include here any or all of the following, based on your assessment
• Plans already under way or in development to address the challenges and priorities identified.
• Arrangements for continued engagement of stakeholders.
• Arrangements for continued monitoring and evaluating the policy for its impact on different groups as the policy is
implemented (or pilot activity progresses)
• Arrangements for embedding findings of the assessment within the wider system, OGDs, other agencies, local service
providers and regulatory bodies
• Arrangements for publishing the assessment and ensuring relevant colleagues are informed of the results
• Arrangements for making information accessible to staff, patients, service users and the public
• Arrangements to make sure the assessment contributes to reviews of DH strategic equality objectives.
1. Since the D&A Recovery PbR is a cross-government programme, this Equality Analysis
will be shared with, and approved by, the OGDs directly involved (as detailed on page 1)
both at Project Team and Steering Group level.
2. Following this, the EA will be posted on both the Co-design forum and the DH D&A
Recovery PbR micro-site, making it publicly available.
3. The D&A PbR Project Team will continue to promote open discussion of possible gaming
opportunities both through the co-design process and, following implementation,
throughout the PbR pilot period.
4. Project Team will ensure Gaming Commission report is adequately disseminated:
o to Co-design Group, which includes all the pilot sites, who will continue to audit their
own Recovery PbR models on an ongoing basis in light of the findings set out in the
Gaming Commission report, and consider mitigating actions to reduce/eliminate
identified risks.
o to the independent evaluators to facilitate their investigation of possible gaming
opportunities that may lead to discrimination;
o findings/recommendations of the report to be made publicly available, to ensure that
other areas wishing to adopt a PbR model for drug and alcohol recovery are aware of
the possible gaming opportunities that may lead to discriminatory practice, and the
interventions that can be put in place to minimise or eliminate these.
5. Project Team will ensure all pilot areas re-visit their original Equality Analysis and update
them, once this overarching EA has been approved.
6. Project Team will encourage and support pilot sites to monitor treatment data for signs of
system-wide discriminatory behaviour.
7. Project Team will monitor central data for signs of system-wide discriminatory behaviour.
8. The independent evaluation process will continue during the life of the pilots. Emerging
evidence of the impact on equalities groups will be shared with the pilot projects to inform
improvements in practice, and will feed into policy review activity.
15

For the record
Name of person who carried out this assessment:
Megan Jones
Date assessment completed: 20 April 2012
Name of responsible Director/Director General:
Chris Heffer, Deputy Director, Alcohol and Drugs
Date assessment was signed:
26 th July 2012
16

Action plan template
This part of the template is to help you develop your action plan. You might want to change the categories in the first column to
reflect the actions needed for your policy.
Category Actions Target date Person/ Directorate responsible
Involvement
and
consultation
Data
collection and
evidencing
Analysis of
evidence and
assessment
Monitoring,
evaluating
and reviewing
Transparency
(including
publication)
Implement Communication Strategy (See Appendix 1) March 2012 to
Sep 2013
Ongoing data collection via:
• National Drug Treatment Monitoring System
• Treatment Outcome Profile
• Police national Computer
• Pilot site monthly reporting
Data sources set out above will be analysed and assessed
17
Ongoing
Ongoing
Monitor emerging findings from DH PbR specialist Alcohol
Treatment pilot and feed into Recovery PbR as appropriate
Data sources set out above will be monitored and reviewed Ongoing
Independent evaluation, funded by DH Nov 2011 to
Oct/Nov 2014
Continue web-based Discussion Forum
Continue posting key documents on DH website
Launch and manage Recovery PbR micro site
Secure ministerial agreement and send out letter from DG PH
re local responsibility and financial liability for the pilots
Implement Communication Strategy (including ongoing webbased
fora, publications and live events)
March 2012
onwards
Ray Smith
Drug Recovery Team Lead
Drug & Alcohol Branch
Dept of Health
Jonathan Knight
Head of Analysis
National Treatment Agency
Alan Hall
Operational Research Analyst
Home Office
Cross-government Project Team members
(DH, NTA, Ho, MoJ)
Pilot site staff
Ruth Chadwick
Principal Research Officer
Policy Research Programme
Research and Development Directorate, DH
Megan Jones
Programme Manager, NTA
Michael O’Kane
Policy Officer, DH
Ray Smith – as above

Annex 1 Communications Strategy
Payment by Results for Drugs & Alcohol Recovery (PbR)
Communications plan February 2012
The eight PbR pilot sites will go live on 1 st April 2012 following an extended period of co-design. This
paper outlines the communications approach suggested by the PbR project team.
The PbR pilots are a key part of the Drug Strategy 2010’s priority of putting recovery at the heart of
the treatment system, which as a whole is being transformed to become more recovery-oriented. In
addition to the eight PbR pilot sites, around 49 other local partnerships have commissioned new
recovery-orientated systems (or are in the process of doing so), of whom half (25) are introducing
payment by results elements to their new systems (incentivisation ranges between 1.5% to 50% of
total contract value, although the outcomes are not the same as the national PbR pilots and tend to
omit specific outcomes on offending, employment and housing). Recovery is the core message for
government communications about drug treatment, and this plan covers communications for the
crucial payment by results component of recovery over the next few months.
Communications aims
1. Improve understanding amongst providers of drug recovery services to increase their
confidence to bid for PbR contracts, both within the eight pilots and for PbR in other
partnerships.
2. To effectively communicate with commissioners outside of the eight pilot sites so they are
encouraged to adopt PbR.
3. To encourage PbR sites and early adopters to learn from the co-design stage and early
implementation what works well and what is less successful, to inform future policy design
and increase the likelihood of successful outcomes during the early phases.
4. To gather information and actual examples of successful implementation from as early a
point as possible during the pilot roll-out, so that they are ready to be used in external
communications and internal briefings as required.
5. To effectively engage stakeholders who may not be directly involved in the commissioning
or provision of services in updates about the progress of PbR, which demonstrate that
government is listening to feedback, as well as smooth the passage of later roll-out.
6. To have clear coherent lines across government departments about the purpose and
progress of PbR D&A throughout the lifetime of the pilots and early adoption.
Audiences
• Commissioners and service providers within the pilot sites
• Commissioners and providers within early adoption partnerships and with the potential to
move to early adoption
• Service users within the pilot sites/ early adopters in particular
• Remaining commissioners and providers
18

• Drug and alcohol treatment representative organisations (e.g. DrugScope, UKDPC, Alcohol
Concern)
• Shadow health and wellbeing boards
• Police and Crime Commissioners
• Health and social care professionals (including GPs, psychotherapists)
• NHS and local authority chief execs, directors of adults and children’s services
• Prisons and probation
Appendix B has a full list of audiences, segmented messages and channels to reach them.
Generic key messages (Appendix A has a draft narrative)
• Drug and alcohol treatment services put the goal of recovery at the heart of what they do so
that users are offered a route out of dependence. Following the co-design phase, eight
Payment by Results pilot sites for drugs and alcohol recovery will start testing radical new
approaches where funding follows success from April 2012.
• The aim is to incentivise local areas to enable as many people as possible to overcome drug
and alcohol dependence and sustain their recovery.
• Government has been working with the pilot sites for the last few months to design a variety
of different approaches, and will shortly be publishing ‘lessons learned’ from this co-design
phase to help other local areas implement similar schemes. In addition to the eight pilot
sites, other drug treatment partnerships are exploring their own PbR model, as part of the
government’s ambition to transform drug treatment to become recovery-orientated.
Channels of communication
Phase 1: Before launch of the pilots February – end March
The main aim of the early phase is to launch the pilots smoothly, to give them space to get going,
and set up early feedback mechanisms so that other providers and commissioners within the drug
treatment sector start to engage favourably with PbR.
The primary vehicle for communicating will be a DH-led microsite which will be populated with any
of the relevant material for PbR in time for the pilots going live on 1 st April. It needs to be updated
weekly to keep the content fresh so it require the pilot sites to provide regular short articles to the
site (two per quarter, one could be a user journey story). The Project Team would be responsible for
commissioning material and editing. The microsite would then be a useful source of material should
early feedback be required for briefings.
The microsite, the one year on Drug Strategy document (which will be published by Home Office)
and ‘lessons learned’ from the co-design period should be available before the sites go live on 1 st
April.
19

Phase 2: Launch of the pilots May – summer
Ordinarily the 1 st April 2012 would be the appropriate marker to launch the pilots, but as it falls in
purdah then although the sites will go live on 1 st April 2012, the external launch should coincide with
a provider event held in London, to be attended by the MS (PH) on 21 st May. The event will be an
opportunity to hear from pilot sites and other early adopters and to promote the ‘lessons learned’
document. Providers were chosen as the focus for this event as the last provider event was held in
April last year, and we are aware that those pilot sites that went to tender struggled to attract
interest from a variety of providers.
Messages aimed at commissioners will need to take account of the timing for commissioning cycles,
so that we get the right messages to DAATs before they recommission their services for 2013/14.
Phase 3: Wider dissemination
Beyond the immediate priority of getting the sites up and running and building support within the
drug treatment field, there is a wider range of stakeholders, particularly within the criminal justice
field, who will need to be specifically targeted. These include health and wellbeing board members,
clinical commissioning groups, Police and Crime Commissioners. These wider networks will have
already received updates in May (at launch) and in August (via e-communications), but it is
recommended that the communications plan is reviewed and updated after the summer to ensure
that PbR messages are being tailored to the new landscape.
20

Communications activity grid
Activity Timing Audience Message/ purpose Communications lead
PbR input into Drug Strategy 23
One Year On
rd March tbc All drug strategy
Key messages as above HO, working with Project
stakeholders
Team
‘Lessons learned’ document March PbR pilot sites, early Emphasis on learning from HO, working with x-govt
to coincide with Drug
implementers, other co-design, aim to increase departments & NTA
Strategy One Year On
interested partnerships positivity towards PbR ahead
of launch
PbR microsite (DH) goes live By end March PbR pilot sites, early Aim to increase positivity DH, working with Project
implementers, other towards PbR ahead of launch Team
interested partnerships & encourage early feedback
National provider event, May 21
held in London with MS (PH)
st Service providers Aim to improve service DH/ NTA, working with
provider understanding of
PbR and promote confidence
in bidding for contracts
Project Team
National announcement of May, to coincide with Professional media and Key messages DH/ NTA, working with
launch to media and provider event
wider stakeholders, and
Project Team
stakeholders
networks (Appendix C)
Druglink or Drink and Drug May, to coincide with launch Service providers and wider Provide sector with further DH/ NTA, working with
News article/ feature
stakeholders
detail on PbR progress Project Team
Commissioner event June (month tbc) Commissioners Increase adoption of PbR DH/ NTA, working with
models
Project Team
E-newsletter update via NTA August Wider stakeholders, To keep rest of treatment NTA, working with Project
providers and
field updated with progress Team
commissioners, networks
(Appendix C)
after May launch
Briefing for ‘new’ public Autumn Wider stakeholders (PCCs, Review communications plan Project Team
health and crime
health & wellbeing boards to refine and tailor messages
stakeholders
etc)
21

Appendix A
Draft narrative for Payment by Results for Drugs and Alcohol Recovery
Drug and alcohol treatment services put the goal of recovery at the heart of what they do so that users are offered a
route out of dependence. Following the co-design phase, eight Payment by Results pilot sites for drugs and alcohol
recovery will start testing radical new approaches where funding follows success from April 2012.
The aim is to incentivise local areas to enable as many people as possible to overcome drug and alcohol dependence
and sustain their recovery.
The government has been working with the pilot sites for the last few months to design a variety of different
approaches, and the Home Office will shortly be publishing ‘lessons learned’ from this co-design phase to help other
local areas implement similar schemes. In addition to the eight pilot sites, other drug treatment partnerships are
exploring their own PbR model, as part of the government’s ambition to transform drug treatment to become recoveryorientated.
At present, drug treatment services are commissioned from providers who are paid an up-front fee to deliver a detailed
specification based on local needs. Under PbR their payment will be more closely related to the actual outcomes
achieved by individual clients during the course of their treatment.
Individuals in the pilots will be assessed prior to entering a recovery service, and a ‘tariff’ assigned to each individual,
taking into account a number of factors that have been shown to impact on the likelihood of their achieving required
recovery outcomes (e.g. primary drug use, age, number of previous episodes of treatment). Clients will then enter a PbR
recovery service, where outcomes will be measured periodically against the initial assessment using nationally verified
data sets (e.g. National Drug Treatment Monitoring System, Treatment Outcome Profile, Police National Computer).
There are nine nationally agreed outcomes across three areas: freedom from drug(s) of dependence; reduced
(re)offending; and improved health and wellbeing. The payments assigned to outcomes are determined locally. The
drug dependence and health and wellbeing outcomes are measured individually, and some of them may be achieved
while the client is still in treatment (e.g. ceased injecting, achieved abstinence, improved housing situation). The
offending outcome is measured on a cohort basis.
The pilots will run from April 2012 to April 2014, during which time other local areas will be continuing to re-orientate
drug treatment services towards recovery through a focus on user outcomes. The pilots will be evaluated by the
National Drug Evidence Centre (NDEC).
Central government will not seek to prescribe the approaches that should be taken in delivering these outcomes, but
will support local areas by developing the evidence base as to ‘what works’ and promoting the sharing of best practice.
The learning from PbR will help to shape future policy and practice in a system that is locally led and locally owned.
The PbR for Drugs and Alcohol Recovery scheme is being co-ordinated with other government PbR exercises – such as
offender rehabilitation – to ensure individuals have the best possible chance of becoming healthy and taking part in
their community, and of rebuilding their lives for good.
22

Appendix B
Full list of audiences, segmented messages and channels to reach them.
Stakeholder Key messages
DH
Methods of distribution
• Importance of the recovery agenda and how the
design of shared care services need to reflect this
GPs and practice team agenda.
GP and Practice Team
staff
• Links to Mental Health PbR.
Bulletin
• Development of Alcohol Treatment clusters.
• Involvement of GPs in Packages of Care.
• Early results from the Alcohol PbR pilots.
All allied health
• Messages could target psychologists/ psychotherapists
professionals (these are given their focus on mental health. Messages could be
professionals in the
healthcare sector such as
Psycotherapists, Speech
aimed around the impact drugs has on mental health,
the importance of effective drug treatment and how
we see a PbR approach making treatment more
Allied Health
Professionals Bulletin
& Language Therapists, effective.
Physiotherapists, etc). • Best Practice Packages of Care based on NICE
guidance.
• Increase awareness of PbR and highlight the move to
an outcome based approach.
Transition focused - for
all staff working in the
public health area
•
•
Links to Mental Health PbR
Role of LAs and Public Health Departments in
commissioning alcohol treatment service in line with
PbR
Transforming Public
Health Bulletin
• Development of Alcohol Treatment clusters
• Early results from the Alcohol PbR pilots
• Messages could target the mental health aspect of
All staff working in social
care
social care. Messages could be aimed around the
impact drugs has on mental health, the importance of
effective drug treatment and how we see a PbR
approach making treatment more effective.
Social Care Bulletin
• Best Practice Packages of Care based on NICE guidance
NHS and local authority
chief executives and
directors of adult services
and children’s services.
•
•
•
•
Increase awareness of PbR and highlight the move to
an outcome based approach.
Links to Mental Health PbR
Development of Alcohol Treatment clusters
Early results from the Alcohol PbR pilots
'The Week'
Stakeholder
• Increase awareness of PbR and highlight the move to
organisations in the drug
and alcohol field
including drug & alcohol
•
•
an outcome based approach.
Links to Mental Health PbR
Development of Alcohol Treatment clusters
NTA e-newsletter
Alcohol learning centre
treatment partnerships • Early results from the Alcohol PbR pilots
Drug and Alcohol
• Outcomes
• Links to Mental Health PbR & Recovery PbR
NTA e-newsletter
treatment providers • Development of Alcohol Treatment clusters
• Early results from the Alcohol PbR pilots
Alcohol Learning Centre
Service users, carers and
families
• Outcomes for users at the heart of PbR
23
NTA e-newsletter and
local teams’ cascade

Police and Crime
Commissioners
HO & MoJ
• Importance of DIP funding going forward
• VFM of PbR (link to DIP funding)
• How drug recovery affects crime
• Offending outcome – working beyond just drug
recovery benefits
Pre November 13 –
candidates
Post November 13 – PCCs
Non-pilot area DAATs • Increasing awareness of PbR and encourage future
take up
• Importance of getting the design of the outcomes
right
• Knowing the difference between outcomes and
activity
• Importance of an outcome to reduce reoffending
• Look at reoffending beyond just the benefits of drug
recovery
• Reducing an individual’s reoffending to aid their drug
recovery. E.g. removing someone from the offending
social circles can aid drug recovery.
Drug Testing Police
Strategic Leads
• Understanding the whole process. Why drug test?
What is the outcome?
• Link into targeted testing, getting the right people
into treatment and how PbR changes relate to it
• Role of the LASAR
Positive Futures projects • Understanding the links into IOM
• Crime reduction – stop young people becoming
offenders/getting involved with drugs
• Holistic view to recovery
• PbR as a potential future method of payment.
CJIT Single Points of • Understanding the links to prisons
Contact
• Understanding the links to drug testing
VCSE • Raising awareness of PbB and encourage
involvement with non pilot daats
• Address their main issues with PbR:
• Perverse incentives (only dealing with easy
targets)
• Small organisations lose out (no capital)
• Correct outcomes
• Understanding the place of Social Impact Bonds
Providers • Raising awareness of PbB and encourage
involvement with non pilot daats
• Importance of understanding the links to offending
• Expectation of the Government is that you will
address offending needs in addition to clinical needs.
24
Police and Crime Bulletin
Monthly SPOC list
Police and Crime Bulletin
Other external
communications?
Ministerial visits/event
attendance/speeches
‘No Offence’ website
Connect database
PSL meeting
Other PSL Communications
Police and Crime Bulletin
Monthly SPOC list
‘No Offence’ website
Connect database
Comms through the
National Programme
Managers
‘No Offence’ website
Connect database
Monthly SPOC list
Stephen Rimmer VCSE
Stakeholder forum
CSU distribution list
‘No Offence’ website
Connect database
MoJ Reducing Reoffending
infrastructure grants:
- Third Sector Advisory
Group
- Clinks network weekly
bulletin
- women’s breakout and
BTEG
‘No Offence’ website
Connect database

Prisons/Probation (MW
to add more detail)
National level adviser
and intermediary
organisations.
Local level adviser and
intermediary
organisations
• Raising awareness of PbB encourage links with pilot Quantum intranet
daats and involvement with non pilot daats
• ensure continuity of care for offenders with
substance misuse issues
DWP
Key messages reflect health generic messages DWP Stakeholder
Bulletin
25
Touchbase
Website for general
DWP advisers site
access aimed at advisers
and intermediaries.
To note: Examples of adviser and intermediary organisations include: Citizens Advice Bureau, MIND, Federation of
Small Businesses, Confederation of Business Industry, and gingerbread – a single parents’ advice organisations

Annex 2 NATIONAL EXPERT GROUP MEMBERSHIP LIST
Name Role & Organisation
Abiba Enwonwu DH PbR branch
Andrew Street University of York
Bill Puddicombe EATA
Clive Pritchard DH
Clive Henn DH
Colin Bradbury Chair – Head of Delivery Central NTA
Colin Wilkie-Jones DWP rep
Damien Mitchell DH Alcohol Policy team
Dave Marteau DH Offender Health
Dr Ben Warner PbR rep from MOJ
Emma Christie NTA Programme Managers
Jason Gough Service User Representative
John Marsden NTA Senior Academic Advisor
Jonathan Knight NTA Head of Analysis
Keith Humphries International Observer
Lorraine Regan PbR rep from CLG – supporting people
Marcus Roberts Drugscope
Mark Prunty DH Senior Medical Officer
Megan Jones NTA Project Manager
Nicola Singleton UKDPC
Rick Ohrstrom International Observer
Rose Scott NOMS
Russ Aziz Department for Education
Ruth Chadwick DH
Sara Mason DH Drug Policy Team
Sara Skodbo Home Office
Sue Young Home Office
Trevor Williamson ACPO Drugs Committee Coordinator
Viv Evans Adfam
26

Annex 3 Co-design Group for Payment by Results (PbR) Recovery Pilots
Megan Jones, NTA (Chair)
Adiba Enwonwu, DH PbR branch
Andrew Street, University of York
Bob Erens, Policy Innovation Research Unit, Department of Health Services Research & Policy
Clive Henn, DH
Clive Pritchard, DH
Dave Marteau, DH Offender Health
Don Lavoie, DH
Dr. Ben Warner, MOJ
Dr. John Marsden, NTA
Dr. Marcus Roberts, DrugScope
Dr. Mark Prunty, DH
Dr. Nicola Singleton, UKDPC
Emily Whitehead, Home Office
Geoff Scammel, DWP
Jason Gough, Service User Representative
Jayne Bowman/James Smith, MOJ
Jon Knight, NTA
Katie Hill, Head of Policy, eATA (representing Colin Wilkie-Jones)
Keith Humphreys, International Observer
Loraine Regan, PbR rep from CLG
Michael O' Kane DH
Nick Garcia DH
Michael Wheatley, NOMS
Mike Jones/Rachel Radice, DWP
Prof. Martin Roland, Professor of Health Services Research, University of Cambridge
Rick Ohrstrom, International Observer (via tele-conference)
Russ Aziz, Department for Education
Ruth Chadwick, DH
Sara Mason, DH/Ray Smith, DH
Representatives from the pilot areas:
Bracknell Forest: Jillian Hunt, DAAT Manager & Commissioner
Bracknell Forest: Mira Haynes
Enfield: Andrew Thomson, DAAT Strategy Manager
Enfield: Fulya Yahioglu
Kent: Lesley Andrews, Head of Service
Kent: Mark Gilbert
Lincolnshire: Mike Casey, Joint Commissioning Manager - Drugs & Alcohol
Lincolnshire: Chris Avis
Oxfordshire: Jo Melling, Director
Oxfordshire: Samantha Read
Stockport: Alison Leigh, Strategic Manager
Stockport: Philip Leigh
Wakefield: Caroline Abbott, Head of Public Health Substance Misuse
Wakefield: Caroline Foy
Wigan: David Gray, Prolific Offender & Drug Intervention Strategy Manager
Wigan: Paul Keeling
27

Annex 4 Attendees at Provider Event 28 April 2011
Organisation
Action on Addiction
Addaction
Addiction Recovery Service
Addiction Dependency Solutions
ANA treatment centres
Barnsley Alcohol and Drugs Advisory Service
Birmingham & Solihull Mental Health Foundation NHS Trust
Brighton Oasis Project
Bristol Drugs project
Calderdale Substance Misuse Service
Can
City Health Care Partnership Hull (CHCP Hull)
Coventry and Warwickshire Partnership Trust
Cranstoun
Doncaster Alcohol Services
Drugs and Alcohol - Greater Manchester Probation Trust
ESCAPE Family Support
Harbour Drug & Alcohol Services
Humber NHS Foundation Trust
Intuitive Recovery Ltd
Inward House Projects
Kenward Trust
Leeds Addiction Unit
Leeds Community Drugs Partnership
Leicestershire and Rutland Probation Trust
Ley Community
Lifeline
Linwood Recovery Group
Mersey Care NHS Trust
Mimosa Healthcare Group
Multiple Choice
Nacro
Newroads Rehabilitation Centre
Nilaari Agency
North East Council on Addictions (NECA)
Northumberland Tyne and Wear NHS Foundation Trusts
Nottinghamshire Healthcare NHs Trust
Oxford Health NHS Foundation Trust
Park View Project
Primary Care Addiction Service Sheffield (PCASS)
Project 6 (Airedale Voluntary Drug and Alcohol Service)
RDasH, Substance Misuse Services, Clearways
Sheffield Health and Social Care NHS Foundation Trust
28

Annex 4 continued
Organisation
SIFA Fireside - Birmingham City Centre Third Sector Adult
Homeless,Drug,Alcohol & Mental Health support Agency.
SMART CJS
Sodexo Justice Services
Spectrum Community Health CIC
Swanswell
Telford & Wrekin Community Substance Misuse Service
The Alcohol and Drug Service
The BAC O'Connor Centre
The Basement Recovery Project
The Cambridge Centre
The Cyrenians
The Gate Christian Outreach
The Nelson Trust
The Social Partnership
THOMAS (Those on the Margins of Society)
TTP Recovery Communities
Western Counselling
Westminster Drug Project
Willowdene Rehabilitation
Work Solutions
Lloydspharmacy
Everyday Skills Ltd - T/A Ease
Northhamptonshire Aquarius
Addictions UK
Turning Point
Equinox Care
Kent and Medway Health and Social Care Partnership Trust
FDAP
RAPT
Compass
Addiction Recovery Foundation
Wigan/Leigh (GMW)
KCA
Alcohol Concern
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29

Annex 5 Respondents to stakeholder consultation
Annex 6
Type Organisation
Provider Pennine Care NHS Foundation Trust (Stockport)
Service User Cirtek Alcohol Service Users (CASU) Stockport
Provider Escape Family Support
Provider NHS Bristol
Commissioner Oldham DAAT
Commissioner Safer Bristol Substance Misuse Team (DAAT)
Commissioner Stockton DAAT
Commissioner Staffordshire Substance Misuse Commissioning Team
Provider RAPt
Provider Addiction Recovery Foundation - Concordat
Representative Org Royal College of Psychiatrists
Provider Mimosa Healthcare
Commissioner Redcar & Cleveland joint commissioning group
Provider Bosense & Boswyns
Provider Central North West London
Provider North Yorkshire Substance Misuse Commissioning team
Commissioner Safer Darlington
Representative Org Adfam
Other London Joint Working Group for substance Misuse & Hep C
Provider Compass
Other Hepatitis C Trust
Commissioner Wakefield Project Board
Commissioner Wokingham DAAT
Representative Org Drugscope & UKDPC joint response
Provider Focus 12
Provider Addiction Recovery Agency
Provider Greater Manchester West Mental Health NHS Foundation
Provider Lanchester Road Hospital
Provider Phoenix Futures
Commissioner North Lincolnshire Substance Misuse Team
Commissioner Luton Drug & Alcohol Partnership
Commissioner Safer Middlesbrough Partnership
Commissioner Sefton DAT
Representative Org The Basement Recovery Project
Provider Trafford Drug Service
Provider The Albert Centre
Provider Royal Free Hampstead NHS Trust
Provider NHS Stockport
Representative Org Oxfordshire User Team
Commissioner NHS Sussex
Provider Clinical Partners
Commissioner Stockport DAT
Provider South London and Maudsley NHS Foundation Trust
Provider Westminster Drug Project
Commissioner Lewisham
Provider Turning Point
Other Lundbeck Ltd - ethical research-based pharmaceutical company focused
on central nervous system disorders
Other The Art of Life Itself
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30

Gaming Commission Report
REPORT
from the
GAMING COMMISSION
on
DRUG AND ALCOHOL RECOVERY
PbR PILOTS
P:\Data\notes99D109\Equality analysis - PbR Programme for Drug & Alcohol Recovery - RMC comments - 15 August 2012.doc
31

REPORT from the GAMING COMMISSION
on DRUG AND ALCOHOL RECOVERY PbR PILOTS
Summary
1. The Gaming Commission (GC) was set up in August 2011 to identify gaming opportunities within the Drug & Alcohol
(D&A) Recovery PbR pilot schemes, and to recommend how these might be eradicated or minimised.
2. This report is based on the outcome of three meetings of relevant professionals using their first-hand knowledge of
commissioning and service provision, and taking into consideration the evidence from other policy sectors and a
note of advice from the Policy Innovation Research Unit (PIRU), London School of Hygiene and Tropical Medicine.
3. Gaming is defined as the deliberate manipulation of the system, outside of the agreed rules, for financial gain, and
unethical behaviour to maximise income.
4. General issues that could impact on gaming were identified:
• The complexity associated with having multiple outcomes and multiple severity groups is unprecedented and
will increase opportunities for gaming or for the accidental introduction of perverse incentives.
• Tariff weighting: if this is not considered carefully, providers may be incentivised to “park” or “fast-track” clients
in order to maximise payments.
• Pressures to game the system will tend to increase if external factors mean it is more difficult to achieve the PbR
outcomes.
• Outcome weighting systems, if too simple, may be too “blunt” to incentivise the required outcomes, while if too
complex may reduce transparency and encourage gaming.
• Tying a high proportion of income to performance is more likely to have perverse consequences when the
outcome is not fully under the control of the provider.
5. Specific risks and gaming opportunities were identified as falling into three key areas:
• the assessment of clients, and particularly the role of Local Area Single Assessment and Referral System (or
LASARS);
• the weighting and timing of payments for different PbR outcomes; and
• misrepresenting or inflating success to obtain outcome payments that are not really merited or deserved.
Many of these gaming risks can be reduced or eliminated through effective setting of tariff weightings and payment
structures.
6. Effective system design should be considered the primary opportunity for minimising and eradicating ‘gaming’, and
‘policing’ the behaviour of providers as a secondary strategy. However, given the complexity and speed of
implementation of the pilots there are many ‘unknowns’ in the design process so monitoring processes will be of
particular importance and flexibility should built into the systems.
7. In order to monitor and identify if gaming is occurring and to deter it, actions of three main types were identified:
• Monitoring data to detect change from previous years (e.g. in the distribution of “complexity groups in an area’s
treatment population). Triangulation with other sources of evidence or using data from other comparable
areas may be helpful for confirming anomalies.
• Auditing processes will be essential. Robust auditing of assessments and outcomes will be important
everywhere but particularly where there are non-independent LASARS.
• Involvement of service users in systematic, independent assessment of their views and experiences of the
services provided.
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32

Introduction
The Department of Health is leading on a cross-departmental project to explore how Payment by Results
(PbR) can incentivise delivery of recovery outcomes for adults with drug or alcohol problems, with pilots being
developed in eight areas. Underpinning the pilots is the principle that providers will no longer be paid on the
basis of activity but on the outcomes they support service users to achieve. The pilots are being developed by
a national co-design group, but with significant scope for local variation.
Role and remit of the PbR for Recovery Gaming Commission
The Gaming Commission (GC) was set up in August 2011 as a sub-group of the Co-design group. Most of its
members were not directly involved in the Co-design group. This was partly because it was necessary to
ensure there was no conflict of interest and, in particular, that GC members were not involved in the pilots in
any way. It brought together policy specialists (including those involved in the design of other PbR schemes
across Government) together with a group of people with operational experience of service provision – as
commissioners, providers and service users. The co-chairs of the GC – from DrugScope and the UK Drug Policy
Commission respectively - were independent from Government. 1
The GC’s ‘main responsibilities’ were identified as:
• To examine the agreed models, outcome definitions and metrics of the Drug and Alcohol Recovery PbR pilots
and consider opportunities for:
- deterring access to treatment for those least likely to achieve outcomes;
- ‘parking’ or delivering minimal treatment to clients least likely to achieve outcomes;
- securing unwarranted payments;
- other ways of ‘gaming’ the system.
• To recommend how these opportunities could be eradicated or minimised.
While the main focus of the discussions of the GC were on the implications for the commissioners of the
services in the pilot areas, the findings will also be of value in informing the design of the evaluation of the
pilots.
The approach taken
The Commission had a tight time scale for deliberating on these issues, which meant that some of the
information for modelling some aspects of the system was not available in time to be considered. As a result
the conclusions have had to be quite broad-brush in nature. It also means that the issues identified below are
unlikely to be a complete list of all possible gaming opportunities but nevertheless provide an indication of
some critical points in the system to which particular attention should be paid.
This report is informed by the deliberations at three meetings on 22 September, 19 October and 15 November
2011. The first meeting introduced the PbR approach being taken in the pilots and the issue of gaming. The
second, and longest, meeting considered the proposed models in more details and what was known about the
outcomes against which payments would be made and then brainstormed the various gaming opportunities.
The final meeting reviewed the gaming opportunities and discussed how these might be identified and/or
mitigated against.
The report also takes into account a note of advice produced by the Policy Innovation Research Unit (PIRU),
London School of Hygiene and Tropical Medicine, on 10 November 2011. 2 PIRU was asked to advise on issues
1
The Terms of Reference of the Gaming Commission, including a list of its membership, are provided as Appendix 1 of this
document.
2
PIRU’s note of advice is published on their website and can be accessed via the following link: http://www.piru.ac.uk/?completed-
project=11
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elating to the evaluability of the pilot schemes. The GC also considered evidence from other policy sectors –
for example, at our first meeting, Dr Maria Hudson presented on the findings from the evaluation of the
DWP’s PbR-based ‘Pathways to Work’ initiative which she led at the Policy Studies Institute.
A note on the Commission’s assumptions about provider motivation
For the purposes of its deliberations the GC has found it helpful to assume that providers and commissioners
will act in a self-interested way to maximise their income and/or minimise their expenditure. In reality, we
know that the commissioners and service providers involved in the PbR pilots are motivated by a desire to
achieve the best possible outcomes for service users, families and communities.
The purposes of this report
The GC intends that this report should inform the development of Drug and Alcohol Recovery PbR by:
- providing an analysis of gaming issues relevant to the development of the Drug and Alcohol Recovery PbR
schemes;
- providing guidance to the eight pilot areas and to other commissioners involved in the design of PbR systems
(now and in the future) on minimising or eradicating opportunities for gaming through effective system design
and other safeguards;
- informing the monitoring, auditing and evaluation of the PbR pilots by highlighting where gaming is most likely
to occur, and identifying some of the early warning signs.
What is gaming?
The Audit Commission (AC) (2005) report ‘Early lessons from payment by results’ identified gaming as a
significant risk for payment by results approaches to the delivery of public services.
In line with the AC, the GC agreed the following definition of gaming:
• The deliberate manipulation of the system, outside of the agreed rules, for financial gain, and in
particular:
- Deliberately manipulating complexity ratings;
- Securing unwarranted payments;
- Deliberately inflating successes.
• Unethical behaviour to maximise income, and in particular:
- Cherry-picking/creaming clients most likely to achieve outcomes; and
- Parking clients who can achieve initial outcomes but are unlikely to achieve abstinence.
The GC also discussed the risks that both commissioners and service users could also ‘play the system’.
Identifying gaming opportunities and developing responses
The GC identified a number of points within the PBR process at which it concluded that there were significant
opportunities for different forms of gaming. (See figures 1 & 2 below). It concluded that the principal risks of
gaming could be captured by focusing on three key issues:
1. Gaming opportunities associated with the assessment of clients, and particularly the role of Local Area Single
Assessment and Referral Services (or LASARS);
2. Gaming opportunities associated with the weighting and timing of payments for different PbR outcomes; and
3. Gaming opportunities for misrepresenting or inflating success to obtain outcome payments that are not really
merited or deserved.
These three themes are considered in more detail below (see pages 5-9).
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Figure 1 The Basic Model
Self referral
CJ referral
GP referral
LASARS
�Assessment &
tariff-setting
�Referral to
provider
�Confirmation of
outcomes to
trigger payments
�Advocacy
Prime
provider
Provider
Framework
Relapse
Figure 2 Gaming Opportunities
Access
Self referral denied LASARS
�Assessment Assessment &
tariff-settingfalsified
CJ referralComplexity
�Referral to
exaggerated provider
GP referral
Holding
service
created
�Confirmation of
Cherry
outcomes to
picked
trigger payments
�Advocacy
Complexity
exaggerated
Prime
provider
Relapse
Creamed
Free from
drug(s)
Reduced
offending
Improved
H&WB
Free from
drug(s)
Waiting Outcomes Reduced
list exaggerated offending
created Provider
Framework
Parked
TOP
falsified
Improved
H&WB
TOP
falsified
Sustained
recovery
Sustained
recovery
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General issues relating to gaming
The Gaming Commission also highlighted some general issues that could impact on the risks of gaming:
1. Setting tariffs for multiple outcomes and groups. Perhaps the key concern is that if the tariff weightings are not
carefully calibrated some service users will be ‘parked’ in treatment with little pro-active support once any
applicable ‘interim outcomes’ have been achieved (it was noted that the risk of ‘parking’ will tend to increase as
the treatment journey progresses and the range of available outcomes remaining for a particular service user
contracts). Equally, there were concerns that service users could be fast-tracked through and out of the
treatment system prematurely in an attempt to maximise payments for treatment success (it was noted that if
this payment is sufficiently high providers could calculate that in business terms they should fast-track exit even
while expecting a significant rate of representation).
2. Strategies for survival. The pressures to game the system will tend to increase if external factors mean it is more
difficult to achieve the PbR outcomes. Qualitative evidence from the evaluation of the DWP’s Pathways to Work
initiative concluded that the tendency to ‘park’ clients who were considered further from entering the labour
market increased during the 2009 recession. Where external factors create additional pressures for drug and
alcohol services, an element of ‘gaming’ could act as a kind of ‘buffer’ – i.e. as an adaptive strategy to sustain
the provision of services in a more difficult environment.
3. Complexity and transparency. Some members of the GC suggested that there would be more opportunities for
gaming the more ‘complex’ the PbR arrangements. Intuitively, this seems right, although it is perhaps the lack of
transparency that is a consequence of greater complexity that is the key issue. On the other hand, it could be
argued that a ‘complex’ tariff and outcome weighting system is required to produce a sufficiently sophisticated
incentive structure to minimise ‘parking and ‘creaming’.
4. Benevolent gaming. The GC noted that while ‘gaming’ is identified with ‘unethical’ behaviour it can also have
positive motivations. For example, a provider may be incentivised to game the system because they believe this
is a necessary strategy for maintaining investment in a service for vulnerable clients. In practical terms, this
means that effective system design should be considered the primary opportunity for minimising and
eradicating ‘gaming’, and ‘policing’ the behaviour of providers as a secondary strategy (prevention is better than
cure).
5. Gaming and flexibility. The GC concluded that there may even be an argument for tolerating a degree of
‘gaming’ in PbR systems, as a mechanism for service providers to manage unintended problems with system
design and to maintain activity and business viability. 3 It may be helpful for practical reasons to give further
consideration to the possibility of distinguishing between gaming as an adaptive strategy for managing
problems and more destructive or fraudulent forms of gaming, and to design and develop calibrated responses
in the light of this distinction.
6. Level of provider control over outcome. We note that PIRU advised that ‘tying a high proportion of income to
performance is more likely to have perverse consequences when the outcome is not fully under the control of
the provider’. The GC expressed concerns about the achievability of the non-representation outcome where
service users were unable to access the ‘recovery capital’ for social reintegration and sustained recovery
(including housing, meaningful activity, pathways to employment and family support). This may be a particular
concern in the current financial climate.
3 It is, of course, difficult to say with precision what forms and levels of gaming could be potentially benevolent for (or, at least,
permissible within) PbR systems or how this would work in practical terms.
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LASARs and the assessment of clients
Background and general points
Some service users are less likely to achieve PbR outcomes than others, and will require a greater investment
of resource from providers if they are to do so. All else being equal, there is an incentive for providers to focus
disproportionately on those clients who they believe will achieve PbR outcomes and/or are ‘closest’ to
achieving them. To counter the tendency to ‘park’ some service users, PbR schemes have: (i) developed
payments for achievement of ‘interim’ outcomes, and (ii) introduced higher payments for achieving outcomes
with clients with more complex and entrenched problems.
The introduction of differential tariffs brings its own risks for gaming into the system. From a business point of
view, providers would prefer service users to be placed on high tariffs (so that they get the highest possible
payments for achieving fixed outcomes), while commissioners have an interest in placing them on lower
tariffs (to minimise the payments they make to providers and to manage budgets). The amounts that are paid
to service providers for achieving PbR outcomes will depend on the assessments of client need and
complexity carried out by LASARS. There is a rational incentive for both providers and commissioners to try to
influence the assessment process.
The LASARS will also have a key role in verifying outcomes, and therefore the process for releasing payments
to providers, and in making referrals.
Risks and opportunities
The GC considered the opportunities associated with LASARS and the assessment process and highlighted the
following issues and concerns:
• there is a particular risk of gaming where LASARS are non-independent, particularly in PbR pilots where the
LASARS function lies with the service provider (e.g., pressure on the LASARS to uprate tariffs and agree ‘false’ or
unverified outcomes);
• in their role as referrers, LASARS would also have scope to manipulate complexity ratings to advantage or
disadvantage particular providers (e.g., by referring less complex clients to a favoured provider);
• even where the LASARS function is not managed by the provider, there was a concern that where LASARS are
co-located with services, then this could reduce independence and increase the risks of gaming (although it was
acknowledged that from a practical point of view, co-location could be positive for service users, providing a
‘one stop shop’);
• service users could have an incentive to ‘play the system’ and/or to collude with LASARS in gaming activities
(e.g., service users may see an advantage in assessments that exaggerate complexity as this may result in access
to other and more intensive support);
• conversely, where LASARS are managed by commissioners there is a risk that assessment and referral decisions
could be shaped by budgetary considerations (e.g. under-estimating complexity where budgets are stretched to
reduce liability for outcome payments).
The GC notes that the PIRU note of advice on the PbR pilots focussed on the role of LASARS in its discussion of
gaming issues, specifically noting that:
• ‘The PbR system places considerable onus on having independent LASARS, yet at least two of the pilot sites have
LASARS that will not be independent of the providers, increasing the potential for the abuse of the system’;
• ‘Even independent LASARS may be influenced by providers and refer clients accordingly (e.g., “easy” clients to
struggling providers, “difficult” clients to over-performing providers’). It was suggested in the Gaming
Commission that there will be particular challenges in allocating payments fairly and appropriately where two or
more providers are working with clients with different levels of complexity).
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We note that time scales for developing the PbR pilots and resource considerations have resulted in different
approaches to LASARS provision being taken in different areas, and have been a factor in decisions to place
the LASARS with service providers in two areas. However, the GC concludes that there are significantly
greater risks of gaming where LASARS are not independent, and further consideration needs to be given to
how these services are monitored and these risks are minimised.
Responses and solutions
The GC considered what sorts of monitoring and auditing could establish whether gaming was influencing
assessment and referral decisions, it concluded that:
• It would be important to establish relevant base-line data, including for ‘case mix’ and for numbers of referrals
to particular providers and it was suggested that if there was extensive gaming on assessment and referral this
should produce a clear ‘spike’ in data trends over a relatively short time period (say, two or three months);
• It will be helpful to use available data to produce a ‘bell curve’ to show the distribution of complexity across
local treatment populations. Any subsequent shift in the bell curve would suggest inflation (or deflation) in
complexity ratings at assessment, to facilitate the detection of any potential ‘drift’ in assessments over time.
This would also provide an indication of variability and hence the size of any shift in assessments that would be
necessary to reliably indicate a change;
• There should be provision for regular and robust auditing of LASARS (particularly non-independent LASARS, and
those co-located in provider services), with provision for service user involvement in the auditing process (one
possibility was that service users could be required to sign off LASARS assessments to indicate their agreement);
• Service users should be involved through on-going systematic and independent assessment of client
satisfaction, and could also act as ‘mystery shoppers’ at LASARS, as a way of identifying poor or fraudulent
practice.
The GC identified three practical recommendations for minimising and/or eradicating this form of gaming:
• Generally, we consider it particularly high risk from a gaming perspective for the LASARS service to be managed
by service providers or commissioners, and we would recommend particularly close monitoring of PbR pilots
that have non-independent LASARS, and further consideration of any additional safeguards that could be
introduced in these areas;
• The contract setting between commissioners and LASARS will be critical in addressing the gaming issues
identified by the GC and PIRU. There should be a clear statement of the standards expected of LASARS and
service providers in their respective contracts, which could include a specific section on gaming based on the
definition provided by the Audit Commission and developed by the GC;
• Reinforcing the significance of robust contract setting, we would like to see a clear statement going forward of
the responsibility of Public Health England and local Directors of Public Health for ensuring that all PbR
commissioning and contracting in their locality is based on good practice. We also feel it is important that there
is some consideration of the relationship of the new Healthwatch arrangements with respect to the pilots.
Weighting and timing of payments
Background
The Drug and Alcohol Recovery PbR pilots are unprecedented in the range of outcomes that they incorporate
– including both ‘interim’ and ‘final’ outcomes. If they are to incentivise service providers to deliver a more
recovery-orientated approach it is important that they encourage and support a balanced approach across the
different outcome domains. It would, for example, be contrary to the intentions of the PbR pilots if the
outcome weightings were set in a way that enabled services to develop viable business models which did not
require a pro-active approach to achieving outcomes in the ‘free from drugs of dependence’ domain.
There are also issues about the timing of payments. If some payments are made immediately while others can
only be verified after a year or more, how will this affect the behaviour of providers? What are the potentials
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for gaming where the potential payments associated with working with a particular service user depend on
the time when they present or re-present to services?
These issues were also highlighted by PIRU in its discussion of gaming and related issues. PIRU advised that
data lags, particularly for measurement of long-term outcomes, expose providers (especially smaller
providers) to cash flow risks, and could lead to pilot sites loading payments onto initial outcomes, which could
undermine the overall aim of incentivising sustained recovery (although the GC would also note the
importance of including payments for ‘interim’ outcomes in view of the strong evidence base that ‘full’
recovery may not be achievable in the short or medium term for significant numbers of service users,
including many of those with the most entrenched and complex needs).
Risks and opportunities
The GC highlighted the following issues and concerns on the weighting and timing of payments:
• If long-term outcomes are not sufficiently weighted, then there is a risk that service providers will
adopt business strategies that focus on securing payments for what are perceived as ‘safer’ interim
outcomes and lose the recovery focus;
• An extreme version of this scenario envisaged weightings set in such a way that service providers could
rely on a combination of funding not tied to outcomes (in areas where payment will not be based
entirely on PbR outcomes) plus attachment fees;
• This sort of approach could incentivise services to seek to engage ‘easy to treat’ clients in large
numbers (described by one participant as ‘ambulance chasing’);
• Where a very high reward attaches to ‘planned exit’ and ‘non-representation’ there could be an
incentive to push service users forwards too quickly to maximise the ‘pool’ who could potentially
attract the high non-representation payment;
• Where service users attempt to represent to services within 12 months of a planned exit there will be
an incentive for providers to prevent them re-entering treatment until they secure the final payment
for outcome 1 (particularly where the service user attempts to re-present close to the 12 month
deadline);
• The GC considered the potential for the creation of ‘representation clinics’ that would hold service
users out of the PbR treatment services until after the 12 month deadline, perhaps providing some
treatment and condition management or involving GPs who don’t report to NDTMS. However, it was
also noted that some form of representation clinic aimed at providing crisis support to prevent lapse
turning into relapse might be a wholly appropriate intervention;
• There was a discussion in the GC about the extent to which service users representing to services
would qualify for a second attachment fee or another payment for re-achieving outcomes that had
been achieved during a previous treatment episode, and the risks that this could create an incentive to
encourage drop out and representation in some circumstances, to secure a second attachment fee or
second payment for an outcome;
• Service providers could deliberately postpone those interventions that they have the most control
over (for example, they can determine when Hepatitis B vaccination is offered and provided), as a form
of insurance to help to manage financial ‘pinch points’.
Responses and solutions
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It was noted that many of these gaming risks should be reduced or eliminated through effective setting of
tariff weightings and payment structures – e.g. by ensuring the rewards for longer-term outcomes are
sufficient to incentivise a recovery-orientated approach. Others argued that too high a weighting for these
outcomes would penalise providers disproportionately, particularly where longer-term outcomes may be
partly outside the direct control of the service provider (as they require access to other services and
resources), and could make the PbR system non-viable. This may be a particular concern during this period of
fiscal constraint.
Specific recommendations from the GC included:
• By establishing base-lines and monitoring treatment length, presentation and re-presentation rates it
should be possible to identify patterns that could indicate a possibility of gaming. This needs to include
consideration of different sub-groups within the overall population as some may be differentially
affected;
• To ensure against premature discharge of clients to maximise opportunities for outcome payments it
would be possible to incorporate independent validation of discharge decisions into contracts with
service providers (this could be a role for independent LASARS);
• Encourage the development by commissioners and service providers of post-exit ‘clinics’ and other
forms of support (for example, engagement with mutual aid) that sustain treatment gains, support
sustained recovery and reduce the risks of representation (this depends on distinguishing between
‘treatment exit’ and ‘recovery exit’) i.e. a concrete example of the non-representation outcome
providing a strong incentive to support the recovery agenda;
• It may be possible to monitor ePACT data 4 on prescribing trends in primary care to identify if GPs are
picking up ‘failures’ that ought really to be considered as representations;
• It was noted that professionals involved in assessment and referral processes should be prevented by
their professional ethics from gaming, and relevant codes of ethics could be developed to highlight
gaming issues.
Inflating outcomes to achieve payments that are not deserved
Background
Perhaps the most obvious opportunities for gaming are to manipulate outcomes data in various ways in order
to attract payments – for example, where an outcome payment depends on self-reporting by service users
there is a clear incentive to influence this process.
This issue was highlighted in the PIRU paper on PbR, which noted, in particular, that the reliance on selfreported
outcomes through TOP ‘provided opportunities for fraudulent reporting both by providers alone,
and in collaboration with service users’ – and that this was a particular issue for the health and well-being
domain.
Risks and opportunities
The GC highlighted the following issues and concerns on misrepresentation of outcomes:
4 A service which allows real time on-line analysis of the previous sixty months prescribing data held on NHS Prescription
Services' Prescribing Database.
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• Clients will not be recorded as representing to treatment where they are entering the system with
different attributers, and it would be possible in principle to conceal re-presentations through small
variations in attribution data (for example, use of different initials) – it was also pointed out that a
certain amount of variation in attribution data will occur anyway (for example, as a result of mistakes
or name changes) with implications for the pilots;
• There are a range of issues around outcomes that are measured using TOP data, given that TOP is
based on self-report (for example, there are various ways in which service users might be steered or
incentivised to improve how they rate themselves on the TOPS ‘quality of life’ scale);
• Where a service user is misusing a range of substances, there may be an incentive for the treatment
provider to limit the number recorded on first presentation. This could be done either to allow a
subsequent treatment episode to address other substances, increasing overall payments, or to reduce
the likelihood of continued usage of substances not seen as a problem by the client preventing
successful treatment payments;
• Service providers could seek to represent treatment drop outs as planned exits;
• Service users could be prescribed drugs (for example, benzodiazepines) as a replacement for a
presenting substance.
Responses and solutions
The solutions that were discussed by the GC were broadly the same as those identified in the previous section
concerning weighting and tariffs – particularly the need for robust auditing and monitoring NDTMS data to
identify any significant deviations in outcomes (for example, if there is a marked inflation in overall quality of
life ratings through TOP compared with TOP data prior to the introduction of PbR).
Additionally, in order to look at the impact of the pilot and to pick up on unintended consequences (such as
less recovery-focused treatment) it is important that things such as the number of times an individual is seen
and what interventions they are getting and the change in use of other services are also considered. This is
probably most easily considered by the evaluators.
Issues not addressed by the GC
The GC did not discuss the offending outcome in detail, in part because pilot areas are adopting cohort
approaches and modelling data was not available. We note, however, that work in the Ministry of Justice on
the development of payment by results approaches in prisons and to resettlement will be relevant. Nor was
the GC able to test the specific potential for gaming based on proposed outcome and tariff weightings, as this
information was not available from the pilot sites.
While movements to PbR will inevitably involve a process of discovery, 5 these PbR pilots are ambitious and
are markedly different from any of the other PbR pilots being undertaken, both in terms of complexity and the
timescale associated with their development and introduction. As a result, there is greater potential for
gaming alongside other risks to commissioners, providers and clients. Therefore it is vital that there is a high
level of investment in both monitoring and evaluation so that critical signs are identified early before crises
develop. This needs to extend beyond the evaluation (as the timing of this will inevitably introduce a time lag)
and probably goes beyond what the pilot sites can realistically be expected to fund and undertake alone.
5 For example see Gary Sturgess and Lauren Cumming (2010) Payment by Outcome: A Commissioner’s Toolkit. 2020 Public Services
Trust
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Given the short timescale within which the GC operated and the limitations of the information available about
the PbR models at that time, it is unlikely that all the potential gaming opportunities have been identified and
it was not possible to provide any indication of which are most likely or would be most problematic.
Nevertheless, the deliberations have highlighted a number of critical potential gaming threats and some
actions that might help mitigate these.
Some general issues relating to gaming were highlighted as particularly pertinent to this PbR model. Firstly,
the complexity associated with having multiple outcomes and multiple severity groups is unprecedented and
will increase opportunities for gaming or for the accidental introduction of perverse incentives. Secondly, it
was noted that ‘gaming’ need not necessarily be harmful, some strategies that could be viewed as gaming
may be necessary for provider survival, while others could be seen as effectively increasing efficiency. The
danger arises if the outcomes focused on or most heavily incentivised are not properly aligned with the
overall outcome required (for example, if it effectively incentivises solely methadone-prescribing without
accompanying recovery-focused activities). There is similarly a risk when the outcome does not take account
of contextual factors such that achievement of the key outcome is effectively beyond the service provider’s
control, as might be the case for the sustained recovery (representation) outcome in areas which are
particularly hardly hit by the financial problems where access to the necessary ‘recovery capital’, such as
employment and housing, may be limited.
Specific gaming opportunities were identified as occurring associated with three main areas:
• LASARS and the assessment of clients; in particular, the GC concluded that there are significantly
greater risks of gaming where LASARS are not independent and hence particular attention must be
paid to monitoring such services.
• Weighting and timing of payments for different outcomes; the considerable time lags associated with
some outcome payments may pose particular cash flow risks for providers and have a big impact on
where activity is focused, but compensating for this by weighting these outcomes more heavily may
impact on provider viability or lead to other perverse practices (eg delaying appropriate
representations).
• Misrepresenting or inflating success; the greater importance of particular outcome measures may
automatically lead to changes in reporting but, particularly for self-reported outcome measures, there
is scope for influencing what is recorded as well as outright fabrication.
In order to monitor and identify if gaming is occurring and to deter it, actions of three main types were
identified:
a) Monitoring data from NDTMS in detail (beyond just the outcomes achieved and looking at different
sub-groups of clients) to detect change from previous years. However, some change is inevitable, as
the data will have become more important and also there are likely to be on-going changes in the
types of individuals presenting to services. Triangulation with other sources of evidence or using data
from other comparable areas may be helpful for confirming anomalies.
b) Auditing processes will be essential. Robust auditing of assessments and outcomes will be important
everywhere but particularly where there are non-independent LASARS.
c) Involvement of service users in systematic, independent assessment of their views and experiences of
the services provided. The importance of the patient ‘voice’ in improving the quality of services is well
evidenced and it is important that in the delivery of the PbR pilots and the inevitable complexity of
monitoring the range of outcomes the perspective of the individual service user does not get lost.
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Their experiences may also be one of the quickest ways of identifying emerging problems with the
system.
It is important in the pilot phase that these processes are set up from the start and information monitored
frequently and regularly. Given the radical nature of this PbR model and the short time scale involved in
developing the models it is important that any potential problems are identified early and that there is
flexibility built in to permit changes to be introduced if necessary. If gaming does occur a range of adjustments
may be required. As Sturgess and Cumming (2010) indicate “Adjusting the mix of performance measures so
they accurately reflect the primary outcome sought; using measures appropriately, assessing impact and
interposing discretion where necessary; changing the intensity and diversity of incentives; and segmenting the
population differently … are among the tools commissioners can use to reduce harmful gaming”. Whatever
action is considered, the contracting process needs to permit change and a good commissioner-provider
relationship will facilitate this.
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Appendix 1
Payment by Results for Recovery
Gaming Commission - Terms of Reference
Background
The Department of Health is leading a cross-departmental project to explore how Payment by Results (PbR)
can incentivise delivery of recovery outcomes for adults who are drug or alcohol dependent. Under the pilots,
providers will no longer be paid on the basis of activity but on the outcomes they support individuals to
achieve on their recovery journey. The aim is to test whether such an approach can help more people to
break the cycle of dependence and achieve long term recovery.
The nationally-agreed outcome definitions and metrics are nearing final sign-off, and pilot sites are starting to
think about how they will weight each outcome and take into account the complexity of each client to arrive
at the price to be paid for each outcome.
Purpose of Gaming Commission
The Audit Commission report “Early lessons from payment by results” 6 identifies gaming as a key risk arising
from payment by results, where gaming is described as the deliberate manipulation of the system by
providers, outside of the agreed rules, for financial gain.
With this in mind, the Gaming Commission brings together a group of people with operational experience of
service provision as commissioners, providers and service users, to explore the possible gaming opportunities
presented by the PbR models under development, and to propose recommendations as to how such
opportunities can be minimised.
Main responsibilities
• to examine the agreed models (i.e. configuration of LASARS, prime and framework providers),
outcome definitions and metrics of the Drug and Alcohol Recovery PbR system and consider the
opportunities for:
o deterring access to treatment for those least likely to achieve outcomes;
o “parking” or delivering minimal treatment to clients least likely to achieve outcomes;
o securing unwarranted payments
o other ways of ‘gaming’ the system
• to recommend how these opportunities can be eradicated or minimised through local weighting and
pricing mechanisms, through independent assessment and audit mechanisms, or by any other means
Membership
The core membership is drawn from:
� The cross-government project team representing the following central government departments:
o Department of Health
o Ministry of Justice
o Home Office
o National Treatment Agency
� Commissioners from non-pilot areas
� Providers (with no direct interest in pilot site service provision)
� Provider representation organisations
6 Early lessons from payment by results. Audit Commission, 2005
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� Service users
The full list of members is shown in the Annex below
Reporting Structure
The Gaming Commission will report to the Co-design Group, which in turn reports to the Officials Steering
Group providing updates on progress and seeking steers where needed.
Meetings
The Gaming Commission is likely to meet for a maximum of three to four meetings.
Agenda and papers will be circulated at least three days before the meeting. Minutes and action points will
be circulated within 10 working days after the date of each meeting.
Full minutes will not be posted on the DH D&A PbR web page, as they are likely to contain information on how
best to defraud the PbR Recovery system. However, major decisions and action points will be published.
Quoracy
The meeting will be deemed quorate if there is representation from at least half the core members.
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Appendix 2: Membership of the Gaming Commission
Name Role Organisation
1. Dr Marcus
Roberts
Director of Policy DrugScope
2. Dr Nicola
Singleton
Director of Policy & Research UK Drug Policy Commission
3. Andy Wooldridge Manager Hungerford Drugs Project,
Turning Point
4. Richard Phillips Director Smart Recovery
5. Andy Stopher Manager C&I MH Trust
6. Anne McKay Commissioner Worcestershire (PbR already
in place)
7. Ben Hughes Commissioner Essex
8. Jason Gough Service User Patient Opinion (Sheffield)
9. Lucinda Owen Service User London
10. Ian Sherwood Deputy Regional Manager NTA SW Team
11. Claire Pennell Deputy Regional Manager NTA West Midlands
12. Bernie Casey Deputy Regional Manager NTA London & SE
13. Dr Mark Prunty Addictions Psychiatrist DH
14. Katie Hill Head of Policy and
Communication
eATA
15. Clive Pritchard Health Improvement Analytical
Team
DH
16. Dr Maria Hudson
Officials:
Employment and Social Policy
Researcher and Analyst
Hudson Research Limited
17. Nic Garcia Policy Advisor DH
18. Clive Henn Senior Alcohol Advisor DH
19. Mike Jones DWP
20. Michael
Wheatley
PbR Custody Commissioning NOMS
21. Jack Feintuck Payment by results - sentencing &
Rehabilitation Directorate
MoJ
22. Daniel Northam-
Jones
Cabinet Office
23. Jon Knight Head of Analysis NTA
24. Megan Jones Programme Manager NTA
ANNEX 7: How pilot sites propose to address gaming risks
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(a) Excerpt from minutes of Payment by Results Co-Design Meeting on Tuesday 28 th February
Oxfordshire
Oxfordshire are applying PbR to the recovery element of the system where the recovery service provider will be
paid an attachment fee and an outcome payment in accordance with the achievement of the initial and final
outcomes. The recovery service contract will be 100% outcome based.
IDENTIFYING AND REDUCING GAMING OPPORTUNITIES:
� Quarterly led review meetings will be held providers to review activity, outcomes and payment
� Reviewing outcome payments on a quarterly basis has been built into the recovery services contract to
safeguard both the provider and commissioner
� LASARS will carry out independent assessments for all those referred for drug/ alcohol treatment
� LASARS are independent of the recovery service and will be completing all TOPs so there is no incentive
for falsifying outcomes
� There is no incentive to park people in treatment as most outcomes payments will not be paid more
than once whilst the service user is in treatment
Stockport
REDUCING GAMING OPPORTUNITIES:
� Will have a fully independent LASARS which will consist of local authority staff
� Will provide a transparent pathway to services
� Will have both quantitative and qualitative targets
� Will audit spikes within data trends
� Will have a base contract value to help reduce TOP falsification.
� Any evidence of fraudulent behaviour will result in decommissioning
Wakefield
MITIGATING GAMING:
� There has been an agreed process in weighting and timing of payments with an 80/20 split, no
attachment fee
� Contract variations are flexible and provide the ability to amend over time – commissioners and
providers will work together to ensure the new system is fair
� Gaming review will be a standard agenda item on meetings held
� Whilst LASARS function is not independent there will be a separate audit tool in place
� NDTMS data auditing
� Only 3% has been attributed to offending as this is something outside of the provider’s control
� Any misrepresenting of success would be a breach of contract
� There would be a monitoring / audit / service user consultation conducted by a recovery champion
Enfield
� Model based on successful treatment completion
� Single data system to avoid error
� LASARS are referred to as a Assessment Care Review Team
� Two providers, one of whom is the Prime provider
� Providers are paid in full upfront with a contract failure adjustment at the end of the year. There will be
claw back if outcomes aren’t achieved
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� Sub-contracting to be undertaken by prime provider
� Prime provider has dropped mentoring service to reduce the financial risk, however there is a concern
over the duty of care
� Currently trying to establish a payment protocol around Hep B
Wigan
� Being paid out on a rolling 12 month basis, so any spikes should jump out in the data
� Payments are made at the end of each quarter which should show any TOP variance
� PbR will operate as a managed system so that when outcomes reach a certain threshold, audit will
automatically kick in
� A cohort level approach will be employed and this is seen as a reducing the gaming risk
� Reduction in the complexity groups and volume of activity and outcomes also seen as reducing gaming
risks
� Income protection, break clause and settlement are all part of the contract
Kent
Kent has a Prime provider model with the LASARS structured from an existing Care Management Team.
Service users will be assigned an overall band according to the highest level of need identified in two domains
with the individual’s needs categorised into one of the following bands: (Critical, Substantial, Moderate, Low or
No need for structured treatment)
GAMING RISKS
� Co-location, reducing independence and increase risk of gaming
� Hold back clients from re-entering treatment until such time where the 12 months has lapsed
� If possible to re-qualify for interim outcome payments there may be incentive to recycle people
� Incorrect attributors i.e. date of birth when re-entering the system, hence dual payment
� Given that TOP is rated on self reporting, payments could lead to influencing / exaggeration /
falsification to improve the ‘quality of life’ scale
� The treatment provider may limit the number of substances recorded on first presentation
MITIGATING FACTORS
� LASARS are independent from the provider
� LASARS will be co-located with CRI to provide a ‘one stop shop’ for service users. To mitigate risks the
LASARS will be rotated across sites in West Kent with a review process across the three sites
� Regular and robust auditing of LASARS assessments will take place
� Contractual clause will enable KDAAT to vary the tariff values and assessment criteria on an annual basis
to manage the budget and adjust the incentives for the provider.
� The highest reward (60% of the overall tariff) has been attached to the final payment (12 months post
successful discharge) to incentivise sustained recovery
� The provider will be paid more for helping clients with critical and complex needs
� Monitoring of re-presentation rates will also take place to identify patterns that could indicate a
possibility of gaming.
� Service users will have the option to re-refer to LASARS directly (re-presentation clinics)
� A certain amount of variation in attribution data will occur naturally. KDAAT will monitor KCC swift data
system and NTDMS to reduce risk
� Multiple Substance use would lead to a higher banding and subsequent higher tariff
� Planned exits will be spot checked by LASARS and verification will be required.
(b) Excerpt from minutes of Payment by Results Co-Design Meeting on Monday 16 th April
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Bracknell Forest
Bracknell Forest are operating a 100% model, with no upfront payment, incorporating 4 complexities with a 30%
attachment fee and a prime provider to help reduce gaming. The LASAR system will be located within the DAAT
but will be independent. An independent audit system (IAS) will be used for case management and has certain
checks and balances within it.
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