Information about the on-going pilot programme will now be published on Gov.uk.

The responsibility for the pilot programme remains with DH, with support from other government departments. To keep up to date with the pilot programme please follow us on Twitter and we will signpost links to newly published material.

• Tweet

• Tweet

One of the direct changes made to the provision of services due to the Payment by Results pilot in Wakefield was the implementation of the Wakefield Accord Recovery Centre (ARC).  ARC built on the existing Wakefield Structured Day Programme to deliver upon the Education, Training & Employment outcomes through consultation with service users, staff, commissioners and Turning Point.

The ARC project set out to achieve the locally agreed metrics for employment, training and education through three areas, each incorporated into daily service delivery. These included:

• Meaningful Activities
• In House Accredited Education
• Externally Accredited Education

Meaningful activities include in house activities in Music, Art, Healthy Lifestyles, Mindfulness and Mutual Aid. With the exception of Mutual Aid and Mindfulness, these sessions were based on the previous service delivery of the Structured Day Programme however they now included clear work schemes for session plans that service users could access, that link with their learning plans. The delivery of the Mindfulness activities required specific staff training to deliver these sessions and this was linked in with the local delivery of Complimentary Therapies. The Mutual Aid group linked in with the local Recovery Reps forum and provided an opportunity to allow service users and the ARC project to be a little more inventive with the provision of such a crucial aspect of recovery work. Alongside semi-structured group therapy sessions based on sharing recovery initiatives, ARC was also able to provide reward days that increased service user engagement and built better group dynamics. These included day trips to various locations and a sports day celebrating the 2012 London Olympics.

ARC developed the provision of In-House Accredited education programmes initially through the recruitment of a Project Worker with a PGCE qualification attached to the role. As a crucial role within the team this individual helped establish the wider timetable of activities, develop the individual learner plans for each service user, develop the in house work schemes for all sessions and ultimately deliver Accredited Education. ARC therefore liaised with Turning Points Learning and Development team to establish itself as a satellite service under the OCN and Open Awards delivering accredited units up to a Level 1 award in English, Maths and ICT. This allows service users to access these units at their own pace and build up accreditations to a nationally recognised Level 1 Award. The service also purchased licences for the BKSB (Basic Key Skills Builder) assessment and diagnostics tool which is utilised to assess and support each individual who accesses the service.

Under the Externally Accredited provision of programmes, Wakefield ARC developed links with both Northern College and a local conservation and employment project called ABLE (Andrew Barker Lepton Employment project). With Northern College, ARC developed a bespoke education programme to provide service users with key skills fundamental to the development of their recovery. This included an Introduction to Education with Northern College, Confidence Building and Self Awareness and Getting Involved in Your Community.

In partnership with the ABLE project, ARC also delivers the Merlin Roundhouse project whereby service users engage in various activities and work to construct an Iron Age roundhouse. This aspect of the project poses great benefits to recovery, teaching service users construction and conservation skills whilst delivering credits towards the ASDAN Activities Award through the completion of workbooks on site.

ARC has recently developed the Employability course delivered in house in partnership with Diverse training. As part of this course service users learn key skills around interview techniques, CV writing and also attend a one day course entitled Employability which is accredited to a nationally recognised Level 1. Service users have the option to attend specific sessions for CSCS (Construction Skills Certificate Scheme) training at ARC and then are taken to a local testing centre and have their assessment subsidised by the ARC service.

ARC continues to receive positive feedback from service users engaged in the service, equipping service users to move forward in developing their recovery capital. The service has grown to provide specific employment, training and education based outcomes for the service users in the district. PbR has given the district clear guidance in terms of service delivery and ARC is a clear demonstration of how to support service users more directly, functionally and provide clear outcomes through engagement with services.

Some of the feedback so far includes:

“I have learned so much on these courses, it is unbelievable what I have achieved so far, and I am proud of myself for doing it”

“I now have a much more well written, visually effective CV with a more professional personal profile”

“All enjoyable, team brilliant, everyone working together and brilliant atmosphere”

• Tweet

Stockport Community Drug and Alcohol Service has faced a number of challenges during the development and implementation of the drug and alcohol payment by results pilot.

Matthew Phoenix, Service Manager, explains more about the challenges and how they have addressed them.

The initial challenge was to gain a full understanding of the concept of payment by results itself. Word travels fast amongst service users and the workforce alike. It was important to avoid panic and to ensure the correct messages were sent out. Through effective consultation between commissioners, service users, and the workforce, we were able to give reassurances that PbR would enhance existing good practice within the treatment system, rather than present a threat.  

A further challenge was to ensure that the service could stay financially viable through a PbR commissioning process. A commissioning culture of dialogue and negotiation has been developed inStockportover a number of years. This helped to ensure that our concerns around financial viability could be addressed, giving us the best chance of continuing to operate. This did not divert or detract from the core principles of PbR, and meant that the pilot stayed true to the original concept of incentivisation around abstinence and recovery.

An additional challenge was the management of change. A workforce familiar with the concept of “retention in treatment” as evidence based practise, struggled initially with the revised emphasis on abstinence and successful outcomes. Service users who had become familiar with treatment systems designed around retention also displayed a reticence to engage in abstinence focussed dialogue. These issues have been addressed through changes in various aspects of service delivery, and through enhanced emphasis on existing elements of service delivery. Changes range in scale from re-designing the premises to provide a more inviting, recovery focussed atmosphere, to setting up an ex-service user employment bank for ex-service users to work in our treatment services. The short lead-in time to the introduction of PbR set the tone for the ongoing pilot. Changes have been developed and initiated at a pace which might not have been evident outside of the pilot, and traditional project design processes have been challenged.

One of the most significant challenges we faced with PbR was developing an administrative system which monitored performance in a way which would also monitor tariff payments. The system had to be responsive enough to give an up to date, accurate financial picture. If shortfalls began to accrue, a point would be reached where the service would be unable to recover. A system of weekly scrutiny and comparison of TOPS activity has proved the most effective way of tracking payments.  

PbR has had a significant impact on both the clinical and the administrative aspects of the service. Through collaborative working with commissioners and service users, the benefits are becoming evident. Abstinence and recovery have moved to the fore, butStockport’s PbR pilot recognises that for individual service users, this will be achieved over varying lengths of time. Further challenges remain, but the cultural shift which has begun suggests that these challenges will also be met successfully.

• Tweet

The CRI West Kent Recovery Services has a real focus on positive sustained outcomes for all of those using the service. It was designed to deliver services holistically and acknowledging that “treatment” as we understand it is a small part of sustained recovery.

The introduction of this service and mindset has been assisted by the fact the service has been commissioned through a “payment by results” (PbR) contract, and that payment is based on identifying and reducing risks not just around substance misuse, but other risk factors that affect the individuals, the people around them and the wider community incorporating education, training and employment, mental health, housing, safeguarding issues and criminal activities.

This should be seen as a positive from an end user point of view as it makes it fundamental that the service provision addresses all aspects of a client’s life in order to achieve payment for the provider. This has created challenges for the service without a doubt. Other agency’s agendas, resources and policies are not always aligned exclusively to our provision.

We have acknowledged and welcomed the challenge in a more assertive and collaborative way to ensure that financial risks are reduced. The PbR has clearly focused our attention on detail around the wider issues of substance misuse and sustained recovery, taking a less passive approach to reducing barriers, ensuring collaborative/joint working with other agencies where substance misuse is not their sole focus, and I have to say they have all responded and supported our delivery in a positive way for example social services, JCP’s, mental health teams and health advisors to mention just a few.

Internally the whole team have embraced a significant amount change through the TUPE process, moving to a single treatment system (which has created more efficient delivery and experience for the end user), up skilling into all areas of drug and alcohol treatment, and sustained recovery. We have always been very good in achieving positive outcomes and supporting positive change for our client group, but the challenge has been for the team to understand PbR and how to achieve and agree evidence of an outcome for payment to an independent assessor team (LASARS), which is typically new for practitioners in this field.

There have been some anomalies with PbR, for example alcohol treatment orders, drug rehabilitation orders, and how alcohol users who achieve controlled drinking within safe limits have their positive outcomes for reflected. We enjoy close collaboration with the LASARS team and commissioners and we are nearly there on intertwining PbR and treatment delivery which impacts positively for those accessing the service.

This change brings newer, greater aspiration and opportunities, for the provider and commissioners to reduce financial risks we would advise a “bedding in” period as significant culture/process/system change requires time to implement which undoubtedly has to be acknowledged.

Lee Ashmore is the Services Manager at CRI in West Kent

• Tweet

The transition to Payment by Results for Recovery has raised key challenges for commissioners and providers alike. While such challenges are inevitable in any major transformation, our experience has made us aware of the importance of managing these with sensitivity, transparency and support to ensure PbR is a successful commissioning strategy.

PbR can be viewed as either the market place achieving the outcomes required, thereby driving up recovery, or the market place failing and not receiving the income available. PbR can also be considered as a framework where risks are devolved to providers with commissioners having limited involvement in the process. However, commissioners ultimately have a responsibility and duty of care to people who require appropriate and effective services to address their drug and alcohol problems. From the outset inEnfieldwe have considered PbR as a means to drive up quality to enable as many service users as possible to achieve full recovery and reintegration. We want our service users to receive the best care and support available as we recognise the negative effects that substance misuse has upon our community.

The establishment of the Assessment and Care Review Team (ACRT our LASARS function, independent from the providers) also means that our commissioners are increasingly finding themselves in an arbitration role to ensure all aspects of the system are fair and reasonable. The importance to both commissioner and provider of sound data cannot be under-estimated when adopting PbR as a commissioning strategy.

In Enfield we have one system-wide database which we have adapted to enable outcome measurement across three of our four outcome domains. The fourth domain not included is reducing offending as that is centrally determined. However, we had under-estimated how data errors can quickly materialise, causing potential conflict between the ACRT, PbR providers and commissioners. When it comes to finances, anxiety is perfectly understandable and we have taken action to ensure problems are resolved quickly and fairly. Strong commissioning leadership has been essential here.

We remain confident that our model is pragmatic and achievable and we have the right PbR providers and ACRT to afford PbR the best opportunity for success. Early evidence of the outcomes they are achieving remains extremely pleasing and we are very grateful to the commissioners and those directly involved with patient care for their determined commitment.

• Tweet

One of the advantages of being a small unitary authority is the strength of our partnership working.  It is easy to adopt a multi agency approach when a lot of agencies are working with the same people for different reasons.  It also means that our interventions can more effective in dealing with underlying issues.

For example we have monthly panel meetings locally looking at accommodation issues.  Staff can nominate people to be discussed by this panel and can attend to advocate on their behalf.  This is particularly useful in terms of people who may need supported accommodation or require support to live independently.

One of the other local initiatives aimed at reducing re-offending is Operation Ladybird.  Targeted joint visits are made by the police and recovery facilitators to offenders who are known to be misusing drugs or alcohol.  These might be people who are in treatment but not engaging fully in the programme, people who have dropped out of treatment or people who have yet to access services.  These joint visits are aimed at increasing engagement and are not used as a putative intervention but to try and over come any obstacles there may be to people using the local services.  People will be offered outreach services for a period of time in order to build their confidence and enable them to be in a position to access the in house services when they feel ready to.

One of the other bonuses of being smaller is the co-location of the LASARS and the Prime Provider.  This means that good communication is easily facilitated and any issues can be discussed at an early stage.   Weekly case management meetings are held between the respective team leaders to discuss problematic cases, people not attending appointments, case allocations and any other issues.

• Tweet

Background

The Wigan-based Pathways to Employment, Training & Education, or “PETE”, Project was established in April 2009 as a partnership between Work Solutions and CRI. Commissioned by Wigan DAAT, its purpose is to increase opportunities for local people to strengthen their recovery and, through training, education and volunteering, enable them to compete for work in the open labour market.

It is now widely accepted that, along with a supportive relationship and stable housing, sustained employment is a fundamental aspect of long-term recovery.

In its first 3 years, a third of all people leaving the service did so either employed or in education, thus providing them with a foundation on which to build a new life outside of addiction. 

Our aims

In partnership with our Commissioners we were keen to contribute to the development of the Payment by Results pilots.  We had witnessed first hand, through our delivery of government welfare-to-work programmes, the positive impact this model can have. We viewed co-design of the programme and the agreement of local tariffs as an opportunity to review our previous practices and, with other local providers, drive change in the system to enable more people in treatment to benefit from our project. 

Challenges

The PETE project delivery model was already one focused on outcomes: people finding work, gaining qualifications, and commencing voluntary work.  Therefore the primary challenge for us was adjusting our funding model to minimise risk whilst continuously improving the service. PETE has relished the opportunity to meet the challenging PbR targets set locally and ensure that the model works as it should; delivering results for those it is here to serve – our clients.

Reflection

Since we went live with the PbR pilot we have seen the rate at which people on our project find work increase by 9% when compared with the equivalent period in 2011. We can attribute this to an increased awareness amongst the local services about what our services can offer; a revision of our assessment criteria to identify realistic goals at an earlier stage; and, in reality, a refocused effort by partner agencies to refer clients now there is a financial imperative to do so.

Since the Pilot began, people accessing our service tell us there has been a renewed urgency to embrace recovery inWigan.  This appetite for change is matched, if not exceeded, by the service users themselves.

“What have I got from coming to PETE? Well, they’ve helped me learn new skills, relearn some old ones, had a share and a laugh and rebuild my confidence and  – yes – given a kick up the backside aswell when needed. Others elsewhere have helped but you’ve done the most and I thank you the most for this because I don’t think I’d be where I am today without you.

 If this sounds like over-sentimental clap-trap to some of you – tough. Others reading this will recognise the feelings I’m trying to express and understand what I mean”

• Tweet

‘I’ve been in trying to get out of [the cycle of addiction] for 30 years, and this has been the only thing which has helped’.

Lifeline Oxfordshire was launched in April, and provides abstinence-focussed drug and alcohol recovery services tailored to the needs of service users, including group-based therapy, alternative therapies, employment and education support and training. Clients are helped to address the issues surrounding drug and alcohol use and can be referred to appropriate counselling support.

The majority of clinical service users are prescribed Methadone administered by the Clinical Recovery team, and a substantial number of service users are reducing their prescription and working towards abstinence.

The community alcohol detox process has been in place since the launch, and is able to reach service users needing an alcohol detox throughout Oxfordshire. The full time community alcohol detox support worker is able to meet one to one with detox clients, and provide a full wrap-around service to support the community detox.

‘I just needed to talk to someone as I was scared I was going to pick up again. I came to the Recovery Hub knowing that there was a group starting, and the group helped me stay clean’.

The 12-Step community rehab program celebrated its first graduation in August with four members who had successfully completed the 12 week programme. Dave Eaton, the rehab facilitator stated that

‘this has been a very successful first community rehab in Oxford. We have had an 80% success rate, and the next rehab is already full with applicants’.

‘There’s something to do here every day, which has really helped me develop a routine – it’s really good’.

There has been an increase in social activity:

The Recovery Hub celebrated the Queens’ Jubilee and their own recovery successes in June. The Hub was decorated and cakes, sandwiches, recovery groups and games provided. One service user commented

‘the centre open on Bank Holiday was really helpful and it was nice to celebrate and have some fun in a safe environment with good people’.

The Donnington Bridge Canoeing Slalom and Sprint competition saw Team Lifeline complete against five other local charities. The team was made up of seven determined service users, some of whom has never tried canoeing before. After a brief training course they soon became the firm favourites, and finished first in the overall endurance race. The day was so enjoyable that the team have decided to have regular canoeing days and have formed a fundraising group to raise the money needed to rent the equipment.

Education, Training and Employment (ETE), and community reintegration support has grown considerably with sessions targeted towards providing benefit support, CV development, employment support, volunteering options, mental health support, and training needs/support.

Six service users took up ETE opportunities, and four service users progressed into volunteering/mentorship. Furthermore, nine service users have been sign-posted to 10 local agencies, enabling joint work between the Recovery Hub and other agencies with the best possible support being offered to service users.

• Tweet

When embarking on any new and untried policy, strategy or system one must be mindful to strike the right balance between maintaining the things that are successful already whilst changing the things that are not.

In the Lincolnshire Drug and Alcohol PbR pilot it would be fair to say that we have made several radical changes to how services are delivered within the county.  From April 2012 people with drug or alcohol problems in Lincolnshire have been able to choose which one of two providers will help them get the support they feel they need.

For many years people were able to access only one main ‘pathway’ into substance misuse services. Our two main providers of substance misuse services worked together in a traditional tiered system albeit achieving notable success. Their dedication and hard word for example placed the partnership into the top quartile nationally on targets such as successful exits and Hep B vaccinations received.

Yet despite these achievements, in Lincolnshire, as with the other 7 PbR pilot sites we are now focussing on the measurable outcomes that individual people with drug or alcohol problems can achieve and rewarding providers  accordingly.

In addition to the PbR outcomes, we felt the need to ensure the success we had already achieved as a partnership was not lost. We are therefore also rewarding our providers in the first year based on the achievement of existing system wide performance targets. These so called ‘quality’ measures such as wait times, Hepatitis B vaccination rates and engagement targets will also hopefully ensure that the opportunities for gaming are reduced.

As we introduce a new system that has service user choice, provider competition and recovery at its core we have also made steps to ensure that in Lincolnshire we don’t ‘throw the baby out with the bathwater’.

• Tweet