Does paying service providers by results improve recovery outcomes for drug misusers in treatment in England?

Aim: To compare drug recovery outcomes in commissioning areas included in a ‘payment by results’ scheme to all other areas. Design: Observational and data linkage study of the National Drug Treatment Monitoring System, Office for National Statistics mortality database, and Police National Computer criminal records, for two years before and after introduction of the scheme. Pre-post controlled comparison compared outcomes in participating versus non-participating areas following adjustment for drug use, functioning and drug treatment status. Setting: Drug services in England providing publicly-funded, structured treatment. Participants: Adults in treatment (between 2010 and 2014): 154,175 (10,716 in participating areas, 143,459 non-participating) treatment journeys in the two years before, and 148,941 (10,012 participating, 138,929 non-participating) after the introduction of the scheme. Intervention: Scheme participation, with payment to treatment providers based on patient outcomes versus all other areas. Measurements: Rate of treatment initiation; waiting time (> or <= 3 weeks); treatment completion; and re-presentation; substance use; injecting; housing status; fatal overdose; acquisitive crime. Findings: In participating areas, there were relative decreases in rates of: treatment initiation (Difference in Differences Odds Ratio (DID OR) 0.17, 95% CI 0.14,0.21); treatment completion (DID OR 0.60, 95% CI 0.53,0.67); and treatment completion without re-presentation (DID OR 0.63, 95% CI 0.52,0.77) compared to non-participating areas. Within treatment, relative abstinence (DID OR 1.50, 95% CI 1.30,1.72) and non-injecting (DID OR 1.32, 95% CI 1.10,1.59) rates were improved in participating areas. No significant changes in mortality, recorded crime, or housing status were associated with the scheme. Conclusion: This ‘payment by results’ scheme was not associated with improvements for most drug recovery outcomes. Despite being a prime marker of recovery with a high payment tariff, comparative rates of successful completion of treatment without re-presentation worsened within the scheme. However, there were relative improvements in some within-treatment outcomes.