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 with 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 2 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 2 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; and 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% confidence interval (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 with 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: Drug addiction recovery services in England that are commissioned on a payment-by-results basis tend to have lower rates of treatment initiation and completion but higher rates of in-treatment abstinence and non-injecting than other services