Perceptions of purchasing and payment mechanisms in alcohol and other drug treatment services in Australia: A qualitative study involving alcohol and other drug service providers and purchasers of treatment
Introduction and Aims. Governments across the globe invest considerable amounts in funding alcohol and other drug (AOD) treatment. Little attention however has been paid to the ways AOD service providers are chosen and how they are paid. This study sought to examine the perceptions of Australian AOD treatment purchasers and providers regarding different purchasing and payment mechanisms. Design and Methods. Qualitative interviews with AOD treatment providers and purchasers (N = 197) were undertaken across the eight Australian states/territories and the Commonwealth. Data were collated against six main AOD treatment purchasing and payment mechanisms (as identified in the literature), then an inductive, comparative analysis to assign codes was conducted, followed by interpretive analysis to explore emergent themes. Results. Five main themes were identified in relation to AOD treatment payment and purchasing mechanisms: (i) applying private sector principles to purchasing; (ii) innovation, sector stability and addressing client needs; (iii) performance monitoring and measuring outcomes; (iv) the threat to designated funding for AOD treatment; and (v) the costs and benefits of having multiple funding sources. Discussion and Conclusions. In many countries reforms are taking place in the health sector consistent with New Public Management principles. These principles, when applied to AOD treatment, have included introducing competition, output and outcomes-based funding models, standards and accountability. Purchaser and providers identified both strengths and weaknesses and highlighted the overarching concern that implementation of any (mix) of these mechanisms should always be underpinned by a client-centred and not a finance-centred approach.
Alcohol and other drug treatment commissioning and purchasing: Is it health care or social welfare?
Treatment for alcohol and other drug (AOD) problems entails health and social-welfare responses. This can be seen in the calls for integrated, holistic responses for those with AOD problems. The Australian National Drug Strategy (2017-2026) states:
'[I]n recognition of the social determinants of alcohol, tobacco and other drug problems and that the age and stage of life issues associated with substance use can result in different risks and harms require integrated, holistic and systems based partnerships. This includes partnerships between both government and non-government agencies in areas such as education, treatment and services, primary health care, justice, child protection, social welfare, fiscal policy, trade, consumer policy, road safety and employment'.
Similarly in the UK, their current Drug Strategy refers to a 'recovery system', which includes greater engagement with other health and social services such as housing, employment, children's services and mental health. Appreciation of the social determinants of health, and the precarious circumstances of many people experiencing alcohol or drug dependence, including homelessness, unemployment and poverty, serve to reinforce the importance of a comprehensive care and support system that is capable of spanning both the health and social-welfare needs of clients.
In this commentary we explore the relationship between a health or social-welfare framing of treatment, and the ways in which AOD treatment is commissioned and purchased. We focus on Australia and the UK because treatment commissioning and purchasing is specific to both time and place (for work focussed on the USA, see Ref.). The ways in which treatment is commissioned and purchased, that is the machinery of government, brings into being a frame for and understanding of what AOD treatment is, in line with a post-structural perspective.
Is health or social welfare the right question? Response to commentaries
We thank the authors of the three commentaries, and we are pleased to have stimulated debate on what we think is an important topic-health versus social welfare framing of alcohol and other drug treatment. In the original piece, we focussed this framing problem specifically around the ways in which alcohol and other drug treatment is purchased and commissioned. The overarching argument, as noted in all three commentaries, is the need for integrated co ordinated treatment across systems of care. Changes in purchasing and commissioning arrangements are attempts to establish better systems of coordinated care, where attention to the social determinants of health, and wrap-around services, better meet client needs. To phrase it more directly; how can the person who is experiencing alcohol or other drug problems be provided with what she needs at the time she needs it?
Does workforce matter? Examining the relationship between workforce characteristics and client treatment outcomes in the alcohol and other drug field
While there is a long-standing and commonly held belief that the characteristics of the alcohol and other drug (AOD) workforce can impact client treatment outcomes, the available literature to date has not been systematically reviewed.
The demand for evidence of 'what works' in relation to AOD staffing and treatment optimisation is growing, and it is therefore critical to synthesize relevant research in this field.
A systematic review was undertaken to locate peer-reviewed research articles to develop a better understanding of the relationship between workforce characteristics and client treatment outcomes.
The impact of the COVID-19 pandemic on the non-government alcohol and other drug sector: future implications
The Drug Policy Modelling Program (DPMP) at the University of New South Wales has released a report on 'The impact of the COVID-19 pandemic on the non-government alcohol and other drug sector: future implications'. NADA commissioned DPMP to undertake the study to explore the impact of the COVID-19 pandemic on it's members and provide advice on the immediate, medium and long-term actions that need to follow.
COVID-19 has demanded significant changes to funding arrangements, leadership and strategic planning, the types of care provided, and workforce requirements and support. It provides the opportunity to review all aspects of non government AOD treatment services, including the ways in which services are commissioned and funded by governments, and how services are supported, led, and delivered.
The actions resulting from the study are directed at treatment providers, NADA, and non government AOD funders. Whilst many of these actions have commenced, some are longstanding issues impacting on the sector, such as the underfunding of AOD treatment, and recruitment and retention of staff. NADA is committed to working with sector to implement the actions.
Alcohol and other drug (AOD) staffing and their workplace: examining the relationship between clinician and organisational workforce characteristics and treatment outcomes in the AOD field
While there is a long-standing and commonly held belief that the characteristics of the alcohol and other drug (AOD) workforce and workplace can impact client treatment outcomes, the available literature has not been systematically reviewed to date. Knowing which characteristics may impact treatment outcomes can help maximise workforce development in AOD services. A systematic review was undertaken, to identify studies of five clinician and organisational workforce characteristics: (1) years of clinical experience; (2) level of education/qualifications; (3) staff turnover; (4) staff-to-client ratio; and (5) professional development, and their relationship to client treatment outcome. Each study was assessed for quality using the Cochrane risk of bias tool. The search identified 1317 records; only 12 studies directly examined the relationship between clinician and organisational workforce characteristics and AOD treatment outcomes. Our analysis revealed a limited number of studies, a lack of high-quality research, and highly variable evidence regarding the relationship between clinician and organisational characteristics, and treatment outcomes. At present, there is an absence of evidence to support a strong association in any direction. Importantly, these findings illustrate the need for higher quality and larger scale research that focuses on clinician and organisational characteristics, taking into account multiple intervening and mediating factors.
Perceptions of funding and commissioning models for alcohol and other drug (AOD) treatment services in Australia: a qualitative study of service providers and policymakers
Governments across the globe invest considerable amounts in funding alcohol and other drug (AOD) treatment. While much research has focussed on the amount of funding available, value-for money, or the cost effectiveness of treatment, there has been less attention to different commissioning and payment/funding mechanisms. This study sought to examine the strengths and weaknesses of different funding and commissioning mechanisms as perceived by Australian service providers and purchasers.
Qualitative interviews with service providers and funders were conducted in groups of 3 to 10 people (N=190). Data on commissioning mechanisms were then collated against four thematic headings: competitive tendering, historical arrangements, fee-for-service/accredited providers, and third party outsourcing. Data with reference to payment/funding mechanisms were similarly collated for block grants, activity-based funding, and payment-for-outcomes.
The data shows that there is a:
1) need for a judicious approach in the use of competitive processes to maximise benefits while minimising risks
2) multiple purchasing strategies are used in a system and deliberations regarding which strategy is applied should include consideration of the relative emphasis on aspects such as service reliability versus innovation
3) funders should aim to minimise duplication and administrative burden wherever possible.
In the absence of an evidence-base, purchasers of AOD treatment are left with an apparently arbitrary set of administrative decisions regarding commissioning and payment/funding processes. This article offers guidance to service providers and funders when navigating the funding environment in Australia, and may facilitate more informed and considered AOD treatment purchasing decisions.
How vulnerable is the alcohol and other drug treatment service sector?
Many community, health and welfare services are provided on behalf of government by non-government organisations (NGOs). For alcohol and other drug treatment, NGOs provide 70% of all treatment episodes in Australia (the remaining 30% are provided by government services). But are NGOs different from their government service provider counterparts in terms of the treatment they provide, their workforce, and the way they are funded? Understanding differences between government and NGO providers is not only important to ensure that a comprehensive suite of treatment services is available and meets individual treatment needs, but to better understand the funding arrangements that provide alcohol and other drugs treatment services with security and sustainability.
This presentation will examine differences between Australian government and NGO alcohol and drug treatment providers in terms of (1) their treatment types and associated treatment settings, (2) their workforce, and (3) their procurement arrangements. We will also examine the extent to which treatment services are considered 'vulnerable'; particularly whether NGOs are more vulnerable than government providers. Understanding systematic and structural differences between these systems of care is important for future treatment planning.
Demand Study for Alcohol Treatment Services in the Northern Territory
The total social and economic costs and harms of alcohol consumption in the Northern Territory (NT) equates to $1.38 billion per year (Smith, Whetton, & d’Abbs, 2019). A comprehensive strategy is required, that includes alcohol treatment services to curb these costs. Typically, alcohol treatment services are defined as clinical interventions such as withdrawal, counselling, residential rehabilitation and pharmacotherapy. However, a broader definition would include a broader range of interventions, such as brief interventions in primary care, and social and emotional wellbeing services provided in the context of reducing alcohol consumption.
This report reflects a Demand Study of Alcohol Treatment Services in the NT. It is a mixed-methods research project examining the current NT alcohol treatment services system. It provides an assessment of how much treatment is currently provided; how much should be provided to meet current demand; and the challenges, barriers and opportunities associated with the planning and delivery of alcohol treatment services in the NT. It responds to multiple recommendations outlined in the NT Alcohol Policies and Legislation Review (Riley, 2017); and a subsequent Northern Territory Government (NTG) commitment to undertake the study in the NT Alcohol Harm Minimisation Action Plan 2018-2019 (NTG 2018). The project is modelled on two recent national demand studies. The first was completed by DPMP and involved a review of treatment service systems across Australia (Ritter et al., 2014). The second was completed by the National Drug Research Institute (NDRI) and involved a qualitative analysis of treatment services involving Aboriginal and Torres Strait Islander people (Gray et al., 2014). The research design has been adapted to meet the unique population distribution, geography and service delivery context of the NT.
This study has been led jointly by Menzies School of Health Research and the Drug Policy Modelling Program (DPMP) at the University of New South Wales, and in partnership with the Aboriginal Medical Services Alliance of the NT (AMSANT).
There were 42,871 episodes/encounters for alcohol treatment in NT in 2016/17, equating to 117 encounters every day across the NT. Aboriginal and Community Controlled Health Organisation (ACCHO) episodes represent the highest number of encounters (41%). The next highest is GP encounters (18%). Self-help also comprises a substantial amount of alcohol treatment in the NT (16%). Brief interventions provided as part of Sobering Up Shelters (SUS) represent the fourth highest number of episodes/encounters (13%). This is a signal that these settings are vital for picking up and referring people into more intensive alcohol treatment pathways.
The subsequent analysis of unmet demand shows that there is currently a relatively small gap between met and unmet demand for alcohol treatment in the NT. It also highlights some areas of additional focus. Key findings reveal:
• There is a large unmet demand for screening and brief intervention, in the order of 18,500 to 19,000 people
• The provision of alcohol treatment (as described in the DASPM care packages), estimates 6,735 people need to be treated in any one year, representing an unmet demand gap of around 2,000 people aged between 18 and 64 years.
• There are currently 158 residential rehabilitation beds provided in the NT for people with alcohol disorders. This is 15% below the modelled estimate of 187 residential rehabilitation beds.
• The level of clinical FTE predicted to meet the care as specified in DASPM is well above the current clinical FTE in the NT. This suggests that while the numbers of people being treated may be about right, the intensity and the level of care is not configured in a way that might best meet needs.
• More treatment is required to respond to mild and moderate needs.
The qualitative component provides a descriptive account of key stakeholder viewpoints from across the alcohol treatment services system. This includes a discussion about alcohol treatment types, including preventative health interventions, brief interventions, counselling, withdrawal services, day programs, residential rehabilitation services and continuing care. The perceived strengths and gaps of each are discussed. A descriptive account of the factors impacting demand; pathways into treatment; intersections with treatment referrals from the criminal justice system; a discussion about the implications of remoteness on treatment accessibility in the NT; and the need for targeted workforce development, are also included.
Are market mechanisms associated with alcohol and other drug treatment outcomes?
Background and Aims: The configuration of alcohol and other drug treatment service systems has been influenced by the uptake of market mechanisms for treatment funding and purchasing. This study measured the impact of market mechanisms for funding and purchasing alcohol and drug treatment services on client outcomes.
Design: An observational cross-sectional study, employing multi-level analysis: episodes of care data, nested within person-level data, nested within treatment site and nested within organization.
Setting and participants: One hundred and seventy-eight alcohol and other drug treatment service sites in Australia.
Measurements: Client outcome variables were length of stay and successful treatment completion. Predictor variables were competitive tendering, number of funding contracts, recurrent funding, the ratio of episodes to staff, type of professions, years of clinical experience, staff turnover and type of provider (government; non-government). Analyses controlled for drug type, type of treatment received and client characteristics.
Findings: There were no significant associations between the procurement and contracting variables and length of stay [incidence rate ratios (IRRs) ranged between 1.01 and 1.07, all P > 0.05; Bayes factors (BF) < 0.03], and inconclusive results for treatment completion [odds ratios (ORs) ranged between 1.04 and 1.15, all P > 0.05, BF = 0.51-0.63]. Having an alcohol and other drug (AOD) work-force relative to an 'other' work-force (IRR = 0.79, P = 0.021) and lower case-loads (IRR = 0.99, P = 0.047) may be associated with longer stay in treatment. Receiving services from a government compared to non-government provider may also be associated with less treatment completion (OR = 0.34, P = 0.023, BF = 2.14).
Conclusions: There appears to be no association between client outcomes and procurement and funding contract arrangements for alcohol and drug treatment services.