Payment by results: Challenges and conflicts for the Therapeutic Community

Abstract

Drawing upon the findings of a 31-month ethnographic study in a residential Therapeutic Community (TC) for substance use, this article sheds light on the challenges and contradictions which surround the introduction of increasingly commercial/business-orientated decisions within the alcohol and drug treatment field. The aim of this article is to critically reflect upon the implementation of an outcome-orientated policy directive, typically referred to as payment by results (PbR), in a residential rehabilitation service, and consider the implications which surround the initiative for those at the coal face of service delivery. The fundamental principles of PbR and the TC are discussed, as are the tensions and dilemmas which surround the implementation of a high-level policy directive that is fundamentally dissimilar to the theoretical ambitions and practice that takes place on the ground in a residential rehabilitation service. To conclude, the article suggests that incentives, with a clear focus on saving money rather than saving lives, provide little more than additional pressures and strains at the coal face of service delivery, transforming individual progression into a financially driven bureaucratic process. The findings not only illustrate the dehumanizing properties of outcome-based payment schemes but bring mainstream representations of effectiveness into sharp focus.