Research_into_Young_People_Needs_and_Evaluation_of_Drug_and_Alcohol_Services_for_Young_People_in_Bir by Phit Bhwp

Research into Young Peopleâ&#x20AC;&#x2122;s Needs and Evaluation of Drug and Alcohol Services for Young People in Birmingham

Final Report

February 2003

Jane Pitcher, Elaine Arnull, Anna Clarke, Susannah Eagle, Mark Fransham, Valerie Johnston and Aikta-Reena Solanki

CONTENTS

PAGE

Executive summary 1 Introduction

v 1

1.1 1.2 1.2.1 1.2.2 1.2.3 1.2.4

The Research Study Methodology for the research Interviews with agency staff Case studies Survey of young people Interviews with young people

1 1 1 2 2 4

Young people’s attitudes, experience of drugs and alcohol and their service needs

2.1 2.1.1 2.1.2

Experience of drugs and alcohol and current use Young people’s experience of drugs and alcohol Extent of use of drugs and alcohol among young people in Birmingham Main substances used Geographical differences/locations of use Age Gender issues Ethnicity Differences between young people in mainstream education and in behavioural support Homelessness Links between different forms of substance use Relationship between risk factors and drug use Attitudes of young people in Birmingham to drugs and alcohol Attitudes to alcohol Attitudes to drugs Young people’s needs Levels of need General education and training Education and other support for problematic drug users Needs of different groups Geographical differences Gender issues Ethnicity Child protection issues: children of substance misusing parents and young people as parents Homeless young people Sexual health issues Links between drug use and crime

5 5 7

2.1.2.1 2.1.2.2 2.1.2.3 2.1.2.4 2.1.2.5 2.1.2.6 2.1.2.7 2.1.2.8 2.1.2.9 2.2 2.2.1 2.2.2 2.3 2.3.1 2.3.1.1 2.3.1.2 2.3.2 2.3.2.1 2.3.2.2 2.3.2.4 2.3.2.5 2.3.2.6 2.3.2.7 2.3.2.8

9 12 13 16 20 11 23 24 28 30 30 31 34 34 34 37 40 40 40 40 42 43 44 45

Drug, alcohol and related services to young people in Birmingham

3.1 3.1.1 3.1.2 3.1.3 3.2

Overview of services to young people Introduction Overview of services at different levels Co-ordination of services Referral processes and agencies’ knowledge of services

47 47 47 49 50

3.3 3.3.1 3.3.1.1 3.3.1.2 3.3.1.3 3.3.1.4 3.3.1.5 3.3.2

Profile of case study agencies HIAH Background HIAHâ&#x20AC;&#x2122;s current work HIAHâ&#x20AC;&#x2122;s role in relation to other services in Birmingham Areas for development Conclusion Higher Education Unit Drugs, Young People and the Community training course Aims and activities of the project The structure of the training programme Participant feedback The impact of the project Future initiatives Gaps in provision Education and training Introduction Educating children Educating Adults Educating those who work with socially excluded young people and those experiencing multiple problems Treatment and other services to young people General issues For specific groups of young people Geographical issues Homeless young people Minority ethnic groups Women Other groups General issues

54 54 54 54 55 56 57 58

Implications for future practice and recommendations

4.1 4.1.1 4.1.2 4.1.3 4.1.4 4.2 4.2.1 4.2.2 4.2.3 4.3 Appendix

Provision for young people in Birmingham Range of provision Education and training Working with vulnerable groups Involvement of communities and service users Role of Birmingham Drug Action Team Communication Involvement of local communities Co-ordination of activities Conclusion Organisations consulted during the research

75 75 75 76 77 77 77 78 79 79 80

3.3.2.1 3.3.2.2 3.3.2.3 3.3.2.4 3.3.2.5 3.4 3.4.1 3.4.1.1 3.4.1.2 2.4.1.3 3.4.1.4 3.4.2 3.4.1 3.4.2 3.4.2.1 3.4.2.2 3.4.2.3 3.4.2.4 3.4.2.5 3.4.2.6

58 59 59 60 61 62 62 62 62 64 65 66 66 69 69 70 70 72 73 74

List of tables and figures Figure 2.1: ‘How old were you when you had your first proper alcoholic drink?’ 5 Figure 2.2: ‘How often do you usually have an alcoholic drink?’ 7 Figure 2.3: Reported number of units alcohol drunk in previous 7 days 8 Figure 2.4: Types of alcohol drunk in last 7 days 9 Figure 2.5: Percentage of ‘drug users’ who have ever used these drugs 10 Figure 2.6: Users of these drugs who have taken them in the past month 11 Figure 2.7: ‘Where do you usually drink alcohol?’ 12 Figure 2.8: ‘Where do you usually take drugs?’ 13 Figure 2.9: Mean units of alcohol drunk in previous 7 days, by reported age of first alcoholic drink 16 Figure 2.10: Types of alcohol drunk in last 7 days, by gender 18 Figure 2.11: Percentage of ‘drug users’ who have ever used these drugs, by gender 19 Figure 2.12: Links between current tobacco smoking and cannabis use in the last month, for all respondents 25 Figure 2.13: Links between current tobacco smoking and cannabis use in the last month, for Year 11 respondents by gender 26 Figure 2.14: ‘Why do you drink alcohol?’ 30 Figure 2.15: ‘When you last drank alcohol, how did it make you feel?’ 30 Figure 2.16: ‘Why do you take drugs?’ 32 Figure 2.17: Young people’s attitudes towards drug-taking 33 Figure 2.18 ‘If you wanted advice on drugs or alcohol, who would you usually ask?’35 Figure 2.19: ‘In the last 12 months, have you had any lessons on these topics?’ 35 Figure 2.20: ‘Would you like more information on…?’ 36 Figure 2.21: ‘Who would you like to provide this information?’ 37

Table 2.1: Percentage of young people reporting having drunk/used alcohol, by school year 14 Table 2.2: Average no. of units of alcohol drunk in the past 7 days (amongst drinkers), by year 14 Table 2.3: Percentage of young people reporting having drunk/used alcohol/current tobacco smoking, by gender and school year 17 Table 2.4: Average no. of units of alcohol drunk in the past 7 days (amongst drinkers), by gender 18 Table 2.5: Percentage of young people reporting having drunk/used alcohol, by ethnicity 20 Table 2.6: Percentage of young people reporting having drunk/used alcohol, 22 by educational provision 22 Table 2.7 Links between different types of substance use behaviours 27

iii

Acknowledgements The research team would like to thank all the stakeholders who participated in this study, including agency staff; young people in schools, pupil referral units and YIPs who participated in the survey; and young people who participated in the interviews. Thanks are due to Karen Miller and Andrew Parker, who assisted with the fieldwork; and to Caroline Dewey and Mary Claricoats, who assisted with production of the report. Thanks also to Toby Seddon for providing comments on drafts of this report.

Executive Summary Introduction Nacro was commissioned to undertake research into young people’s support and information needs and drug and alcohol prevention and treatment services to young people in Birmingham. The research was undertaken between July 2002 and January 2003 and included interviews with agency representatives and young people and a survey of young people in a sample of schools and pupil referral units. Young people’s attitudes, experience of drugs and alcohol and their service needs Extent of substance use Similar to the national picture, the research found that a significant proportion of young people surveyed (87 per cent) had had an alcoholic drink at some point in their lives. Nearly three quarters of these had had their first drink between the ages of 10 and 13 years. Alcohol use was found to be more prevalent amongst young people than use of other drugs. Amongst the young people surveyed, drinking was fairly widespread, with more than a third stating that they drink at least once a week. This is similar to national findings. While most alcohol consumption was at a fairly low level, around 16 per cent of young people reported drinking 21 units or more in the previous week. Much drinking was concentrated around the weekend. Most popular alcoholic drinks were beer, followed closely by alcopops. Most young people appeared to drink at home, in friends’ houses or at parties. Girls were somewhat more likely to drink than were boys. Awareness of most types of drug was high amongst the young people surveyed, although the number of young people who reported having been offered drugs apart from cannabis was markedly low (59 per cent had been offered cannabis, whereas for other drugs the proportion was significantly lower). In terms of actual drug use, just over a third of young people surveyed reported ever having taken a drug of some kind (even if only once). The most common drug first taken was cannabis and this was the main drug of current choice for young people surveyed. A very small proportion of our sample had taken drugs such as crack or heroin. Stakeholders interviewed perceived that there was significant social use of drugs at weekends, although much of this did not necessarily constitute problematic use. The most popular place for young people to take drugs was outside in public, followed by friends’ houses or at parties. The survey found that young people in Year 11 were much more likely to have used drugs than those in Year 10: v

this was especially the case for girls. Young people in behavioural support were also more likely than those in mainstream provision to have taken drugs. Girls were also more likely than boys to smoke tobacco. Our survey also found that tobacco smoking and drug use were often linked, particularly cannabis use. There was perceived to be a link between homelessness and problematic drug use, particularly among rough sleepers. Hostel accommodation also appeared to be problematic, in that it often brought young people into contact with drug users. Attitudes to substance use Most young people responding to the survey described positive reasons for drinking and also attributed good feelings to their last experience of drinking. While a large number who had used drugs described positive reasons for doing so, a significant number appeared to take drugs for negative reasons such as feeling depressed or bored. Additionally, many responses to the survey indicated a prevailing anti-drugs attitude amongst young people generally, although this did not necessarily mean that they would reject friends who were taking drugs. Young peopleâ&#x20AC;&#x2122;s needs Stakeholders felt that many education and training needs are at a relatively low level, such as general education for young people and their parents about substance use and also about the dangers of different drugs. It was felt that there was more information available on drugs than on alcohol and that this should be addressed. Most young people responding to the survey cited their friends as their main source of information, although when asked who they would like to provide more information about substance use, many wanted their schools to provide it, perhaps at a more general level rather than one-to-one. What most young people interviewed described was a general need for support, combined with practical skills and advice focused on housing, training and employment. There was seen to be a high need for further training for workers in agencies dealing with excluded young people. Despite high levels of problematic drug use described by a small number of interviewees, some reported that they had not received support at crucial times in their lives. This is an issue of concern particularly around homeless people, who have high levels of need which are not currently being met. The evidence from the interviews with young people shows a link between problematic drug use and crime and the need for early intervention and ongoing support to help young people achieve a more stable lifestyle. The importance of self-help was also emphasised.

Services also need to be sensitive to the needs of different groups, particularly young people from minority ethnic communities, who currently are not seen to be accessing service provision to the same extent as their white counterparts. Differences between the needs of young men and women also need to be observed.

vii

Drug, alcohol and related services to young people in Birmingham Overview of services to young people Birmingham has a wide range of agencies working with young people, many of whom provide a service relating to drug, alcohol and substance use and prevention. These range from organisations working with young people generally, through agencies targeted at specific groups of young people, to those focusing exclusively on substance use. In this latter group, HIAH is the only service for young people aged 18 and under, whereas a number of drug and alcohol services exist for young people aged 19-24. Services are provided at each of the four HAS tiers of support1, with less provision at the intensive treatment level. The main issues raised in relation to provision of treatment were that having one agency only catering for the 18 and under age group might prove restrictive as demand increases, as similar problems may arise to those encountered with adult services, where the length of the waiting lists is seen as problematic. Co-ordination of services and referral systems Networking between agencies working with young drug users was seen to operate fairly effectively, although it was felt that information-sharing and liaison between agencies on a broader level is less effective. Lack of information on the part of agencies working with young people about the substance misuse prevention and treatment services in the city have often led to inappropriate referrals, which can prolong waiting periods. Another issue is that young people may present with a range of social or health problems and this creates difficulties for agencies when deciding where to refer. There was considerable concern at all levels about the time lag between referral and acceptance for treatment. Although HIAH does not currently have a waiting list, this was not always reflected in agency perceptions and some expressed concern about future capacity should demand increase, particularly as HIAH becomes better known. Other issues which were perceived to create problems revolved around confidentiality and consent. Gaps in provision: education and training While there is a significant amount of education aimed at young people in school, albeit sometimes of variable quality, a major gap in provision relates to young people who do not attend school. This is a particular concern for 1

Further details of these are included in section 3 of the main report. The tiers range from general education aimed at young people or those working with them to intensive treatment for problematic substance users.

viii

vulnerable young people, including those who are homeless or who are not involved in any form of education, training or support. Training is provided for agency staff working with young people, but the current courses provided by the Health Education Unit are over-subscribed and there have not been mechanisms for updating knowledge in the past. Staff working with socially excluded young people and those experiencing multiple problems, many of whom are likely to be problematic drug users, have found a need for more intensive training than that currently provided. A multi-agency approach, providing the opportunity for training at different levels and progression through those levels if required may be a way forward, with the option for updating knowledge on a regular basis. Gaps in provision: treatment and other services to young people In addition to the major problem of waiting lists for young people aged 19 and above, there were also seen to be gaps in types of provision, particularly in terms of residential rehabilitation for the younger age groups. A further problem raised was that some organisations may not be equipped to deal with the multiplicity of problems faced by many drug users and may not take a holistic approach in dealing with these young people. The transition from childrenâ&#x20AC;&#x2122;s to adult services might also be developed, to ensure a step-by-step â&#x20AC;&#x2DC;seamlessâ&#x20AC;&#x2122; multi-agency approach, catering for all the levels of potential input when a young person might need help. Concerns were also raised about longer-term aftercare following treatment, which is not currently provided. There were differing views on the appropriateness of methadone prescription, although some representatives argued that a fully structured, appropriately targeted prescribing service would be helpful in certain circumstances. There was perceived to be a lack of alcohol-related services in comparison with those aimed at drug prevention and treatment. Counselling for young people who are substance misusers was also seen as a major gap in provision. Most services are based in central Birmingham and there was perceived by many to be a need for satellite services and more detached/outreach work to reach young people on the outer estates, many of which are areas of deprivation. Certain groups of young people, particularly rough sleepers, are less likely to access services, partly because the services themselves do not facilitate access, for example by having unnecessary restrictions in place. Another group of young people who may be deterred from seeking help is women with children, who may feel afraid to disclose problems because of fear of losing their children as a result of their substance use.

Many of those interviewed felt that black and minority ethnic young people were often neglected in terms of a comprehensive needs assessment and adequate drugs services provision. Many drug treatment agencies promote their services in terms of a well-defined and restricted range of drug problems, which may deter the take-up of services by vulnerable young people. Implications for future practice While HIAH already provides specialist services for young people aged 18 and below, including complementary therapies, there is also perceived to be a more general need for continued development of holistic approach to substance misuse treatment and prevention. To counter problems of lengthy waiting lists, a longer-term strategy needs to be in place to ensure that agencies have the organisational systems and sufficient skilled staff to cope. There is also a need for a wider range of education and training to encompass different needs and to enable professional development. This requires a coordinated multi-agency approach. In addition to greater variety in training offered to staff working with young people in different settings, it is important that mainstream treatment and prevention agencies are sensitive to the needs of different groups and issues faced by them. This requires close liaison with those organisations working with vulnerable young people. The need for both early intervention and longer-term support and aftercare for problematic drugs users are issues which continue to require consideration. The importance of engaging service users and groups in the local communities in service planning and delivery is an ongoing issue which needs to be addressed. Finally, there is a clear role for Birmingham Drug Action Team in co-ordinating many activities and taking a lead in developing and improving substance misuse prevention and treatment services to young people.

Introduction

1.1

The research study

Nacro was commissioned by Birmingham Drug Action Team to undertake research in relation to young people’s support and information needs and drug and alcohol prevention and treatment services to young people in Birmingham. The research was undertaken between July 2002 and January 2003. The purpose of the research was:  To produce an overall picture of young people’s needs which would inform the development of the Young People’s Substance Misuse Plan for the city; and  To explore the extent to which current services in the city are addressing the needs of young people and to assess the gaps in provision. This was undertaken in the context of the HAS 4-tier model of prevention and treatment services for young people. A particular concern was to explore whether minority ethnic, vulnerable and hardto-reach groups have sufficient access to appropriate services.

1.2

Methodology

The research had four main components:  Semi-structured interviews with managers and staff in prevention and treatment services for young people2 and a sample of agencies which were likely to refer young people to these services;  Detailed case studies of two of these services: HIAH (the young people’s treatment service) and the Health Education Unit’s ‘Drugs, young people and the community’ course;  A survey of young people in years 10 and 11 in a sample of schools, plus a small sample of pupil referral units and youth inclusion projects; and  Semi-structured interviews with a sample of young people through different prevention and treatment services and referring agencies, to be supplemented by ‘snowballing’ techniques.

1.2.1 Interviews with agency staff Interviews were undertaken with 35 staff in agencies: 15 in prevention and treatment agencies (including those providing educational services) and 20 in agencies working with young people, including specialist agencies 2

For the purposes of the study, ‘young people’ were defined as 24 and under, with a subgroup of 18 and under to take into account the major young people’s treatment service, which catered for this age group.

working with homeless young people, young women, young offenders and those considered to be at risk of exclusion. The broad content of these was: i)

Representatives in referring and prevention agencies  Strategic issues - e.g. how the DAT's Annual Plan and plans specifically concerning young people link in with the agency's business plan or wider strategy;  Referrals - process, profile and gaps in provision, plus details of referral process to particular agencies; and  Treatment/services for young people in Birmingham and future development.

ii)

Staff in treatment agencies  Relationship between agency and the DAT (e.g. linkages to the Annual Plan, Young Person's Substance Misuse Plan);  Induction and training;  Referrals to the project;  Young people and substance misuse (including perceptions on current need and services to young people in Birmingham);  Referrals to other agencies;  Case study examples; and  Future development of services for young people.

Unfortunately it was not possible to interview any members of staff or volunteers from organisations that worked specifically with young people from minority ethnic communities. Historically this particular group of young people has been classified as a ‘hard to reach group’ and has therefore been under-researched. However when approached by our researchers it was found that some, if not many of these organisations, had been frequently approached by researchers and felt ‘consulted to death’.

1.2.2 Case studies Following these interviews, additional caseload reviews were undertaken with staff in HIAH, to get a more in-depth picture of their recent clients and work undertaken with them; and interviews undertaken with ten individuals who had recently attended the ‘Drugs, young people and the community’ training course to assess the extent to which they had found this course useful to their role and what further training they might require.

1.2.3 Survey of young people A questionnaire was designed to be used in schools, pupil referral units and youth inclusion projects3. This was largely based on questions used in 3

With years 10 and 11 pupils or excluded young people of equivalent age.

previous surveys of school children, such as the Schools Health Education Unit survey and the NCSR/NFER survey of smoking, drinking and drug use among young people. Some attitudinal questions and questions about where young people usually took drugs or drank alcohol, similar to those used in the Youth Lifestyles survey, with some questions also based on those developed by Howard Parker and colleagues, were also added to the questionnaire. Finally, the questionnaire included some new questions about sexual behaviour and young people’s advice and information needs. The aim was to get some picture of young people’s awareness of drugs and alcohol issues and the extent to which they used drugs or drank alcohol, with data being comparable with that from national sources. Ten schools in Birmingham were approached, with the aim of generating a sample of 5-6 which was representative in terms of geographical location and ethnicity. Some schools declined on the basis of other commitments and the timing of the survey4. The final sample included five schools, based in the areas of Bartley Green, Druid’s Heath, King’s Norton, Yardley and north Birmingham (Sutton Coldfield). In addition, two pupil referral units participated in the study: one based in the north-west and one in the south of the city; and one youth inclusion project also based in the east of city. The final sample thus gave fairly wide geographical coverage. The final achieved sample of young people was 281, of which 84 per cent were from mainstream schools and the remainder from pupil referral units/youth inclusion project. Questionnaires were handed out to young people in PSHE sessions by the researchers, who introduced the research and sat in while the questionnaire was completed. Teachers were not involved in administering the questionnaire, but their presence varied; some were present in the classroom whilst young people filled out the questionnaire and others left the room whilst the questionnaire was being completed. It was made clear to young people that their individual responses would not be passed on to the school. Once the questionnaire was completed, young people returned the questionnaires to the researchers in sealed envelopes. In section 2 of this report comparisons are made between the results from this small survey of Birmingham Year 10 and 11 pupils and larger scale national surveys such as the Youth Lifestyles Survey (YLS), the Schools Health Education Unit (SHEU) questionnaires and the school survey conducted on behalf of the Department of Health (DoH). Although such comparisons can be useful, it should be acknowledged that direct comparison is somewhat problematic, due to differences in approach and timing5. For example, whereas the DoH survey is supervised by independent researchers in schools, the YLS survey is completed on a laptop by young people at home. Schools volunteer themselves for the SHEU study, but the DoH survey draws a random sample of all young people in secondary schools in England. Clearly these and other 4

These unfortunately included the two schools in areas with a high minority ethnic population. This has been discussed comprehensively in Goddard, E. (2001) Evaluation of various data sources on drug use, drinking and smoking by children of secondary school age, Office for National Statistics

differences in methodology can affect the results of such surveys, and so care must be taken to consider whether differences in results are due to a genuine difference in drug and alcohol use amongst young people in Birmingham, or due to differences in the approaches to the surveys.

1.2.4 Interviews with young people Semi-structured interviews were undertaken with 14 young people6, aged between 13 and 21 (half of whom were male), primarily through agencies such as youth inclusion projects, but also with some clients of treatment agencies7. The sample includes young people from different ethnic groups.8 The interviews covered issues such as:  How they became involved with project (if with a particular project/agency);  Perceptions of the project;  Use of drugs/alcohol;  Relationship with services/treatment agencies for young drug/substance users and perceived needs;  Experience of school;  Friends/family relationships;  Health; and  Perceived impact of projects/services. As the timetable for the research was relatively short, it was not possible to reach many young people through snowballing, as this aspect of the research can take some time, particularly in terms of gaining trust of individuals and disseminating awareness of the research amongst young people. We did receive calls from some young people, however, who it transpired had heard about the research project from their friends. The majority of achieved interviews were through agencies9. The interviews reflected a range of young people, from non drug-users or those who only used drugs occasionally, to those who were or had been at the heavier end of use.

At this stage, only 13 have been transcribed. Leaflets were given out to staff in agencies and young people were encouraged to contact the research team directly, which some of them did. 8 7 white; 2 Asian British; 2 black Caribbean; 2 'mixed' (self-describer). 9 Although as is common with this kind of research, on several occasions our researchers set up appointments with young people at various sites, which the young people failed to keep. 7

Young people’s attitudes, experience of drugs and alcohol and their service needs

2.1

Experience of drugs and alcohol and current use

This section contrasts the views of agency representatives and young people, through the survey of young people in years 10 and 11 (plus excluded young people in similar age groups) and interviews with a sample of young people aged 16-24. Where possible, comparisons are also made10 with other national data, mainly from the 1998-99 Youth Lifestyle Survey11 (YLS), the 2001 survey conducted by the National Centre for Social Research and the National Foundation for Education Research12 (NCSR/NFER) and the Schools Health Education Unit data for 200013 (SHEU).

2.1.1

Young people’s experience of drugs and alcohol

Of the 281 young people responding to the survey, 87 per cent stated that they had drunk an alcoholic drink at some time in their life, a figure comparable with YLS findings. The profile of young people’s age when they had their first drink is displayed in Figure 2.1. Figure 2.1: ‘How old were you when you had your first proper alcoholic drink?14’ 25

Median value = 12 years

Percent

0 7 or less

Age at first alcoholic drink (years)

Though see caveat in 1.2.3 above. Harrington, V. (2000) Home Office Research Findings No. 125 Underage Drinking: Findings from the 1998-99 Youth Lifestyles Survey, Home Office 12 Boreham, R. and Shaw, A. (2002) Drug use, smoking and drinking among young people in England in 2001, National Statistics 13 Balding, J. (2001) Young People in 2000, Schools Health Education Unit 14 Expressed as a percentage of the number of respondents who answered this question. Five of the 244 respondents who said they had drunk alcohol did not answer this question. The median value is the value above and below which half the cases fall i.e. the middle value in an ordered array of values. 11

This shows that 74 per cent of young people who had drunk an alcoholic drink did so for the first time between the age of 10 and 13 years. The awareness of most types of drugs was high amongst the young people. At least 78 per cent of young people had heard of cannabis, amphetamines, LSD, ecstasy, poppers (amyl nitrate), heroin, cocaine, crack, solvents, magic mushrooms and tranquillisers. However there was lower awareness of methadone (57 per cent), ketamine (33 per cent) and anabolic steroids (59 per cent). This is a similar pattern to that found by the NCSR/NFER survey, except that poppers had a much lower awareness rate â&#x20AC;&#x201C; possibly because the NSCR/NFER results were averaged over Years 7 to 11, thus encompassing much younger pupils. As for previous surveys of this kind, a bogus drug, semeron, was inserted in the list of drugs in order to test reliability of responses. The proportion of young people who stated that they had heard of semeron was 15 per cent: somewhat higher than the responses to other surveys such as the ONS survey of schoolchildren. The reasons for this higher rate can only be speculated upon, but may be a result of young people discussing their responses and wishing to boast about their knowledge to friends; although discussion was discouraged and kept to the minimum possible, the practicality of conducting the survey in often cramped classroom conditions meant that this was impossible to eliminate completely15. The number of young people who reported being offered these drugs was, apart from cannabis, markedly low. While 59 per cent of young people reported being offered cannabis at some point, 29 per cent had been offered poppers, 19 per cent had been offered solvents and 17 per cent had been offered ecstasy. Following these, the most commonly offered drugs were (in order) magic mushrooms, amphetamines, cocaine, crack, LSD and heroin. Nearly 35 per cent of young people reported ever having taken a drug of some sort16, a proportion that was affected by the school year of the young person. Whilst 29 per cent of young people in Year 10 reported having taken a drug, for Year 11 the same proportion was 45 per cent. This pattern is also borne out by the NCSR/NFER data. Of the 98 respondents to our survey who stated that they had used drugs, the most common first drug was cannabis, with 90 per cent stating that this was the first drug they had taken. Some of the young people interviewed had no experience of drug use, some had had problems associated with drug use and others had tried drugs. Most had used alcohol, although not all. There were few positive messages about drug use from the young people and some strong anti- drug messages. The findings largely support the work of Parker and Aldridge 15

However only 7 respondents (2.5%) reported having been offered semeron, and none reported having taken it. 16 Just over 59 per cent stated that they had never taken any of the drugs listed, with 6 per cent of young people not responding to this question.

(1998) which suggests that even those young people who have never and who will never use drugs, have a familiarity with the names of drugs, with their existence, have friends who use drugs or know others who do and have an acceptance of drugs as part of the overall context of their lives. This it is suggested is different from the past when drug use was a more confined activity and when knowledge of certain drugs (especially Class A drugs) was very limited. The suggestion is that this change may be attributable to the increasing availability of most drugs in many parts of Britain and as a result to the increasing normalisation of drug using behaviour. This small sample of face to face interviews cannot therefore offer any concrete proof, but it is of interest that this pattern is demonstrated (see also 2.2.2 below).

2.1.2

Extent of use of drugs and alcohol among young people in Birmingham

Figure 2.2 shows that amongst the young people surveyed drinking was fairly widespread, with 39 per cent of young people stating that they drink at least once a week, and 54 per cent stating that they drink at least once a fortnight. The SHEU data presents similar findings, with 44 per cent of young people drinking once per week. Figure 2.2: â&#x20AC;&#x2DC;How often do you usually have an alcoholic drink?17â&#x20AC;&#x2122; 30

Percent

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te os

o Ab

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a ye

h ig

k ee

f'n

ee w

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The reported volume of alcohol consumption in the seven days prior to completion of the survey was highly varied (Figure 2.3). Most alcohol consumption was at a fairly low level: 42 per cent of young people had not drunk any alcohol in the preceding seven days, whilst 65 per cent had drunk six units or less. However, a significant proportion (16 per cent) reported drinking 21 units or more in the previous week18. Whilst the broad pattern is

There were 10 missing responses which were excluded from analysis; these are percentages of 234 cases who reported having drunk alcohol. 18 There are a number of extremely high values for alcohol consumption recorded in the survey which it would be imprudent to take literally; it seems likely that these values have

very similar to the SHEU findings, 57 per cent of Year 10 pupils in the SHEU survey reported no drinking in the previous 7 days, compared with 44 per cent in this survey. Also there was more large-volume drinking reported in the Birmingham survey. This may be due to a real difference between the SHEU sample and the Birmingham sample in drinking behaviour, or possibly due to the SHEU survey being administered by teachers, so encouraging under-reporting by pupils. Figure 2.3: Reported number of units alcohol drunk in previous 7 days19

Percent

0 0

4-6

7-10 11-14 15-20 21-27

28+

Units of alcohol

Amongst those young people who had drunk in the previous 7 days, the median number of units consumed was 10 units20,. Amongst this group, drinking was concentrated around the weekend, with nearly a third of the sample stating that they had last had a drink on Saturday. This corresponds with the perception of agency representatives, who felt that usage of both alcohol and drugs was similar to the national picture and related to social events at weekends. A quarter of respondents reported having taking a drug of some sort during the month prior to completing the survey, slightly higher than the NCSR/NFER figure of 20 per cent. In common with all surveys of this type, the main drug taken was cannabis, with 89 per cent of those who had taken been exaggerated. Equally however these cases are likely to indicate a high level of alcohol use, even if the exact level cannot be determined. 19 This was calculated from the number of individual drinks respondents reported having in the past 7 days e.g. if a young person reported drinking two pints of beer, their recorded total units of alcohol would be 4. This calculation largely follows that used by Balding (2001). All 281 respondents recorded a score on this variable. 20 The categories ranges (of alcohol units) used in this chart reflect those used in Balding (2001). The median value is the value above and below which half the cases fall i.e. the middle value in an ordered array of values. The mean value, which is adversely affected by exaggerated values, was 16 units.

a drug in the last month having used this. We also asked about tobacco smoking: 59 per cent of all young people reported having smoked tobacco in the past, whilst 29 per cent stated that they currently smoke tobacco. These levels of prevalence are comparable to SHEU results.

2.1.2.1

Main substances used

Agency representatives perceived that one of the most predominant drugs among young people was alcohol and this was borne out by the survey (Figure 2.4). In response to the questionnaire, the most popular forms of alcohol which young people had drunk in the 7 days prior to the survey were beer (50 per cent of young people who had had a drink in the last 7 days had drunk this), alcopops (48 per cent) and spirits (43 per cent), patterns of use which reflect those found in the 1998-99 YLS survey. The advent of alcopops was seen by some agency representatives to heighten the taste for alcohol, by making it more attractive to young people, which presented a potential danger for addiction. Figure 2.4: Types of alcohol drunk in last 7 days21 60%

Percentage

50% 40% 30% 20% 10% 0% Beer

Shandy

Wine

Martini

Spirits

Alcopops

Type of alcohol

Figure 2.5 shows the percentage of young people who had ever used a particular drug (expressed as a percentage of those young people who reported ever having used drugs).

Expressed as a percentage of 244, the number of young people who reported having ever drunk alcohol.

Figure 2.5: Percentage of ‘drug users’ who have ever used these drugs22

94%

100% 80% 60%

32%

40%

13% 12% 12% 8%

20%

ag M

LS D C Tr r an ack qu ilis er s H Am er ph oi n et am in es St er oi ds

pe So rs lv ic e m u s n ts hr oo m s C oc ai n Ec e st as y

na C an

Po p

bi s

As can be seen, cannabis is by far and away the drug of choice for young people, followed by poppers and then solvents. This pattern is similar to that reflected in Balding (2000); however the incidence of use of poppers, solvents and cocaine presented here is somewhat higher, whilst the use of amphetamines is markedly lower. These figures are inspected more closely in Figure 2.6, which shows the percentage of young people who had taken each drug in the past month, expressed as a percentage of young people who said they had ever taken it.

‘Drug users’ here is a broad term encompassing all those respondents who reported ever having used drugs, even if only once. These are percentages of 98, the number of young people who reported having ever used drugs. Missing responses were treated as ‘never used this drug’.

Figure 2.6: Users of these drugs who have taken them in the past month23

100% 80% 60% 40% 20%

LS D

St er oi ds C an na bi s H er oi n C ra ck C oc ai ne Po Am pp er ph s et am in es Ec st as Tr y an qu ilis er s M So ag lv ic en m ts us hr oo m s

This chart attempts to show the relationship between type of drug and frequency of use. It shows that as well as being the drug most young people had used, cannabis had been used recently by the vast majority of those who have ever used it. Conversely, whilst poppers were the second most commonly taken drug, this chart shows that only about half of those who had taken them had done so in the previous month. Equally, whilst magic mushrooms and solvents featured prominently in the drugs most commonly taken, here it is shown that few young people had taken these drugs in the past month. It could be that these drugs tend to be experimented with at a younger age. It is perhaps unsurprising that the most addictive drugs, heroin, crack and cocaine, featured prominently in drugs which had been taken recently. Agency representatives commented that in terms of problematic drug use, heroin use was more likely to be found among the older age groups, as was crack, which was seen as becoming increasingly prevalent in the city. Again, the perception of agency representatives was that there was significant social use of drugs such as ecstasy and cannabis at weekends, but that much of this did not necessarily constitute problematic drug use. Where it might become problematic was in cases where young people were not aware of what they were taking. For example, heroin might sometimes be mixed with cannabis, which young people would not necessarily know when they were smoking it, particularly if this was in a social situation such as a club, where there was less control over what they were given.

Respondents who had taken each drug in the past month, expressed as a percentage of young people who said they had ever taken it. Some of these figures should be approached with caution, as they are based on very small samples of young people who reported having taken that particular drug.

2.1.2.2

Geographical differences/locations of use

Contrary to perhaps popular representations of young people congregating outside to drink alcohol, the young people in our survey mostly drank inside24 – at home, friends’ homes or at parties (Figure 2.7). It should be noted, however, that the prevalence of outside drinking was much higher than found in the YLS survey – 37 per cent in the Birmingham sample compared with 11 per cent in the YLS survey. This may merit further investigation. Figure 2.7: ‘Where do you usually drink alcohol?25’ 160 140 120 100

Number of cases

80 60 40 20 0 O

er th

rs ba

ic bl pu

e in

w or

de si ut

bs Pu

es rti s Pa ub cl or os sc es Di us ho s' nd es ie Fr om 'h es iv at el

m ho At

In contrast, the most popular place for young people to use drugs was outside in public, followed by friends’ houses or at parties (Figure 2.8).

Although it must be noted that this survey was conducted during winter months – when drinking outside is less attractive. 25 This was a multiple choice question. The total number of respondents eligible to answer this question was 244.

Figure 2.8: ‘Where do you usually take drugs?26’ 80

Number of cases

0 ew r he

e in

de si ut

m So

/w bs Pu

e se el

ic bl pu

rs ba

es s rt i ub Pa cl or s s co e is D us e ho m s' ho nd ie es Fr tiv la re

er th

From the interviews with agency representatives, it appeared that the pattern of usage in Birmingham was not dissimilar to the national picture, with perceived higher usage in the inner city and areas close to the centre (e.g. Alum Rock and Nechells). It was noted by some that drug use was also problematic in some of the outer areas, for example on the ‘white working class estates’ such as Kingstanding and Castle Vale, with the links with deprivation and crime also being raised. Some interviewees felt that South Birmingham has developed particular problems with drug use. In terms of locations, again the perception was that drug use centred more widely on the club scene, particularly at weekends, but some agency representatives observed that many young people do not experience ill effects in these circumstances. The problem is that the rave and club scenes may put young people in touch with the dealers, which can lead to more problematic drug use. In part, this is also linked to the extent to which the young person him- or herself is likely to take risks. This also signals a need for more effective supervision in clubs, which is an issue which has already been recognised by the police. Most young people interviewed described their access to drugs and alcohol as being through friends, or an older sibling. All but one described use as taking place in a social atmosphere, although that might be a public place such as the street. This was particularly pertinent to young users of alcohol or cannabis.

2.1.2.3

Age

As young people get older, so their likelihood of having drunk and having taken drugs increases, as Table 2.1 illustrates.

This was a multiple choice question. The total number of respondents eligible to answer this question was 98.

Table 2.1: Percentage of young people reporting having drunk/used alcohol, by school year27 Yr 10

Yr 11

Have drunk

83.7 per cent

90.5 per cent

Have used drugs

29.1 per cent

44.9 per cent

However, as Figure 2.1 suggested earlier, most young people have their first experience with alcohol between the ages of 10 and 13, so the increase in ‘alcohol experiences’ is small between Years 10 and 11. Conversely, there is a larger difference in the proportion of young people in Years 10 and 11who have used drugs28, which replicates the pattern found in NCSR/NFER data (though the difference between Years is smaller). These findings correspond with the observations of agency representatives, who perceived that alcohol and tobacco were more likely to be taken at an early age, whereas it was rare to see young people under 11 using drugs. After this age, however, there was more likelihood that young people would start to experiment and thus usage would increase. The influence of older siblings or drug-using parents was also seen as an important factor in experimentation with drugs.

Table 2.2: Average no. of units of alcohol drunk in the past 7 days (amongst drinkers), by year29 Median30

5 per cent trimmed mean31

Yr 10

7.75

11.9

Yr 11

11.50

14.9

As a percentage of all young people in each year. Missing responses were treated as ‘have not drunk’ or ‘have not used drugs’. Sample sizes are 147 for Year 10, 126 for Year 11. 28 It should be borne in mind that the samples in each year were of different groups of young people, possibly with different characteristics and thus this might also influence the difference in patterns of drug use. A longitudinal study following the same group would be required to measure changes in drug and alcohol use according to age. 29 The average units of alcohol drunk in the past 7 days amongst those who reported drinking any alcohol in the previous 7 days. 30 The median value is the value above and below which half the cases fall i.e. the middle value in an ordered array of values. 31 The 5 per cent trimmed mean is the arithmetic mean calculated by removing the smallest 5 per cent and the largest 5 per cent of cases, thereby removing outliers which skew the value.

The table above, displaying the average number of units of alcohol drunk in the past 7 days amongst reported drinkers, shows that young people in Year 11 consumed more alcohol than those in Year 10, suggesting that consumption rises according to age. Taken together, these two tables suggest that the age around 14-16 years is a crucial time when young people may first begin to experiment with drugs other than alcohol, and increase their level of alcohol intake. Clearly this has implications for the relative timing of alcohol education and drug education, and the content of such education at different ages. There is a clear association between reported age at first alcoholic drink and the volume of alcohol drunk in the seven days prior to completing the survey (Figure 2.9), a pattern which has been found in other studies32. The large mean reported at 8 years old is due to a (presumably) exaggerated response from one individual; however the pattern remains and would probably be smoothed out over a larger sample size. In summary, in this sample, young people who reported drinking their first alcoholic drink at 9 years old or younger drank on average approximately twice as much alcohol in the previous week than other respondents.

Van Ours, J.C. (2002) CentER Discussion Paper: A pint a day is good for your pay but smoking takes the gain away, University of Tilburg (cited in Pudney, S. (2002) Home Office Research Study 253: The road to ruin? Sequences of initiation into drug use and offending by young people in Britain, Home Office)

Figure 2.9: Mean units of alcohol drunk in previous 7 days, by reported age of first alcoholic drink33

Mean units of alcohol drunk in last 7 days

0 7 or below 8

Age at first alcoholic drink (years)

2.1.2.4

Gender issues

From the survey, there was little difference between boys and girls in the age at which they first have an alcoholic drink, although boys were more likely to first drink below the age of 10 years. Looking again at the proportion of young people who reported having drunk alcohol and used drugs between Years 10 and 11, and breaking this down by gender, Table 2.3 shows some differences in drug and alcohol use between boys and girls, particularly in the older age group.

From a total of 239 respondents.

Table 2.3: Percentage of young people reporting having drunk/used alcohol/current tobacco smoking, by gender and school year34 Yr 10

Yr 11

Male

81.3%

86.5%

Female

87.3%

95.9%

Male

32.9%

38.2%

Female

23.6%

55.3%

Male

25.3%

31.1%

Female

21.8%

40.8%

Have drunk

Have used drugs

Currently smoke tobacco

This shows, as 2.1.2.3 above, that the proportion of young people who had drunk alcohol in Year 11 was slightly higher than that for Year 10. However it shows that the difference in proportions of young people who had used drugs between Years 10 and 11 is almost entirely attributable to the female population. This snapshot suggests that boys are more likely to have first used drugs at a younger age, but girls tend to overtake them in proportion by Year 11, a pattern which is replicated in tobacco use. The NCSR/NFER study reports that boys are more likely to have taken drugs than girls; however, their data are averaged over Years 7 to 11, and may be hiding a pattern which is similar to that shown here. The NCSR/NFER study does show similar findings for tobacco use, and notes that surveys have consistently shown girls to be smoking more than boys since the early 1980s. Without following these behaviours through further age groups or undertaking a longitudinal study it is impossible to see how this pattern continues through additional years. The above does suggest, however, that it is particularly important to target girls for drugs education at this age. As displayed above, the proportion of boys who had drunk alcohol is lower than the proportion of girls, and this is reflected in the reported number of units of alcohol drunk in the past seven days. Whilst more boys than girls reported having drunk no alcohol in the seven days prior to completing the 34

Sample sizes are Yr 10 male 91, Yr 10 female 55, Yr 11 male 74 and Yr 11 female 49. Missing responses were treated as â&#x20AC;&#x2DC;have not drunk/used drugs/do not currently smokeâ&#x20AC;&#x2122;.

survey, the average number of units drunk was reported as higher for male drinkers than female drinkers. This is displayed in Table 2.4.

Table 2.4: Average no. of units of alcohol drunk in the past 7 days (amongst drinkers), by gender Median35

5 per cent trimmed mean36

Male

11.50

15.4

Female

8.25

10.5

The differences between types of alcohol drunk by boys and girls are, perhaps, those that would be expected by examining stereotyped drinkers of particular beverages: boys drink more beer, and girls drink more wine and alcopops (Figure 2.10). This replicates the pattern in SHEU data. Figure 2.10: Types of alcohol drunk in last 7 days, by gender37

90.0% 80.0% 70.0% 60.0% 50.0%

Boys

40.0%

Girls

30.0% 20.0% 10.0% 0.0% Beer

Shandy

Wine

Martini

Spirits

Alcopops

There are also some differences between the types of drugs used by boys and girls38, which are summarised in Figure 2.11.

See previous footnotes. See previous footnote. 37 The number of respondents who drank particular drinks, expressed as a percentage of boys (93) and girls (64) who said that they had drunk alcohol in the past week. Missing responses were treated as â&#x20AC;&#x2DC;did not drink this type of alcoholâ&#x20AC;&#x2122;. 38 These figures must be treated with some caution however, as they are based on small samples of about 30 girls and 30 boys. 36

Figure 2.11: Percentage of ‘drug users’ who have ever used these drugs, by gender39

100.0% 80.0% 60.0%

Boys Girls

40.0% 20.0%

LS D C Tr r an ack qu ilis er s Am H e ro ph in et am in e St s er oi ds

C an na bi Po s pp er M So s ag ic lv en m us ts hr oo m s C oc ai ne Ec st as y

0.0%

Figure 2.11 shows greater use of cannabis, solvents and heroin amongst drug-using girls than drug-using boys, and greater use of amphetamines, poppers and ecstasy amongst boys. The most striking difference is clearly the much more prevalent use of solvents amongst girls than boys: this pattern also shows in SHEU data, though less strongly. It could tentatively be suggested (though a bigger sample would be needed to conclude this definitively) that boys are somewhat more likely than girls to try drugs other than cannabis. This corresponds with the perception among some agency representatives that problematic drug use is proportionately high among young (white) males compared with females. Agency representatives also commented on issues relating to gender and drug use. For example, the connection between sex working and drug use was observed by some, with drug dependency seen as keeping young women on the streets. It’s a big problem [among sex workers]. I think the economic thing is the main thing with crack and drugs like that. Because the dependency, as soon as you have a shot, you want another one. The dependency is quick. If we think about a young person, she will say, you know, she’s spending £200, £100 a day. I mean, there’s a very quick turnover, she had to make her money quick for her dependency. (Worker in voluntary organisation).

‘Drug users’ here is a broad term encompassing all those respondents who reported ever having used drugs, even if only once. The sample sizes for these two groups are 57 boys and 39 girls. Missing responses were treated as ‘never used this drug’.

2.1.2.5

Ethnicity

A particularly important shortcoming in the sample which we obtained from conducting the school survey is in the representation of non-white ethnic groups, particularly from the Asian community in Birmingham40. This resulted from the non-participation of schools in predominantly Asian areas which were approached. As a result, the breakdown presented below is based on small numbers of respondents from non-white ethnic backgrounds, and as such should be treated with some caution.

Table 2.5: Percentage of young people reporting having drunk/used alcohol, by ethnicity41 White (n=223)

Asian/Asian British (n=22)

Black/Black British (n=14)

Mixed (n=12)

Have drunk

91.5%

45.5%

92.9%

75.0%

Have used drugs

32.3%

36.4%

57.1%

33.3%

There are two striking figures in this table: that the level of drinking amongst Asian young people in our sample was much lower than that amongst young people from other ethnic backgrounds; and that the level of drug use amongst black young people in our sample was markedly higher than young people from other ethnic backgrounds. The former might be expected due to religious and cultural norms towards alcohol in the Asian, particularly Muslim community, and is a pattern which can also be seen in the NCSR/NFER and YLS data. However, contrary to the findings reported above, the NCSR/NFER data shows that the prevalence of drug use amongst black pupils is the same as that amongst white pupils. Having noted the small sample sizes, it would be unwise to draw conclusions without studying larger numbers. Due to the small samples here, it was not possible to present analysis according to main drugs used, but in response to the question on first drug taken it would appear that black young people were more likely than white young people to have taken cannabis as their first drug. There were few other differences in our sample in the types of drugs used by white respondents and other respondents, with the exception that white

From a sample total of 281, 22 (7.8%) declared Asian ethnicity and 14 (5.0%) reported Black ethnicity. 41 Sample sizes are white 223, other 55. Missing responses were treated as â&#x20AC;&#x2DC;have not drunk/used drugsâ&#x20AC;&#x2122;.

young people were more likely to have used ecstasy, magic mushrooms and solvents. Qualitative information from agency staff regarding the prevalence of illicit drug use and alcohol use among minority ethnic communities in Birmingham was piecemeal. As mentioned earlier very few if any staff representatives who worked primarily with this client group were able to participate fully with this research and further research would be required to investigate levels of drug misuse among minority ethnic communities within the research area. That said, three agency representatives commented upon drug use amongst the minority ethnic communities. One youth worker suggested that he had seen a three per cent increase in the use of crack cocaine during the last six months, most notably amongst young people from ‘minority ethnic communities’ aged between 12 and 13 years. Another representative reported differences in drugs used by ‘White’ and ‘Black and minority ethnic’ groups. Contrary to national data, it was believed that the vast majority of crack users in Birmingham were black and the young white population was more likely to be dependent on heroin: I mean heroin is more a young white person’s drug. You’ve got just as high a problem with crack which is a young black people’s drug. A staff member from a treatment agency recounted how a significant number of young people generally were using heroin as their primary drug of choice and suggested that this was not least as a result of its price and availability over the recent months. She went on to report how she had heard from service users that heroin ‘sold in Birmingham was the cheapest in the country’. The extent of drug use was also deemed to be linked to deprivation as one agency representative from an educational organisation commented. The interview respondent asserted how wide spread drug use was no longer restricted to the inner city but: …we’re finding more on the large, predominantly white working class council estates…It does seem to be those poor white areas.

2.1.2.6

Differences between young people in mainstream education and behavioural support

There are some considerable differences between young people in mainstream education and young people in educational behavioural support services, especially in terms of drug use. Table 2.6 displays the proportion of young people who declared having drunk alcohol and used drugs, by type of educational provision.

Table 2.6: Percentage of young people reporting having drunk/used alcohol, by educational provision42 Mainstream

Behavioural support

Have drunk

86.9%

90.3%

Have used drugs

31.6%

54.8%

Whilst the difference in the proportions of young people who had drunk alcohol is small, the difference in the number of young people who had used drugs is striking, particularly so when one considers that the majority of young people (73 per cent in our sample) in behavioural support services were in Year 10. This is due to the policy of the behavioural support service to provide alternative provision, in the form of work placements and college training courses, to excluded pupils from Year 11. In section 2.1.2.3 it was shown that there is a likely increase in young peopleâ&#x20AC;&#x2122;s use of drugs between Years 10 and 11, and thus it might otherwise be supposed that, given their younger age profile, the proportion of behavioural support pupils who had used drugs would be lower than mainstream pupils. The difference in proportions who reported using a drug in the month prior to completing the study presents an even starker picture: 18.6 per cent of all mainstream pupils declared this, compared to 45.2 per cent of all young people in behavioural support provision43. This pattern was also found in a Home Office study which used the 1998-99 YLS data to investigate drug use by vulnerable young people44. Whilst there was little difference in the reported age of first alcoholic drink between the two groups, the young people in behavioural support reported a greater number of units of alcohol consumed in the past 7 days45: amongst the drinkers, the median46 was 15 units for behaviour support, compared with 10 units amongst mainstream pupils. The greater prevalence of drug and alcohol use amongst young people who are excluded from mainstream education provision begs questions about the levels of pastoral care provided outside a mainstream educational setting, particularly for Year 11 pupils, who are more likely to be in work placements 42

Sample sizes are mainstream 237, behavioural support 31. Missing responses were treated as â&#x20AC;&#x2DC;have not drunk/used drugsâ&#x20AC;&#x2122; 43 These differences are even more striking when it is taken into account that the young people in behavioural support services completed the questionnaire in the more private surroundings of small classes. There was markedly less opportunity for boasting and exaggerating answers than was the case in large mainstream education classes. 44 Goulden, C. and Sondhi, A.(2001) Home Office Findings No. 152 Drug use by vulnerable young people: results from the 1998/99 Youth Lifestyles Survey, Home Office 45 However the proportions of young people who reported drinking no alcohol in the previous week were about equal. 46 See previous footnotes.

or on college courses, where they may be less likely to receive the additional support required.

2.1.2.7

Homelessness

There was clearly perceived to be a link between homelessness and problematic drug use, particularly among rough sleepers. According to one representative from a voluntary organisation, around 75 per cent of rough sleepers were substance users, with heroin being the main drug used. This corresponds to findings from national research studies. A significant proportion of homeless people also have mental health issues, which raises the issue of dual diagnosis needs. Eight of the young people we interviewed had disrupted family relationships and had had to leave the parental or grandparents’ home. This forced them into temporary accommodation. Hostel accommodation appeared particularly problematic, for whilst it might offer the young people other forms of support, it also brought them into close daily proximity with drug users. This proximity was described by drug users and non-drug users as difficult and as bringing added pressure: 'Cos its hard like living in a place like this when you've been on drugs for so long..and then you are clean..because if you get those people coming in and out like taking drugs. (Male aged 20 years). Interviewer: Do you remember the first time you were offered anything? Respondent: When I was living in the hostel…It was the first time I'd seen people taking drugs. I was like 'No, no too scared, don't want it’. (Female aged 18 years) Oswin Baker (2002) highlights the problematic inter-relationship between unstable housing, hostel and B&B living and drug use.47 He discusses the research which suggests that those in unstable accommodation or who are effectively homeless are more likely to use heroin and cannabis. What the interviews with the young people would suggest is that there is not a straightforward causal link between homelessness and drug misuse, but a complex one. What Baker’s article and this research would suggest however is that there is a need to more effectively target drug prevention, advice and treatment at a range of homeless provision.

Oswin Baker (2002) ‘Yes, but it all depends what you mean by homeless’. Druglink Sept/Oct DrugScope

2.1.2.8

Links between different forms of substance use

This section briefly explores some of the links between the different forms of substance use which were investigated in the school survey. It should be noted that any associations reported here between different behaviours cannot be used to imply that one behaviour causes another. Whilst it is possible in principle to disentangle such causal links48, it requires advanced statistical manipulation of larger datasets which is beyond the scope of this study. In 2.1.2.4 it was found that there was a higher prevalence of both smoking and drug use amongst Year 10 males than females, a pattern which was reversed in Year 11. This suggests a link between smoking and drug use, and, given that it is by far the most commonly used drug, a more specific link between smoking and cannabis use. This is an intuitively appealing link given the fact that cannabis is usually smoked. Therefore it might be supposed that the higher prevalence of drug use amongst Year 11 females be associated solely with the fact that more Year 11 females smoke than Year 11 males, a pattern which has been widely reported in national data. Figure 2.12 shows the proportions of all respondents who declared that they did or did not currently smoke tobacco and the proportions of these two groups who reported using cannabis in the month prior to completing the survey. It shows a strong association between tobacco smoking and recent cannabis use: whilst 7.5 per cent of non-smokers used cannabis in the month prior to the survey, the figure was 65.9 per cent amongst smokers. Therefore, amongst this sample, a smoker was over eight times more likely to have used cannabis in the last month than a non-smoker.

See Pudney, S. (2002) Home Office Research Study 253: The road to ruin? Sequences of initiation into drug use and offending by young people in Britain, Home Office

Figure 2.12: Links between current tobacco smoking and cannabis use in the last month, for all respondents Per cent Smoke tobacco 29.2

65.9

All pupils

Used cannabis last month

70.8

Donâ&#x20AC;&#x2122;t smoke tobacco

7.5

However, this phenomenon does not entirely explain the difference in prevalence of drug use amongst Year 11 males and females. Figure 2.13 breaks down the above statistics into the same proportions for Year 11 males and Year 11 females. It shows that whilst Year 11 females are more likely than Year 11 males to smoke tobacco, Year 11 smoking females are also more likely than Year 11 smoking males to have used cannabis in the last month: whilst 56.5 per cent of male smokers reported using cannabis in the last month, the proportion was 75.0 per cent for female smokers.

Figure 2.13: Links between current tobacco smoking and cannabis use in the last month, for Year 11 respondents by gender

Per cent

Smoke tobacco 31.1

56.6

Used cannabis last month

Boys Yr 11 68.9

40.8

Don’t smoke tobacco

Smoke tobacco

9.8

75.0

Girls Yr 11

Used cannabis last month 59.2 Don’t smoke tobacco

6.9

Thus there is a stronger association between smoking and cannabis use for girls than there is for boys at this age. Table 2.7 summarises the links between different types of reported behaviour amongst this sample. The rows are split into five dichotomous variables which represent greater and lesser extents of substance use; the columns show the percentages of each of these groups who reported additional ‘greater substance use’ behaviours.

Table 2.7 Links between different types of substance use behaviours49

Alc. ď&#x201A;Ł 10 yrs old

Vol. Alc. > 20 units/wk

Used drugs ever

Drugs last mth

Smoke now (n = 82)

30.6 per cent

32.9 per cent

76.8 per cent

67.1 per cent

Donâ&#x20AC;&#x2122;t smoke now (n = 199)

19.6 per cent

9.5 per cent

17.6 per cent

8.0 per cent

39.1 per cent

29.7 per cent

46.9 per cent

45.3 per cent

26.3 per cent

12.4 per cent

31.3 per cent

19.4 per cent

Smoke now

Alcohol ď&#x201A;Ł 10 years old (n = 64) Alcohol > 10 years old (n = 213)

Vol. alc. < 20 units/wk (n = 235)

Vol. alc. > 20 units/wk (n = 46)

Used drugs ever (n = 98)

Not used drugs (n = 183)

Used drugs last month (n = 71)

No drugs last month (n = 210)

58.7 per cent

41.3 per cent

58.7 per cent

56.5 per cent

23.4 per cent

19.1 per cent

30.2 per cent

19.1 per cent

64.3 per cent

30.6 per cent

27.6 per cent

64.3 per cent

10.4 per cent

18.6 per cent

10.4 per cent

0.0 per cent

77.5 per cent

40.8 per cent

36.6 per cent

100.0 per cent

12.9 per cent

16.7 per cent

9.5 per cent

16.7 per cent

For example, looking at the last column of the first two rows, the association already investigated above emerges again. Amongst the 82 young people who reported current tobacco smoking, 67.1 per cent had used drugs in the 49

Top to bottom, the rows of this table represent: those young people who reported current tobacco use, and those who did not; those who reported drinking their first alcoholic drink at or younger than 10 years old, and those who drank at an older age or had never drunk; those who reported drinking more than 20 units of alcohol in the previous 7 days, and those who drank less; those young people who had ever used drugs, and those who had not; and those who had used drugs in the last month, and those who had not. The number of young people in each category is also reported. The columns represent the respective categories of greater substance use.

last month; and amongst the 199 young people who reported no current tobacco smoking, only 8.0 per cent had used drugs in the last month. Broadly speaking, this table reflects the findings of other studies that substance use behaviours are highly interrelated. This shows that young people who fall into any of the â&#x20AC;&#x2DC;greater substance useâ&#x20AC;&#x2122; categories above are more likely than other young people to also register in the other high substance use indicators. For example, smokers are more likely than nonsmokers to have first drunk at or younger than 10 years old, more likely to report having drunk more than 20 units of alcohol in the past 7 days, more likely to have ever used drugs and more likely to have used drugs in the last month. As well as the link between smoking and drug use reported above, there is an association between alcohol use and drug use. Those young people who first drank at 10 years or younger are one-and-a-half times more likely than others to have ever used drugs, and those who reported drinking more than 20 units in the past 7 days are almost twice as likely as others to have ever used drugs. What is perhaps more interesting is the link between alcohol use and the likelihood of recent drug use. Amongst those who report drinking at or before 10 years old and those who report drinking more than 20 units in the past week, almost all who report having ever used drugs also report having used drugs in the last month. In the â&#x20AC;&#x2DC;lower useâ&#x20AC;&#x2122; categories only around twothirds of young people who have used drugs have used them in the past month. The pattern is similar amongst smokers. In summary, in this sample smokers, early-onset drinkers and high-volume drinkers who had ever used drugs were highly likely to have used drugs in the past month.

2.1.2.9

Relationship between risk factors and drug use

Family problems leading to homelessness or the need for temporary accommodation were discussed in section 2.1.2.7 above. The family difficulties, where mentioned in the interviews with young people, appeared to relate to arguments amongst family members. This was often related to the young person's drug use or criminal activity. Many of the interviewees appeared to have sympathy with their families' hostility to their drug use or their inability to cope with the effects of it on the family any longer. One young man had been in local authority care all of his life and although he had established contact with his sister they had become estranged. Family breakdown also appeared significant within the group and mothers, siblings and grandmothers were the most frequently mentioned members of family. Of the five who did not report family difficulties there was little evidence of any of the young people spending time with their families engaged in joint activities. This group included most of the younger interviewees.50 This 50

One thirteen year old; two 15 year olds; a seventeen year old and eighteen year old.

entire group reported alcohol use and some cannabis use, but only one person had tried other drugs. All of the young people reported school difficulties and many had experienced suspension or exclusion. The difficulties at school were most often reported as the interviewee getting into fights, either with other children or staff. This applied to females and males. Other young people appear to have become disaffected and to have drifted away. The latter is particularly pertinent where Class A drug use became a feature in their mid teens (at about age 15 years). Only one young person (the thirteen year old) anticipated that their family would disapprove of their alcohol use and that is possibly related to their age as no other particular reason was cited. A number of respondents did discuss alcohol and cannabis use within their families and this was particularly related to siblings, but included parents. Some young people referred to family members or those close to them who had also experienced problems with drug or alcohol use. What the interviews indicate overall is that the areas of common vulnerability as highlighted by DrugScope (1999)51 are present in this group of interviewees who were a sample drawn largely from contact with YIP programmes, a voluntary organisation working with the homeless and drug agencies. These are all groups of young people therefore that would be seen as vulnerable. The areas highlighted by DrugScope include:  Difficulties with school, training or employment;  Housing difficulties;  Living with families who use drugs;  Living in a family where there was violent behaviour;  Experience of physical or sexual abuse;  Becoming pregnant or responsible for a pregnancy and/ or a parent;  Experiencing bereavement. Many of the issues were raised by at least one respondent. What is important therefore is that although the interviewees included a small number of young people who would reportedly never use drugs, all fourteen respondents had drunk alcohol and most had used cannabis and all were aware of the availability of a variety of drugs. All of the young people reported having tried alcohol by the age of 13 years. The concern that this raises is that it highlights some of the issues raised by Parker et al in 1998. They suggested that in terms of personality young drug users are more likely to be risk-takers and that when this is combined with poor school performance and attendance, light parental supervision, social exclusion such as poverty then 'you have a basic identikit of a young heroin user'52.

DrugScope & The Children’s Legal Centre 1999 Young People and Drugs – Policy Guidance for interventions pp36. 52 Parker, Bury & Eggington 1998 'New Heroin Outbreaks amongst young people in England and Wales' Crime Detection and Prevention Series Paper 92, Police research Group Pp45

What is important to be aware of therefore is that whilst some of our small sample of young people were not drug users, the life circumstances they described and the proximity to drug use which they highlighted, together increase the likelihood of going on to try a wider range of drugs and experience potential problems. Some of the sample had already developed serious problems with their drug and alcohol use. Of those who described their drug use as problematic all cited those drugs problems as leading them into acquisitive crime in order to support their drug use. The fact that many of them were engaged with projects focusing on diversion or prevention is an important factor which it is hoped would help them to work towards other outcomes.

2.2

Attitudes of young people in Birmingham to drugs and alcohol

2.2.1 Attitudes to alcohol Most young people responding to the survey who had ever had an alcoholic drink described positive reasons for drinking – because it’s fun, helps in relaxation, to be sociable, and to celebrate on special occasions (Figure 2.14). A significant number also described alcohol as something which helps them feel more confident. Figure 2.14: ‘Why do you drink alcohol?53’

Additionally, most young people attributed good feelings to their last 100 experience of drinking – they felt happy, had a good time, or relaxed with friends. Relatively few young people described their last experience of 80 drinking alcohol in negative terms. This pattern is not affected by age or sex of respondent, and replicates the findings from the YLS data.

Number of cases

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Figure 2.15: ‘When you last drank alcohol, how did it make you feel?’54

Number of cases

100

This question could be answered by the 244 young people who reported having drunk alcohol. It was a multiple choice question, so the responses total more than the number of respondents. 54 See previous footnote. 0 er ov ng ha s g ad in H th ot rg Fo y gr An py ap nh ty U il gu lt Fe ck si rs lt ge Fe he c an da /str ea w H ds ed en ax /fri el w e R ed im ax d t el o R go a ad py ap

Most of the young people interviewed described drug or alcohol use as making them feel 'chilled'. It was most often associated therefore with relaxing in the company of friends in order to have a good time, which might mean just sitting around or might mean boosting social confidence so that you would get up to dance: the latter was referred to by two young men.

2.2.2 Attitudes to drugs A large number of the young people who had used drugs described positive reasons for having done so – to be sociable with their friends, or because they like the feeling (this was included in the ‘other’ category). However a significant number described their reasons for using drugs as either ‘because I get depressed or worried’ or ‘because I am bored’. These responses figured much more prominently in reasons for using drugs than they do for drinking alcohol.

Figure 2.16: ‘Why do you take drugs?55’

Number of cases

10 Prefer to alcohol

Get depressed

Sociable w/friends

Other I am bored

Figure 2.17 shows young people’s responses to a number of statements about drugs. It indicates an interesting complexity in young people’s attitudes to drugs. Whilst many responses indicate a prevailing anti-drugs attitude amongst young people (especially in responses to the statements ‘people who live drugs live life to its fullest’, ‘most people who take drugs will eventually have problems’, ‘taking drugs is just a bit of fun’ and ‘taking drugs is always dangerous’), this is not the whole story. Many young people observed whilst completing the survey that they felt they could not comment about all drugs in the same way, cannabis being most often singled out as different from other drugs. This is borne out in the results, which shows a significant proportion (approximately 45 per cent) of young people agreeing that cannabis should be legalised. Additionally, the NCSR/NFER survey generated results which suggest that young people see cannabis use as more acceptable than other forms of illegal drug use. Most young people disagreed with the statement ‘I could no longer respect someone who I found out took drugs’ and this is reinforced by the fact that, despite the aforementioned prevailing anti-drugs attitude, there was no clear pattern of responses to ‘most of my close friends take drugs’. This indicates that although most young people feel that they do not want to take drugs, they would not ostracize someone else who did; indeed, some young people, in commenting on gaps in information, asked how they could support someone else who had problematic drug use. Again, as already suggested in 2.1.1, this supports the normalisation thesis of Parker and Aldridge (1998) that young people accept drugs as part of the overall context of their lives. Furthermore, over subsequent years of data collection the NCSR/NFER survey shows an increased tolerance of drug users 55

This was a multiple response question, and therefore the total number of cases will add up to more than the number of respondents. The number of respondents who could have answered this question was 98.

amongst young people, despite a prevailing anti-drugs attitude similar to that found here. Finally, there was a good deal of agreement with the statement ‘older people worry too much about the dangers of drugs’. This is perhaps explained by a common complaint in discussions with pupils that too much emphasis was put on drugs education, again reinforced by the large proportion of young people who stated that they did not want any more information about drugs (see section 2.3.1.1 below). Figure 2.17: Young people’s attitudes towards drug-taking56

Most people who take drugs will eventually have problems Taking drugs is just a bit of fun

Cannabis should be made legal People who take drugs have mostly good experiences with drugs Older people worry too much about the dangers of drugs Taking drugs is morally wrong

Strongly agree Agree

I could no longer respect someone who I found out took drugs

Neither Disagree Strongly disagree

People who take drugs live life to its fullest

Most of my close friends take drugs

Taking drugs is always dangerous

I have a negative attitude towards drugs

Taking drugs always leads to addiction.

Taking drugs is OK if it makes you feel good 0%

20%

40%

60%

80%

100%

Two of the young men interviewed were non-drug users who held strong anti-drugs views although they had been offered drugs and knew drug users. One of them also talked about the power of drug education at school: 56

Note that these questions were drawn from those developed by Howard Parker and colleagues.

Respondent: Yeah. I know about drugs and alcohol now. I know a lot about it. Interviewer: Is that from your own experience? Respondent: No, I’ve just like, like I just, I’ve done education on it, so I know about it. The young man was nineteen years old and was describing drug education which occurred whilst he was in contact with the probation service. Later in the interview he described this education in more detail. Interviewer: In what way do you think it has been helpful. Respondent: Because you learn what to do like, just say not to put your drink down and like don’t take drinks off someone you don’t know, all that. What it can do to your body, your lungs and all that. The young man in this interview appeared to describe many life experiences which relate to vulnerability criteria. He was also someone who was often seen to have missed mainstream school drug education programmes. His comments are therefore valuable in describing why drug education programmes might also be of use at different points in a drug prevention programme. He also accurately described many of the key areas which drug education programmes seek to target: for example health awareness, self-efficacy and prevention strategies. The value of education and training is discussed in later sections.

2.3

Young people’s needs

2.3.1 Levels of need 2.3.1.1

General education and training

Agency representatives perceived that much need is likely to be at a relatively low or generic level, particularly in terms of a need for education and training for young people generally and also counselling for young people and parents concerned about the dangers of different drugs (Tier 1). There was some perception that there was more education and training available on drugs than on alcohol and that this should also feature more widely. In response to the survey, young people most often cited their friends as their source for information about drugs and alcohol, with parents or carers following very closely behind. Professional sources – youth workers, teachers or GPs – featured less often.

Figure 2.18 ‘If you wanted advice on drugs or alcohol, who would you usually ask?57’

180 160 140 120

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The majority of young people reported having lessons, videos or discussions at school in the previous 12 months on smoking, alcohol and drugs in general, but few reported having such lessons about specific drugs.

Figure 2.19: ‘In the last 12 months, have you had any lessons on these topics?58’

200

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Number of cases

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100

80 60

ru y

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This question was open to all 281 young people in the sample. It was a multiple choice question, therefore the total responses add up to more than 281. 58 See footnote 1.

In each case, at least two-thirds of the respondents who said they had such a lesson or discussion reported having found it useful. Those drugs – heroin, crack, cocaine, solvents and ecstasy – which did not feature highly in reported lessons on drugs did feature prominently in the substances about which young people wanted more information (Figure 2.20). Very few young people stated that they wanted more information about alcohol or tobacco, which does not reflect the view of some agency representatives. It might be that young people do not perceive the dangers of alcohol or that they feel that they are sufficiently briefed, as Figure 2.19 might indicate. Of course, this sample was drawn primarily from young people in school, who are more likely to receive education in these subjects. The gap is likely to remain in relation to young people not in school, however. Figure 2.20: ‘Would you like more information on…?59’ 60.0% 50.0% 40.0% 30.0% 20.0% 10.0%

of t

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ai ne oc or c lv en t So

Al co ho l

H er oi n C ra ck

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It should be noted however that the most common response to the survey question was for young people to state that they did not want more information about any of these substances – 48.4 per cent (136 individuals) responded this way. Of those who stated they would like more information, most young people wanted schools to provide it.

These are the percentage of young people who answered yes to this question, out of the total of 281 respondents.

Figure 2.21: ‘Who would you like to provide this information?60’

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This somewhat contradicts the low standing of teachers in sources of advice above, but can perhaps be explained by young people wanting general discussions in school, but not feeling comfortable about approaching teachers for advice on an individual basis. There was a feeling amongst teachers spoken to at schools that it was generally very difficult to access external drugs educators, a resource that they would appreciate. Equally however there was some debate over who is best placed to deliver such education: teachers because they know the children, or external educators because there is less formality and more confidence in such a relationship. Young people were also asked to write down what kind of information they would like. Most responses were ‘about drugs in general’ but more specifically young people were interested in the physical effects of different types of drugs, both short-term and long-term, and the dangers associated with them. Additionally there were a number of respondents who wanted information about how to support someone else who was taking drugs, and how they could be helped: a potential gap in support currently offered.

2.3.1.2

Education and other support for more problematic drug users

At Tier 2, there was seen by agency representatives to be a high need for further training for workers in agencies dealing with excluded young people. Another need also identified was counselling for young people and generally a more holistic approach to dealing with young people with drug problems. This is explored in greater depth in section 3. 60

This question applied to the 145 respondents who stated that they wanted more information. The abbreviation ‘ind.’ in the category labels stands for ‘independent’.

Staff in agencies working with excluded and problematic young people were noted by some as needing further specialist training or support in dealing with drug-using young people with border-line learning difficulties, or problems with social skills. The issue of a wider range of provision at this level relating to problematic alcohol use was also raised by some agency representatives. There was also seen to be a need for further services which explore the related problems accompanying drug and alcohol use. At Tier 3 and above, the main issue related to waiting times for services, particularly for getting scripts. This is discussed in further detail in section 3. In terms of what are perceived to be the main drugs necessitating services at this level, heroin was seen by agency representatives to be the main ‘problem’ drug, particularly for the older age groups, with crack use also seen to be increasing, particularly on some of the inner city estates. Criminal behaviour was seen to be associated with more problematic drug use, which was also viewed as strongly related with deprivation, as well as problems of low self-esteem. In the interviews with young people, some of the respondents described problematic drug use which had caused problems with their families, had rendered them homeless or led to their imprisonment. What most described, however, was a general need for support, combined with practical skills and advice focussed on housing, training and employment. All of the young people had realistic and what one person described as 'very simple' hopes for the future. For all of them this included the ability to have a successful relationship, a job they liked and, for some, children. The routes out of drug use were therefore those traditionally described as supporting desistance from crime; a supportive long-term partner and work. Some of the young people who had experienced problems could evidence the positive effects of the above. Respondent: "Got out on the Friday and on the Monday...went to the Job Centre, got a job in interview on the Monday and 2 o'clock. They dropped me down there like, 'cos I got the job, start tomorrow, so it was Tuesday. So I got the job, so that keeps me off the streets see. Interviewer: So what I was going to ask is, has there ever been a time since you got out ..that you have been tempted to have some? Respondent: No not really. Because my routine was now like, going to work first thing in the morning getting home, having a bath and like staying in and watching telly. And come weekend…there's a club down the road and I know a few people…people that never

took it, took a different road and never touched it, do you know what I mean? Decent friends. Another young man described his aspirations for the future without drugs: Interviewer: Where do you see yourself in a few years time? Respondent: Just make sure I am a family man and that. Do you know what I mean? I don't want to in prison. I don’t want to be homeless. I don’t want to be an addict. I want to be working and successful and that. Have a flat or a house or a car and a nice wife in it. And some kids when I'm about 25. That's it really. Perhaps as a result of their youth most also cited renewing or strengthening family relationships as something that they desired or which would help them. Two of the young men described their pleasure that their mothers now seemed proud of them and 'showed them off' because they had stopped their drug use. Two others referred to a family mediation input as a useful piece of 'help' that they had received. Despite high levels of problematic drug use described by a small number of interviewees, not all had received help from a drug agency in the community. For those that had received help, it tended to be after their drug use had become problematic and more than one felt that their lives might have been different had they received advice earlier on. Of course, it is always easier with hindsight to think that it was possible to have changed a course of direction, but as one young person put it, ‘if someone was there telling me what to do when I was younger about drugs and homelessness maybe I wouldn’t be here’. One also described the assistance he had received from the CARAT team in a local prison and another appeared to describe the same input but without naming that team. This input focussed on goal setting and practical assistance which both described as useful. What is interesting was that most respondents, whether they were drug users or not, did not anticipate that there was help which they would like to receive, or could have usefully received. However because of the way in which we accessed these young people, most had been subject to a substantial amount of professional advice and assistance. The young people usually detailed this and referred to it. What they seemed unable to do was to 'imagine' or describe help in an abstract or counselling sense. What this may indicate is that the holistic, one stop shop approach to young people's services may by the most practical because it will include the sort of assistance young people may envisage themselves using. This can make planning potentially difficult within a 4 tier model, although it is not incompatible with an open point of access at tier 2 which feeds into more specialist support. This would of course require effective referral mechanisms and quick access. While some interviewees did not consider that there was anything concrete that agencies could offer at this point in time, some of the young people

stated that the need or desire for help related to how they perceived themselves at the time. For example, one young person related how he had started to think about the future and how he might not be able to achieve his goals if he continued to use drugs in the way he had: ‘You don’t wanna be… do you know what I mean coming into your twenties and that you don’t wanna be doing that no more. You wanna grow up and that …So I wanna be working and …have a family of me own and that I ain’t gonna be able to do that if I carry on the way I was going. So you gotta stand up and say yeah I was wrong and I thought I wanna do better’. This corresponds with some of the research literature, which has found that cessation of drug use is for many young people linked with the process of moving into adulthood. With regard to methadone scripts just one person thought they may have found it useful if it had been available to them. They saw its usefulness as reducing their offending; they saw methadone use itself however as potentially problematic and this was echoed by other respondents.

2.3.2 Needs of different groups 2.3.2.1

Geographical differences

An important issue that was raised in discussions with agency representatives was that of ensuring that young people on outlying estates have access to services, through satellite services or detached/outreach activities. There are severe problems of deprivation on some of these estates and limited access to services and information more generally. This need also applies to some of the hard-to-reach groups discussed below and in section 3.

2.3.2.2

Gender issues

Some interviewees observed that young women and men are likely to have different needs, partly related to their different reasons for and attitudes to using drugs and alcohol, or to the consequences of their use, as discussed in section 2.2. They also have different patterns of drug use and appear, as discussed in section 2.1, to vary their use according to age. Services need to be sensitive to these differences.

2.3.2.4

Ethnicity

It would appear that young people from minority ethnic communities in Birmingham are not being adequately reached by all the drug and alcohol services and many are therefore not accessing service provision. Of those staff interviewed from a wide range of agencies and organisations combining different service types, only two of these agencies, a probation office and a project undertaking outreach work with young people, reported

how their clients were largely drawn from ‘black and minority ethnic communities’. They stressed however that this was essentially a result of where these projects were based as opposed to offering services which had been specifically developed for ‘visible minorities’. “They’re [the clients] mostly from ethnic minorities, mostly Asian…it’s just to do with the areas we work in. There are a very large percentage of Asians”. It was not apparent from the interview data whether one particular ‘minority’ group was more or less provided for as the above agency staff stated that their caseloads fluctuated between black and Asian clients. However one education agency believed that young people from the ‘Somalian community’ were increasingly emerging as a group who requested assistance. Based upon the responses of some interview respondents it was suggested that there were several dimensions to the access issue, relating both to the thoughts and practice of service providers as well as those of potential service users. While the majority of potential young service users from minority ethnic groups were born and educated in Britain, there remains a vulnerable minority for whom English is a second language. This can pose a huge problem as very few service providers can function in other languages (e.g. Bengali, Urdu etc) and there are often insufficiently translated materials. One respondent in a drug treatment agency explained how language barriers affected communication between them and the client about specific treatment procedures: “He was an Asian man and it was almost like he weren’t quite sure…He couldn’t quite understand. I actually did get somebody to speak to him before he left to explain to him in his own language and the person couldn’t actually get a lot out of him either. So you know it was difficult.” Similarly one interview respondent believed that language difficulties and ignorance of cultural issues also impacted upon the take up of services available: “Generally young people from ethnic minorities are less likely to engage with organisations like HIAH because of cultural and language differences and because they are suspicious of a bureaucratic organisation.” (representative from criminal justice agency) Interview data with agency representatives also revealed access issues around trust between black and minority ethnic communities and agencies managed and provided by predominantly white front-line staff. One agency representative recounted how he was working with a ‘young Asian female’ 41

who was prevented from attending the service by family members because it was staffed by: “White workers and one or two men at that, that put him off allowing his sister to access the services. They didn’t relate to the service so they didn’t want her going there”. What the research highlights is that there are issues of access to drug services for those from minority ethnic groups. Accessibility of service provision is clearly a key requirement however. As Kazim Khan (2002) has argued accessibility cannot be and should not be premised on a notion that each service has to be wholly physically representative of the client group it seeks to assist61. Therefore whilst drug use would appear from the limited data we have, to be lower among visible minorities than amongst the white population62 there are needs, which it has also been evidenced that are not being met. It is a key responsibility therefore for both the DAT and the service providers to seek solutions, which make services accessible.

2.3.2.5

Child protection issues: children of substance misusing parents and young people as parents

It was felt by some workers that because of their chaotic lifestyles, young mothers who are drug users may not always comply with child protection plans (for example, not keeping contact with agencies on a regular basis, not picking up prescriptions etc). If they are experiencing a large number of problems or if significant events take place which change their lives, even if only on a temporary basis, then it was remarked that they might turn to drugs to ‘block out the pain’. Young women in this situation may often not be aware of the dangers of not complying with a child protection plan and may need extra assistance and patience. This issue is also dealt with in greater depth in section 3, which also discusses the issue of fear of social services intervention on the part of pregnant young drug users. In terms of children of substance-misusing parents, one of the main needs was seen to be in relation to information and education at Tiers 1 and 2, as well as counselling. Although the numbers of young people we interviewed were small, there was testimony within them that many of the young people were introduced into drug or alcohol use by older siblings and some referred to parental drinking which they saw as problematic. Whilst the interviews cannot suggest a pattern or link between parental misuse and the young person’s misuse, family relationships do play a significant part in young people’s stories about drugs and alcohol. Parental disapproval and parental support

Kazim Khan (2002) ‘Culture before client. The wrong way for drug services.’ Druglink Vol 17;6 DrugScope. 62 This is in line with most national data.

appear influential in assisting a young person to want to change drug misusing behaviour. Respondent: “I reckon you’re going to do it for your family more than anything. You do it to your family, because you are breaking your family’s heart and you don’t want to do that no more.” Whilst many of the interviewees had disrupted family relationships and family breakdown, this was an important factor for many of them in their discussions about their lives. It is perhaps therefore a differential factor when dealing with young people who are also drug misusers, that family responses and relationships are perhaps more immediately significant than for adults who are also drug misusers.

2.3.2.6

Homeless young people

Homeless young people, particularly rough sleepers, have high levels of need which currently are not being met, as discussed in greater detail in sections 2.1 and 3.2. Some of the problems include mobility and chaotic lifestyles and also lack of a permanent address, all of which reduce the likelihood of service provision in relation to problematic drug or alcohol use (which in turn perpetuates the problems). The circularity of this situation and the links between problematic drug use, homelessness and crime are exemplified by a discussion with one of the young people interviewed: Respondent:…when I realised I was addicted to it [heroin], I couldn’t always get money, so obviously I had to, I started shoplifting and started doing things. Like erm just before I turned 17 I got sent to prison. Interviewer: What for? Respondent: Shoplifting. Interviewer: Right. There must have been a lot of shoplifting to get sent to prison for it. Respondent: Yeah, it was, it was quite a few actually. Erm I come out from that spell. Interviewer: How long did you get then? Respondent: Erm four months at the time. Interviewer: So you did two did you?

Respondent: Yeah, I done two months. I come out. …. I didn’t touch it for a couple of weeks. Tried to stay away from it for one night but I was bored so, I thought to myself I can stay away from it, not have it, but obviously I thought wrong, because I started taking it again and- …because my tolerance was quite high at that time, it didn’t take me long to get back on it. So within a couple of weeks I was back on it again. And I went back to prison. I got two years for a burglary. I come out, but I come out to nothing ‘cos my family had enough. I didn’t have no, no decent friends. ….So basically as soon as I come out from prison, I come out to nothing, nowhere to live. I was, I just was straight back on it, the day I got out. Interviewer: Right. And how old were you, about 18 or 19 then were you? Respondent: Erm 18 yeah. Interviewer: Was that after a whole year of not having had any was it? Respondent: Yeah. Which was a bit of a waste really. Interviewer: What do you think that was about? Do you think, do you think if you’d, if there’d been like people around to support you and that sort of thing, do you think you would have been less likely to go straight back on it? Respondent: I think so, yeah. ‘Cos I was living, I was on the streets and most of the people who are on the streets nowadays are users. So I couldn’t, I couldn’t really get away from it. Straight back on it. The discussion above indicates the importance of ongoing help for young drug users, which is especially crucial at particularly vulnerable stages of their lives, for example after leaving prison, where they often find themselves distanced from other sources of support such as networks of friends or family.

2.3.2.7

Sexual health issues

In the survey of young people, we asked them whether they had ever had a sexual relationship with anyone else after they had used drugs or were drunk. Just over 24 per cent of the sample (66 young people) stated that they had: with boys more likely than girls to answer ‘yes’ to this question (28 per cent of boys compared with 18 per cent of girls). We also asked them how they felt after this. There were some interesting differences according to gender. For example, boys were more likely than girls to state that they had enjoyed it, whereas girls were more likely to feel

bad about themselves63 afterwards. Boys were also much more likely to state that they thought that they would have a sexual relationship again because they were drunk or had used drugs (78 per cent of boys compared with 48 per cent of girls). A Health Education Authority report in 1998 found that 1 in 10 16-24 year olds could not remember who they had sex with the night after drinking. This raised particular issues and concerns about sexually transmitted diseases, HIV/Aids and unwanted pregnancies for certain groups of young people. As a result this was a question included in the survey and the face to face interviews. Just over 15 per cent of respondents to the survey (mainly boys) said that they felt worried after having sex with someone after drinking or using drugs, because they did not remember their partner the next day. The question about having a sexual relationship after drinking or taking drugs was not put to all of the young people interviewed in our study, but of those who were asked just one respondent replied that she had experienced this once.

2.3.2.8

Links between drug use and crime

The evidence from the young people’s interviews supports other research findings in showing a link between problematic drug misuse and crime, but not between drug use and crime per se. Most of the young people interviewed had used drugs and or alcohol in the past and some of them had tried Class A drugs on more than one occasion. Some of them had also committed criminal offences. However it was only those who described longstanding, problematic drug misuse who linked that behaviour to crime. Respondent: But that’s why I ended up losing my job in the end because that’s when I started getting addicted. You know I played around with it too much for too long. Later on in the interview he is asked: Interviewer: If you don’t mind me asking you a little bit about how you kind of got into crime as well. Do you think that was linked to your drug use? Respondent: Definitely yeah…..I did stuff when I was little like every kid does and I had never been in trouble with the police. I had never been to court or nothing….But yeah. So most of the crime I’ve done is drug related. Interviewer: How is it related?

Note that samples sizes in relation to some of these questions were relatively small, so these results should be treated with caution.

Respondent: The only reason why I’d do crime was to get heroin or to get crack. I would be out every day like doing something. Getting my fifty quid together, my sixty quid and that. The relationship between problematic drug misuse and other factors such as crime, homelessness and negative relationships is spelled out by this interviewee: Respondent: But you can’t sort it out (drug use) because you have no money. So what are you going to do? …So you got to offend…..And then I kept getting nicked for shoplifting and little things…..But then my Mum… the police like came round to my house…I’d got a little bureau in my bedroom. It was full of…My mum found out and she said look, if I find that again the next time she’d kick me out. So I’m homeless. Still I’m needing the thing. Interviewer: So where were you living? Respondent: Just like on the streets….. But that’s when I was getting to the worst. The interviewee then went to jail and on release returned at first to his mother’s home. This arrangement broke down again because of his drug use. He then went into a hostel and described how networks develop in the hostel with the other people there and how you lose contact with other friends and other influences. These relationships led him to engage in new forms of crime for him. Respondent: Er and then, through the hostel, people from the hostel, I started going out burgling this time, I started burgling for other drugs. I never done it before. It was only like new to me that, burgling was…..I did a burglary, the alarm went off….Got a twoyear sentence but appealed to 18 months. Some interviewees also testified to the importance of help when in prison. Help in terms of resettlement and employment advice which leaves no time on release for boredom and which offers opportunities for new friendships and activities was discussed. Interviewer: Just going back, you said about a CARAT..? Respondent: Yeah they helped me a lot. The interviewee then proceeded to describe advice and support across a range of things from housing to relapse prevention strategies. What he and others described was also the importance to each individual of their own will and ability to help themselves whilst supported by others, be they professionals or family and friends.

Drug, alcohol and related services to young people in Birmingham

3.1

Overview of services to young people

3.1.1 Introduction Birmingham has a wide range of agencies dealing with young people many of whom provide a service relating to drug, alcohol and substance use and prevention. These range from organisations working with young people generally, through agencies targeted at specific groups of young people and agencies providing education and training on drugs and alcohol for young people and project workers, to those focusing exclusively on substance use. In this latter group, HIAH provides the only service for young people aged 18 and under, whereas a number of drug and alcohol services exist for young people aged 19-24. A mapping of drug and alcohol services and need is being undertaken in another report, so what follows relates more to the findings from stakeholder interviews. The research focused on a sample of agencies throughout the spectrum, ensuring that there was representation from the main agencies in Birmingham within each category. This section presents an overview of the different agencies in the city, from the perspective of stakeholders, including perceptions on co-ordination of services to young people and a discussion on good practice. The overview is then followed by a discussion on referral processes, including the extent to which referring agencies appear to be aware of treatment and other services for young people; two case study examples; and an exploration of the perceived gaps in treatment, education and training and other services relating to young people and substance use/misuse.

3.1.2 Overview of services at different levels The overview of services to young people is presented in the context of the HAS 4-tier model. At Tier 1 (provision of substance misuse education, information and referral to support services), a number of agencies were approached in the course of the research. These included: ď&#x201A;ˇ A sample of schools (primarily to undertake the survey of pupils in years 10 and 11, but also discussions with PSHE teachers and pupils); ď&#x201A;ˇ Agencies involved in training for young people and individuals working with young people, including teachers and staff in projects working

with young people and also parents of young schoolchildren. These included the Health Education Unit, Midland Life Education Centre Trust, Parents for Prevention (at this level particularly in terms of drug awareness sessions for school parents, and training for staff), the Saltley Gate project and the SRB4 drugs prevention co-ordinator;  Agencies dealing with young people generally, including Connexions. While there is a significant amount of provision at this level, it was felt by some respondents that there should be greater investment in diversionary activities and an increase in capacity at Tier 1, through further training of project staff coming into contact with young people, so that they are aware of the issues and confident of assessing when it is appropriate to refer a young person to another agency. The issue of education and training is discussed in further detail later in this section. At Tier 2 (provision of drug-related prevention and targeted education, advice and appropriate support for those identified as at risk of developing problems with substance misuse, in addition to Tier 1 services), the agencies included:  Some of the agencies involved in education and training above. For example, Parents for Prevention provides a specialised service for families of young drug users and other trainers provide services for agencies working with excluded young people;  Agencies dealing with young people who are considered to be ‘at risk’, including youth inclusion projects, pupil referral units, homelessness agencies, the Saltley Gate project and other voluntary organisations working with specific groups of excluded young people;  Criminal justice agencies, including Youth Offending Teams and Probation. Many of the agencies dealing with young people at risk or involved in offending either have specialist drugs workers or have staff who have received training in the issues. At this level, there is perceived to be a high demand for project workers with appropriate knowledge in drugs and alcohol prevention, which is not met by the existing skills base. The Voluntary Sector Drugs Forum plays a major role in bringing together voluntary agencies in the city working with drug users and also provides links with the Drug Action Team. For Tier 3 and above (specialist, mainly non-medical or multi-disciplinary services at Tier 3 and very specialist medical forms of intervention at Tier 4), the main agencies contacted were:  HIAH for young people aged 18 and under (primarily at Tier 3 and above, although HIAH also provide some education and information services);  Adult services which include provision for young people aged 19-24, including Turning Point and the Addictive Behaviour Centre (primarily 48

Tier 4), with its specialist sub-services, such as the mother and baby unit, crack outreach team and arrest referral scheme;  GPs and Primary Care Trusts. The main issues raised in relation to this level of service were the fact that there is only one agency catering for the 18 and under age group, which could prove restrictive in future years; and the long waiting lists for the other agencies. It was felt by some that although treatment services were expanding, they were not keeping up with increasing demand. These issues are discussed in further detail below. For services more generally, while the HAS 4-tier model was seen to provide a useful initial structure for assessing services (by those agencies aware of the model), it was also noted that there is a need to provide further guidance on how this model should function. For example, advice on what a multi-disciplinary team should consist of was seen to be important. Similarly, more thought needs to go into defining what a young people’s service should actually comprise; and there need to be clearer links between the different levels of service and options available to young people.

3.1.3 Co-ordination of services The HAS 4-tier model is in part predicated on a co-ordinated multi-agency approach to drug and alcohol prevention and other associated services. We asked stakeholders about the extent to which they perceived services to be co-ordinated in Birmingham. In terms of agencies working with young drug users, Care Pathways, concerning drug use in Birmingham and organised by the DAT, meets on a monthly basis. This includes Probation and Social Services, as well as the agencies providing treatment and services to young drug users. At this level, networking was seen to operate fairly effectively. The Voluntary Sector Drugs Forum has also helped to provide a link between different organisations which may come into contact with drug users, as well as a link to the DAT. There was recognition, however, that information-sharing and liaison between agencies on a broader level is less effective. One stakeholder in a statutory agency working with young people made the observation, which was echoed by others, that ‘…there is a lot to be done in terms of joined up working…there is still not a consortium to address needs and strategies. We’ve made a start, but there is not a joined up mutual vision’. This is reflected in issues such as the lack of knowledge about where to refer which is discussed later in this section. Information-sharing between agencies is also an important issue. In some cases, this was seen to be limited because of confidentiality protocols. Some organisations were seen as good at providing feedback to referring agencies, whereas others were regarded as providing relatively little,

primarily because of their stricter confidentiality rules. An informationsharing protocol between agencies was seen by some stakeholders as being an important need. Worker exchange, or the possibility of drugs workers attending clinics based within agencies working with excluded young people was raised by one group as a potential option, which would help to increase knowledge between agencies. Such a system is already operating between HIAH and the YOS and with Connexions. At other levels, there might be representation from drugs prevention services on specialist committees, such as the ACPC on sexual exploitation.

3.2

Referral processes and agenciesâ&#x20AC;&#x2122; knowledge of services

Young people with a substance misuse problem may get help in a number of different ways. If an agency who works with young people finds that one of their young people needs help with addiction or other substance use problems they can attempt to provide some in-house counselling or, if necessary, refer that young person to a treatment agency. There are a number of these operating within Birmingham. For those aged 18 and under the main agency would be HIAH. For those over 18 there are a variety of agencies, generally Community Drug Teams such as Mark Street or Azaadi but also including Drugline. There is also the possibility of direct referral to a GP. Young people may also self-refer if they know about a treatment agency which will take self-referrals or if they have a GP who is willing to provide help or a referral elsewhere such as to a Community Drug Team or the ABC. Young people who are involved with the criminal justice system may obtain help either via a DTTO or via the YOTs, the Probation Service, secure units or BART (the Birmingham Arrest Referral Team). In the case of those under 18, for whom the DTTO is not applicable this would effectively mean referral to HIAH which has a drug worker attached to each of the YOTs. For those in the Probation Service aged over 18, the option would usually be Drugline (if the young adult involved had no previous contact with one of the other agencies) and Swanswell, who now have eleven people working directly with the Probation Service. In theory there should be a progression of referrals following the HAS 4-tier model, so that most referrals would not go immediately to tier-4 services. In fact some doctors have been referring to this level inappropriately and the tertiary agencies then refer the young people involved back down to the Community Drug Teams and other relevant agencies. This serves only to prolong waiting list periods. From the point of view of the voluntary agencies or agencies outside the criminal justice system referral was seen as, perhaps, one of the most problematic areas of their work. Some of these agencies such as YIPs or some of the homeless agencies may have a HIAH worker who attends. Otherwise there was considerable ignorance amongst stakeholders about

what agencies exist and what they provide and considerable concern about the time a referral will take. â&#x20AC;ŚI know there is a long waiting list for counselling services - about nine months. In the meantime, the problems are not dealt with and get worse. (Agency working with homeless people) It is common knowledge that there isn't really anywhere to refer people onto. I've done in the past and like we've tried Mary Street. And they kind of say 'Well good luck, come back, you know there is a six month waiting list'. So you get someone who comes to you and at some stage they may say 'Well I do want to stop this' and to be honest there is nothing you can do for them' (Youth project worker) In the past I have referred to Barker St/Wheeler St/Azaadi but the waiting list is a problem. (Drugs education project worker) Question - Would you refer them onto any other agency if you knew they had a drug problem? Answer - if there was another agency to refer them onto, yeah. (Police officer) Concerns about capacity extended to HIAH which some feared will be unable to cope with the number of young people needing help, particularly once they become better known. HIAH is a small agency. The combined YOTs probably have 1500 people on order and there are less than twelve people at HIAH. (YOT worker) In at least one case an agency working with young people would make no referrals on the grounds that there was no one to whom they could refer and expect assistance within the foreseeable future. In several other cases referrals might be made but this would not be done as a matter of course and expectations of immediate assistance would not be great. HIAH, now the main agency working with young people aged 18 and under is relatively new and youth workers who had not received training within the past 18 months were not familiar with it. As the agency becomes more established this problem may well diminish but in the interim improved communication would be useful. There was considerable concern at all levels about the time lag between referral and acceptance for treatment. Several of those interviewed stressed that there may be only a short time period in which someone who wishes to stop using drugs (or alcohol) and has nerved themselves up to do this will maintain that resolve and if they are not helped immediately, the opportunity may be lost.

When you have the level of motivation there to do something it has to be now. You can talk to our Managers and you see it time and time again where they've worked with a young person and they've got them to admit they need help and then three months, maybe never and you're back and that's the tragedy I think - it's not the kind of a service you can go on a list and wait for. (Agency for homeless people) All of the Community Drug Teams spoken to appear to have waiting lists and there are doubts that HIAH will be able to cope with those under 19s in the future. Deciding when to refer and at what level is also a problem. Very few of the non-treatment agencies knew much about the HAS 4-tier model and referring on would appear to be very much a hit or miss affair. Some would leave it until the individual themselves requested help. In other cases the organisation itself might provide some counselling if they thought that would be sufficient. Within the YOTs it is expected that drug problems will show up on ASSET assessment. Some drug workers would refer all cases to their HIAH worker where it is judged that drug talking is affecting criminality. Others would say HIAH is de rigueur if there is any mention of drugs. Others might only refer if there is evidence of serious addiction. And when it comes to problematic alcohol use as a factor in crime the situation is even more clouded Another problem is that drugs may be less of a problem in themselves but related to mental health or wider social issues. It can be very difficult for an agency to decide to whom they should be referring a young person. A considerable degree of professional expertise may be needed to determine what treatment might be effective. In drug teams you haven't got a psychiatric nurse. You've got people from different backgrounds who perhaps don't know how to handle mental health problems - so they pass them on here. (Treatment agency) The question of self-referral is also difficult. Young people may not want to reveal to an agency with which they are working that they have a drug/alcohol problem. This can be a particular problem for agencies working with homeless young people because potential clients may feel that the revelation of a drug problem would preclude other help. However, people with a problem do not necessarily know what treatment agencies exist nor feel confident about visiting one of these. In any case not all agencies will take self-referrals. Referral usually involves meetings in which the agency assesses and decides on treatment. However, many young people lead a chaotic life style

and, if they turn up at all, may turn up late thereby putting pressure on agencies already frustrated by their workload. Some of those interviewed suggested that clinics or one stop shops might be the answer to this, particularly if these were held in venues where at risk populations such as homeless people were likely to be found. These have been judged as successful when they have taken place. Other issues that create problems revolve around confidentiality and consent. From the perspective of the YOTs what may be needed is a course of treatment that can be made compulsory under a sentence. This does not, however, fit in with policies of voluntary treatment in some agencies such as HIAH or the ABC Mother and Baby Team. For example, it was observed that social workers, doctors or probation workers â&#x20AC;&#x2DC;will say you're pregnant and you have got to go the ABC and see the Mother and Baby team and we won't accept referrals like thatâ&#x20AC;&#x2122;. (Worker on a mother and baby team). This conflict of interests is an issue which possibly merits further discussion. Confidentiality may be a problem in two ways. In the first case the referring agency may be unwilling to provide information to the treatment agency or may supply insufficient information. In the second the treatment agency may be unwilling to provide feedback which the referring agency (in particular referring agencies within the criminal justice system) would view as important. There are also major problems for schoolteachers who on the one hand may feel that a young person needs outside help but on the other are concerned about child protection, confidentiality and the Data Protection Act. A final area of concern was voiced by a tier 4 agency which stated that there was often a log jam caused because 'clients like being here' and because 'doctors still don't want to take these people on.' There is also perceived to be a lack of a tier 4 agency that could deal with the 'chronically chaotic' who are under 19. Ironically most of the problems listed above affect people who are not involved in the criminal justice system. DTTO clients are seen fairly rapidly and, while there are concerns that HIAH may become overloaded this is not yet viewed as a problem. This dichotomy is apparently well-known and it was even suggested that young people desperate to get off drugs would commit crimes so that they would receive treatment more rapidly either under a DTTO or in prison.

3.3

Profile of case study agencies

3.3.1 HIAH 3.3.1.1

Background

HIAH (Holistic Innovative Approach to Health) was established in Birmingham in 2000 with a brief to provide a young people’s drug treatment service on a city-wide basis. The age range is up to (and including) 18 years of age. A variety of services is offered, all on-site at city centre premises, and in addition, HIAH is currently in the process of developing outreach services to some of the outlying areas. HIAH’s approach to drug treatment is holistic, with a strong emphasis on non-medical interventions and alternative therapies such as acupuncture. There is, however, also a substitute prescribing service. The staffing includes a specialist GP, a social worker, a community psychiatric nurse, counsellors, and complementary therapists, with case managers individually assigned to each client. There are also workers shared with the Youth Offending Teams, and with the Connexions Service. This multi-disciplinary team means that HIAH is able to offer a fairly comprehensive response to meeting young people’s needs and makes many referrals within itself, rather than needing to refer to external organisations.

3.3.1.2

HIAH’s current work

The services HIAH offers to its clients varies considerably according to need. Initially, all are offered an assessment to establish their needs in terms of substance misuse, physical and mental health, emotional wellbeing and social circumstances. Those with a lighter drug use problem are often offered a programme educating them in the effects of the drugs they are using. Others with more serious problems are offered counselling or referred to the GP who may prescribe either subutex or methadone, for heroin withdrawal. Most are also offered regular appointments with their case manager, and can drop in without an appointment for acupuncture, in which all the staff are trained. In the first 2 years of running, HIAH worked with over 300 young people. Clients can be referred to HIAH from a variety of other agencies, and can also self-refer. Youth Justice currently makes a large proportion of the referrals, a result of the close links between the two agencies. A substantial proportion of those referred fail to take up the services offered. In some cases this was thought to be due to the young person being referred by parents or others who thought they had a drug problem, although the young people themselves did not perceive there to be a problem. Those who did engage with the service, however, generally continued to come and receive support for many months, accessing different elements of support as they needed it. Many of these withdrew from drugs early on in their time with HIAH, but continued to receive support to help maintain this situation.

Each case manager currently has a caseload of around 15 to 20 clients, most of whom have been attending regularly for many months. Most of the clients are aged between 16 and 18, with just a small minority of 12 to 15year-olds. In terms of ethnicity, the vast majority of clients seen are white, and there are more males than females. The most common drug with which the clients reported problems was heroin, followed by cannabis. Only a small number of crack cocaine users were seen. The young people’s home circumstances varied a great deal, as could be expected of this age group. Most had left school, few with any qualifications, and some were now in work, with many others being unemployed. Most were, however, still living at home, although in many cases this situation was under threat because of their drug use. Many others moved between addresses during their time with HIAH.

3.3.1.3

HIAH’s role in relation to other services in Birmingham

Prior to HIAH, there was no dedicated drug service for young people in Birmingham. There is extensive and unanimous support for the existence of a drug service which is specifically for young people. Many agencies interviewed expressed concerns about young and vulnerable teenagers coming into contact with long-term heroin or crack users, which would often happen when they were accessing the same service. There was also support for “a more young person centred approach, and an appropriate range of services” (Manager of drug and alcohol service), a service where staff were experts and specialised in dealing with young people. I think HIAH is a really good organisation and I think they’ve got a really good idea about treating young people. You know, they don’t just stop at prescribing pills, they look at different therapy. (Staff member at drugs education agency). There isn’t anywhere else as specialist as HIAH. (Manager of drug and alcohol service). In all my time as a drugs worker, I’ve never come across a drugs service that’s so ‘spot on’ for young people. (Drug prevention worker). HIAH’s holistic approach to drug treatment has also met with much support throughout other agencies. Many expressed support for the level of nonmedical treatment offered. Although some did express personal doubts about the effectiveness of alternative therapies such as acupuncture, the general view was that if the staff believed in it, then it could only be beneficial. No one reported any clients having been put off by the alternative therapies; indeed many seemed to report back positively about the service they had received.

There was also a great deal of enthusiasm for the speed with which HIAH was able to see new clients. Agencies used to having to refer to the adult services emphasised how good it was to be able to refer a young person for help, knowing that they would be seen within a week or two. This was thought to be especially important to younger drug users, who would often want help quickly, or would reject it altogether.

3.3.1.4

Areas for development

The above views on the value of HIAH have, however, been offered only by a proportion of potential referring agencies in Birmingham. There are many other agencies who work with young people, often with drug problems, who are clearly unaware of who they should be referring on to HIAH. There was a good deal of confusion as to the age range which should be referred. At least one agency thought it was only for under-17s and several others thought the age range to be up to 25. Other agencies appeared not to have heard of HIAH at all and stated that they would refer a young person with a drug problem to their local CDT, or to Drugline. Some had heard of HIAH, but felt they didn’t know enough about it to make referrals: If we knew more about agencies such as HIAH, we’d probably use them. (Youth Services co-ordinator). They’ve grown rapidly and are adapting fast, and I don’t have upto-date information on what they do. We need updated information about the range of services. (Manager of drug and alcohol service).

This raises concerns, as inappropriate referrals will inevitably increase the time people wait for treatment, and may lead to young users accessing adult services when their needs could in fact be better met by HIAH, an issue that was raised in section 3.2. In addition, there was also a lack of knowledge amongst other agencies as to the services HIAH offers. Some thought it only offered Tier 3 plus services, or only helped those in need of detoxification from drugs. In fact HIAH offers a broad range of education and information services, but these clearly need more promoting. Some agencies also seemed unaware that there was not currently a long waiting list for HIAH’s services, and stated that they did not use the service as much as they would like because they believed it to be overrun with clients. In fact the opposite problem appeared to be perceived by HIAH’s own staff, who expressed concern about the lack of referrals, and the large numbers of drug-using young people who were not accessing their help. Concerns were also expressed by many agencies over the lack of communication they had with HIAH. Many of these concerns were rooted in difficulties over HIAH’s policy of confidentiality. Confidentiality is clearly of great importance in a young people’s drug service, as many clients will be

fearful of their parents or schools finding out about their drug use. However, many agencies clearly felt that HIAH’s approach to confidentiality was hindering joint or co-ordinated work taking place between agencies: It’s difficult, because of the confidentiality. We know what they do but we don’t really know how they do it. We want to follow through but we don’t get told. (Staff member at drugs education agency). Sometimes it’s essential to issue information which unfortunately isn’t always shared and then one’s left in the dark and the other agency’s in the know. It becomes a bit confusing. (Staff member at project for vulnerable young people). Aside from issues around confidentiality, there were also more general difficulties raised around communication with HIAH. Many agencies seemed to have trouble in carrying out co-ordinated work with HIAH, and highlighted problems encountered when the different aspects of a young person’s life (such as their offending and their drug use) were being dealt with by different agencies without good information-sharing procedures. There were also difficulties at a more strategic level, with managers unsure of HIAH’s current working practices. There were also issues raised by several agencies regarding the accessibility of HIAH’s premises for young people. The city centre building has an intercom entry system and no receptionist. It does have a pleasant waiting room for young people, on the second floor with reading material and a radio on, but whether all young people would find their way to it was queried by some. The location of the building itself was also brought up as an issue preventing greater use of services, as there are many communities in Birmingham whose members rarely travel to the city centre, or indeed anywhere outside of their own area. However, this issue is currently being addressed, as HIAH is extending its outreach activities and making use of other locations to access different communities throughout Birmingham. This may help to reach greater numbers from minority ethnic communities, few of whom appear to be accessing the service at present.

3.3.1.5

Conclusion

HIAH is clearly filling a much needed role in Birmingham, and the existence of a specialised young people’s service is greatly appreciated by all those working in the field. The holistic approach and use of alternative therapies appear also to be widely welcomed. HIAH’s client group are largely white 16 to18-year-olds, most commonly with a heroin problem. To what extent this reflects need, or whether it may under-represent younger teenagers and those from minority ethnic communities is unclear. The main difficulties other agencies are encountering with HIAH generally centre on communication issues. More publicity for the work that HIAH does, and whom it works with, is clearly much needed. This needs to be 57

given not just to drug agencies but also to the large array of agencies who work with disadvantaged young people (including homeless people, school excludees, sex workers and those on troubled estates), many of whom may have issues with drugs. HIAH sees itself as a holistic agency, and works with young people around other areas of their lives as well as their drug use. However, developing communication with other agencies would enable HIAH to make better use of other help on offer to young people throughout Birmingham, whether this be housing, education or any other service provided outside of HIAH’s umbrella. Agencies that were aware of HIAH’s existence expressed concerns about poor communication. Whilst some of these issues are clearly inevitable consequences of the speed with which HIAH has developed, greater use of multi-agency meetings and further developing agreed systems of joint working might help address some of the strategic issues here. Front-line staff in other agencies may benefit from opportunities to visit the premises and meet the staff they would be making referrals to. This would probably increase the numbers of appropriate referrals. The extension of outreach activities is clearly a positive move, and this will hopefully allow HIAH to be accessible to the many young people who have problems with drugs but are currently not engaging with any service. This development, together with increased co-operation and established systems of working with other agencies, could help see HIAH develop and fill a vital role in Birmingham’s drug prevention.

3.3.2 Health Education Unit ‘Drugs, Young People and the Community’ training course 3.3.2.1

Aims and activities of the project

The Birmingham Health Education Unit (HEU) established the Drugs, Young People and the Community training course almost five years ago. The aim of the course is to develop the capacity of local communities to handle substance misuse, through:    

raising awareness and initiating local drugs education support/referral activities and networks; encouraging and supporting schools, businesses, community organisations and individuals in playing an active role in drug prevention within their community; identifying and enskilling key individuals to play a role in drug education and prevention within their community, organisation or workplace; and improving support to those at risk, through appropriate referral.

3.3.2.2

The structure of the training programme

The drugs training is delivered through approximately twenty two-day courses over the course of the year. Since 1998, a total of 1580 delegates have attended the training. The course is founded on school based drugs education, and so the training is primarily targeted at teachers in the city: in fact the HEU sets a target that at least twenty per cent of delegates should be teachers. However, a wide range of individuals attend the courses including police officers, social workers, probation staff, youth offending team officers and voluntary organisations. The criterion for attendance is broad: anyone working with young people in Birmingham, or providing a service to those who do is eligible to attend, with ‘young people’ including those aged 25 or under. The course structure includes basic drug information; guest speakers from relevant agencies such as HIAH or Turning Point; group discussions of issues including attitudes towards drugs and changes in the law; and sessions on recognising drug use. The training course is currently free of charge, which is important given that many drugs training courses on offer in the Midlands were thought to be prohibitively expensive for schools and voluntary organisations.

3.3.2.3

Participant feedback

Feedback on the training course illustrated the diverse backgrounds of delegates and their varying requirements of the course. Many had received no prior formal drugs training and wanted basic information on the drug issues facing young people in Birmingham or felt their knowledge of such issues needed updating or refreshing. Specific requirements included being able to identify young people with drug problems, gaining information on services for young people with drug issues and updating drug related vocabulary. The feedback received on the course was generally very positive and the content of the course was felt to be highly relevant and informative. Highlights of the two-day course included the speakers from external agencies and the way in which delegates’ own attitudes were challenged through various activities. The course was described as ‘fresh and stimulating’ and for many the only criticism was that two days was not enough time to fully explore the issues raised, with some suggesting that the course would be best delivered over five days.

It was also suggested that the course might seek more input from young people themselves, perhaps inviting them to participate in the course alongside the external agencies involved in delivery. The greatest challenge facing the HEU is meeting the needs of such a range of individuals with widely differing levels of knowledge and different expectations of the course. It is recognised that some delegates come with unrealistic expectations and that the course was not designed to be an exhaustive exploration of the drug issues facing young people in Birmingham. The courses are run on a ward basis, with the opportunity to network being seen as a crucial element of the training. All delegates are provided with lists of other individuals from their ward who have attended. The chance to forge links with agencies was seen as valuable by many, although only few had actually made use of this opportunity and contacted colleagues working in the field.

3.3.2.4

The impact of the project

Generally, participants had made use of the information gained on the course. Many had found the written material they received useful and had referred to it since the course. For some, the course had increased their confidence to deal with young people facing drug related issues by cementing their knowledge. Many could identify areas where they would appreciate further training, recognising that the HEU course only provides an introduction to the issues. Most had not received any training on dealing with the issues facing the children of drug using parents, and were not aware of their organisationâ&#x20AC;&#x2122;s specific policies relating to this (if indeed there were any) despite this being seen as a growing problem. Other training gaps identified included the psychological and physiological effects of drugs, specific training on solvent abuse and training focusing on the families of drug using young people. Most participants expressed a need for future refresher courses to ensure their knowledge remains current and relevant, particularly as changes to laws relating to drugs come about. It was also suggested that information and relevant resources could be circulated amongst participants on a regular basis, alongside the directory of course delegates. The HEU are currently considering developing a half-day refresher course, which would only be accessible to those who had previously attended the two-day training, and would not be a short cut to attending the full course.

It is a positive development that some of those who had previously received no formal drugs training were not now expected to deal with young people with drug problems since qualified drugs workers had been employed by their agencies. This is particularly true for Youth Offending Team staff working in Birmingham. The wider impact of the course was identified as encouraging communication between agencies and promoting a better understanding of how different organisations in Birmingham were facing the same problems. There was a feeling that drugs services were not well co-ordinated across the city and that a course such as Drugs, Young People and the Community could facilitate better joint working. Some of those attending the course hold senior positions within their organisations and so the training received may impact on the formation of future policies or practices relating to drug using young people in the city.

3.3.2.5

Future initiatives

The projectâ&#x20AC;&#x2122;s target is that twenty per cent of delegates should be from minority ethnic groups, and current figures are encouraging at thirty per cent. Currently, the course organisers are targeting the Chinese community who have seemingly not engaged in the provision of services or training. The HEU has recently appointed a regional drugs training co-ordinator which is likely to impact on the work they already undertake and future work being developed. The co-ordinator is currently looking at drugs training already available in the Midlands and investigating the need for a more specialised course, with the opportunity for accreditation. The Drugs, Young People and the Community course does not currently target employers, although a â&#x20AC;&#x2DC;small but steadyâ&#x20AC;&#x2122; number are attending the training. A worker has recently been employed to focus on small, local employers. Structured interviews are being offered to middle management tackling work placed drug issues and providing free resources, as well as offering places on the training course. A training course targeting learning mentors who have not received formal educational training is also being run. The course is three days long and covers much of the information given in the Drugs, Young People and the Community course, plus elements of counselling and listening skills. Six such courses have been offered to date, and as interest increases, the HEU may have to increase the frequency with which the course is run. At the end of 2002 the HEU began delivering a programme in schools to assist with the development of school drug policies. This course is likely to run twice a year.

The potential links with other agencies in the city delivering education and training in relation to drugs are discussed in section 3.4.1

3.4

Gaps in provision

3.4.1 Education and training 3.4.1.1

Introduction

Education and training falls into three basic categories which shadow the HAS 4-tier model: 1. Educating children and young people about drugs and substance use/misuse generally - related to tier one 2. Educating adults who come in contact with vulnerable children and young people about drugs and possible substance abuse so that they can advise, educate and spot problems related to tier two. 3. Educating and training those who work directly with young people who are already misusing substances so that they can counsel and arrange for treatment roughly related to tier three.

3.4.1.2

Educating children

Most of the first category of training is completed through the schools and, indeed, providing information about substances, and 'challenging attitudes pupils may have regarding substance use and misuse' are among the key objectives set out by the Birmingham City Council Education Department (Drug Education and Management of Drug-Related Incidents, Policy Guidelines for Schools). Content of courses on drugs would appear to be left up to the individual school. Key Stage guidelines are set but the amount and quality of education is likely to vary across the city. The schools are assisted in providing this education in two ways. Firstly, the provision of courses specifically designed for young people, such as those provided by the Midland Life Education Centres for primary school children, by Turning Point, by the HEU and by Parents for Prevention. Secondly the schools are assisted by the HEU courses which train teachers in drug awareness. The HEU also advises PSHE co-ordinators on what to teach and how to teach it and produces resources for schools. Information about substance abuse may also be provided by other organisations outside school hours. For example, YIPs may have a drugs worker either on a continuous or temporary basis who can not only give information but counsel and refer young people. Parents for Prevention also provides drug awareness classes through the Youth Service and other

organisations. There are also numerous other organisations who may provide classes or, at least, a talk on drugs and drug misuse. However, extra-curricular training in this area depends often on the goals, funds and administration of the individual project and can be somewhat random. Not all young people, of course, attend such projects and not all those who do attend at the times drug awareness courses are issued. Therefore the gap in provision in this area is most likely to affect those young people who do not attend school, such as those who are excluded. They will not receive the information in school and, though they may receive it elsewhere, this is by no means certain. Kids [who're] fed up with school at 13 they may be truanting a lot or not going to school at all - quite dangerous ages and through the Youth Services or whatever I get these kids and give them some drugs education and speak to them about it because if they're not going to school they'll miss the schools education. (Drugs prevention worker) Another potential area of concern is that provision for those who do attend school is likely to be of variable quality. All school children should receive some information but it is impossible to state how much and to what intensity. There is also a potential gap in knowledge for those young adults who left school five or six years ago. Young adults who come in contact with the Probation Service on Drug Treatment & Testing Orders are supposed to receive courses but it is questioned by some of the agencies whether these are effective. We were supposed to be doing a programme called PRISM but the PRISM one after nearly two years seems to have gone by the board - it seems to have been shelved. The result is ever since it started we've just sort of cobbled together things from other programmes we used to use. (probation worker) There may also be some provision via homelessness agencies, training and health agencies but young adults who do not come in contact with the criminal justice system or with these other organisations may receive nothing. In terms of content professionals in the field seem to have moved away from the stance that all drugs are addictive and potentially fatal. This is due to the recognition that young people are quite aware that some drugs, such as cannabis or ecstasy are not notably addictive and that more addictive drugs are not instantly lethal or, indeed, instantly addictive. Instead there is a much greater concentration on holistic bodily health and upon providing young people with the knowledge which will allow them to make their own informed decisions. Discussions of substances are not limited to illegal

drugs but also include warnings of the physical and mental effects of using alcohol and, increasingly, tobacco and, indeed, other legal drugs. â&#x20AC;&#x201C; â&#x20AC;&#x2DC;integrated drug information [put] into the general health education and then ongoing discussion based type education around health issues'. We are there to try and encourage young people to develop the skills. Give them the information for the schools to build on to make what they say is an informed choice. It is trying to get them to understand what sort of things will happen if they decide to use x, y or z. (worker in drugs education project) However, this is not necessarily happening in schools, nor systematically across other agencies working with young people. Some agencies felt that school drugs education is still based upon scare-mongering and was likely to be ineffective - 'it has to be a real person who's talking about the real issue and who can show them the 'real negativities'. (Arrest Referral worker). These concerns echo those expressed in a recent review of drug service provision in Birmingham64, which pointed to the need for a health promotion strategy to address the needs of young people who may be experimenting, or tempted to experiment with certain drugs, but who may not be considered problematic drug users.

3.4.1.3

Educating Adults

Adults in contact with young people may have a variety of different needs for information. They may be involved in educating young people, they may work with children on an extra curricular basis or they may be simply parents or carers worried that their child may be in contact with drugs. Thus their needs may range from simply wanting general information to the need for much more extensive training in substance abuse, sources of treatment and related issues. Several organisations in Birmingham operate a help-line. Parents for Prevention informs parents about drugs and tries to assist them in talking to their children. Drugline provides advice, and training and the Community Drug teams can also assist with information. The Health Education Unit provides a course (Drugs, Young People and the Community) primarily aimed at teachers and youth workers, as discussed in section 3.3.2 above. This course focuses upon several different areas. Firstly, it deals with substances and their effects. Secondly upon recognising those signs which would indicate that someone has a problem with substance abuse and possibly invoking the HAS 4-tier model to give some idea of the level of the problem and thirdly upon where help with problems may be sought.

Williams, N (2002) Review of Drug Service Provision in Birmingham. Report to the Drug Action Tem.

These courses are, within the time limit allowed, quite extensive in their coverage. Anyone attending them would certainly go away with an enhanced knowledge of the substance abuse problem and some knowledge of where help may be sought. However, the number of people who can attend the course each year is limited and knowledge may become dated. This is a particular concern with regard to seeking help for young people who are having problems, because the agencies involved may change. For example, those who attended the course in the past would have little knowledge of HIAH as a key player in Birmingham. Other courses are also available but are not necessarily geared around young people. The main gap with the provision already in place is that the person seeking training may have difficulty in accessing the right course for his or her needs or, indeed, even finding out what courses are available. This will be a particular problem for those who are not teachers or who do not work for organisations closely aligned to criminal justice work. There may also be problems because this is a rapidly changing field and information particularly with regards to where help may be obtained - may go out of date. A clearinghouse or one-stop shop, where adults who are either ordinary members of the public or those who may be involved in children's education or extracurricular activities can obtain advice would be useful.

3.4.1.4

Educating those who work with socially excluded young people and those experiencing multiple problems

A third area in which education and training is very important concerns those people who may already be working with young people who have a problem with substance misuse. Leaving aside those, such as GPs who are actually providing treatment this is still a very wide area. It includes, for example, all those who work in the criminal justice system who are likely to come into daily contact with drug and alcohol users but also those who work in projects designed for young people at risk of offending such as YIPs. It also includes those who work with homeless young people and many who work in such areas as education, training and employment. Arguably it might also include many of those who work for treatment agencies in an advising or counselling capacity. All of these people are more or less expected to know about drugs and about how to discuss substance abuse with young people but in fact their training may be outdated or not intense enough and as one agency representative stated -'you have to keep fresh with the issues What I'd like to see is ongoing information and training, e.g. what services are available, resources funding, good reference books. For example, a phone directory of resources, with a brief description of what each service does. (worker in agency for homeless people).

The HEU's course is useful as an induction for staff. It's good but they need more in-depth knowledge to improve the quality of the work they're doing. (worker in agency for homeless people) There is a demand in this arena for training which is more extensive than the HEU course provides, particularly among agencies dealing with vulnerable young people and among agencies dealing with young people already involved in the criminal justice system. In particular one agency cited the need for more training in in-depth counselling 'especially in terms of specialised services dealing with issues such as sexual abuse, physical abuse and drugs'. Another stated 'Ok I've had my drug training on the effects of drugs and what they do and blah, blah. But then you need to go to the next level about how would you start the process of having that discussion with that person to come off drugs. OK let's say they want to come off drugs. What would you do as a drug worker, what are the different therapies that can be done? So you can be informative, you know'. (Worker in women's project) Continuous professional education is what is needed here and, though, this is to an extent available and being developed through various agencies there would not appear to be a clear-cut and well publicised path forward for those working in the field. We do get a lot of things about what drug training is out there but it still seems to be on a very general basis and I think we've gone past that stage. Or we need to get past that stage if we're to look at the person holistically. And it's find out, OK, where we get the next level up if we're not identified drugs workers. (project worker) This suggests the need for greater co-ordination between different agencies providing education and training at different levels and aimed at different groups, to ensure that agency staff can access the level appropriate to their needs and update their training on a regular basis; as well as progressing through the different levels if required.

3.4.2 Treatment and other services to young people 3.4.2.1

General issues

The major problem, which has been highlighted in earlier sections, is that of waiting lists, particularly currently for those aged over 18. As HIAH becomes better known and the volume of referrals increases, this is also likely to become an issue for the younger age group. Many interviewees felt that there is a good range of services for adults (problems of long waiting lists aside), but that having services for young people based in one agency might be more restrictive, despite the variety of service that HIAH provides. To some extent, this is being addressed by having HIAH link workers based in other agencies such as the Youth Offending Service.

There was some perception, which is summarised by a quote from an educational organisation, that ‘it’s quicker for someone to get into treatment if they get arrested first, rather than if they just walk through the door of a treatment agency’, i.e. that young offenders may be fast-tracked through the system. On the other hand, some people remarked on the need for immediate help to be offered to drug users with other severe problems, including a criminal record and homelessness, to ensure that they are given the support they need to divert them from offending and motivate them to change other behaviour that puts them at risk. At the different levels of provision, there was felt to be a need for improved services for the younger age groups at Tier 4. For example, there were seen to be gaps in detox facilities and residential rehabilitation for the under 18s. There is currently no local residential rehab service in Birmingham, which can be problematic for some groups, such as women with families or other caring responsibilities, who may find it difficult to move away from the area. This needs to be counterbalanced against the argument that for some young people, moving away from the area may be beneficial, as it can take them away from some of the negative influences in their lives. In the past, demand for services for young people at this level has been relatively low65, but service provision specifically for young people at a national level is currently limited and there is a need to consider the implications should the demand increase. There is also the issue that some organisations and individuals, for example some GPs, may not be equipped to deal with the multiplicity of problems faced by many drug users, which could include homelessness, problems with family relations, mental health problems, sexual exploitation and others. Many GPs and some of the agencies working in the drug treatment field were seen by interviewees as operating from a medical model and not working with young people as individuals through a holistic approach. On the other hand, at least one GP commented that this was a problem of what people expected from him (both clients and referring agencies): they only came for medication, whereas he would have liked to do further work with them. This may reflect a gap in awareness on the part of individuals and referring agencies of the services that might be offered, as well as a potential training need for some practitioners in holistic approaches to drug use. Agencies such as HIAH, however, were seen to adopt a more holistic approach, which was better suited to the target group. For example, the integration of complementary therapies was seen to be an important component to this work. It was felt by some that connections between young people’s and adult services might be improved and that further consideration should be given to the potential continuation from one to the other, because, as one manager in a drug treatment agency observed, ‘young people …. become adults ….and at the moment there’s no mechanism worked out’. HIAH have recently 65

Williams, N (op cit).

started to develop a system for transferring 18 year olds smoothly over to the adult services, but this development needs to be promoted more widely. Consideration could also be given to a step-by-step multi-agency approach catering for all the levels of potential input when a young person might need help. Some interviewees advocated a â&#x20AC;&#x2DC;one stop shopâ&#x20AC;&#x2122; approach to encourage open access among young people. Other agencies would debate this approach: for example HIAH would not generally see young people without an appointment, on the grounds that young people should learn to keep appointments. While this approach has its merits, it also raises questions about whether this can meet the needs of the most chaotic drug users. Some concerns were also raised about longer-term aftercare following treatment, which is not currently provided. When young people have been using drugs for some years, it can take a degree of time for them to change their lifestyle and this is a time when support may be particularly needed. There was also perceived to be a gap in terms of child psychiatric oriented services and little work being done in the area of dual diagnosis for young people. Currently the Addictive Behaviour Centre undertakes dual diagnosis work, but this is an adult service. Several agency representatives remarked on the perceived need for a fully structured appropriately targeted prescribing service. There appear to be opposing views on the appropriateness of methadone prescription, but there is an argument that if there is a strong, vigorously applied protocol, with supervised consumption to ensure that prescribing is safe, then there are circumstances in which it may be acceptable. This may work only if a prescribing service is closely linked with other services so that the young person is given the support to move forward (for example, related counselling in anger management and other issues). Having more clinic slots with GPs in attendance in drug treatment agencies was also put forward as a suggestion. The issue was raised of services to poly drug users, with a concern that agencies did not always have the resources or expertise to work with this group. In addition to the gaps in drug-related services discussed above, there appears to be a lack in some instances in alcohol-related services, which may affect particular groups such as women and homeless people. For example, there appear to be vacancies for specialist workers in alcohol use, in teams working with issues such as domestic violence and homelessness. Other perceived gaps in services were discussed by agencies. These included the need for some more specialised services, such as in family therapy, particularly for the over 16s. Some work is undertaken by agencies, including mediation and support counselling, but it is this specialist service for young people that is seen as currently lacking.

In some cases, the perceived gap may be due to lack of awareness of the issues. For instance, some interviewees felt that services were geared towards crack and heroin use, but that there was little help for example for parents concerned about their children using other drugs. In some cases this might result in inappropriate referrals. For example, one agency cited examples where young people were ‘brought in’ by their parents who thought they had a drug problem (usually cannabis), but the young person refused help saying that they had no problem with their drug use. Parents for Prevention receive and support large numbers of parents with concerns about drug use, but this may indicate a need for other services also to provide information for parents, particularly given the high profile that drug use among young people is given in the media. Counselling for young people who are substance misusers (apart from the services provided by HIAH) was also seen by some as a major gap in provision. Often, however, young people’s needs may be relatively low level, for example someone to talk to about their drug and alcohol use. Another issue related to the lack of suitably qualified drugs workers, particularly as demand has increased and competition between agencies is thus relatively high. This can impact on the range of services that agencies are able to offer. Finally, on a general level, the need for early intervention was raised. While this can include the work in schools already taking place, it may also indicate a need for further training for staff in agencies dealing with excluded young people.

3.4.2

For specific groups of young people

3.4.2.1

Geographical issues

Most services are based in central Birmingham and there was perceived by many to be a need for satellite services and more detached/outreach work. Many young people are not able to, or do not feel able to travel. This can relate to their economic circumstances (for instance the cost of travelling, which can fairly easily be catered for, as in the example of one agency which offers weekly bus passes), plus other issues such as childcare. As one staff member in a drug treatment agency remarked ‘it’s very hard for [them] to travel when you’ve got a paranoia. You are terrified and you are scared and you have got to come on the bus and you haven’t got any money …it’s just a nightmare’. Some satellite services and outreach working are already starting to be put in place, for example, through HIAH.

3.4.2.2

Homeless young people

With homeless young people, particularly rough sleepers, there is a need for immediacy in response. This is a serious problem if they do not have an address, as they will then have difficulty in gaining access to a GP or other agencies such as community detox and thus are not accessing the services they need. Some agencies in our study expressed the pessimistic view that it was unrealistic to hope that a young person would stop their drug use whilst on the streets and useless to try until they had got accommodation of some kind sorted out. This is contrasted with comments from agencies working with homeless people, who pointed to the need to take into account the whole ‘package of trying to register with a GP, health issues etc’ and the fact that unless homeless young people are getting support simultaneously from a range of agencies, the likelihood of their stabilising their lifestyle, including their drug use, is much reduced. Drug and alcohol treatment agencies need to be much more sensitive to the needs and difficulties faced by homeless young people and to provide a safe but flexible service. Homeless young people also are likely to face a range of problems, including abuse, family separation, low self-esteem and other issues which may be linked in to their drug use and agencies need to be aware of these issues. For young people to get to us, it means that most of their safety networks have failed. With rough sleepers, around 50 per cent or more have suffered abuse as kids, or some other trauma such as parental death or separation. Drugs can be a barrier to pain. Detox is easy, it’s dealing with the emotion that comes as well, through rehab, or for example counselling therapy – a more holistic service for young people, dealing with all their needs together, such as learning social skills, trauma counselling, self-esteem, sexual practices, health. Treatment reduces harm, but it’s a question of how well we pick up on the other issues. (Worker in agency for homeless people). Recent good practice guidance66 has identified the need to include agencies working with homeless people in the planning and design of drug treatment services, which may help to address some of the concerns raised above.

3.4.2.3

Minority ethnic groups

As mentioned earlier one of the strands of this research was the qualitative interview programme with agency representatives. One of the questions posed as part of the interview was whether staff identified any gaps in drugs 66

For example, Randall, G and J Britton (2002) Drug treatment services for homeless people. London: Home Office.

services provision more generally and more specifically, if their were particular groups of young people who it was felt were not being catered for. Almost half of all those interviewed believed that young people from ‘Black and minority ethnic communities’ were often neglected in terms of a comprehensive needs assessment and adequate drugs services provision. Moreover these professionals believed that young people from black and minority ethnic communities and service providers had needs which must be met if prevention and treatment work were to be relevant and effective. I think a lot of our clients tend to be young white males. As I say we’ve very, very few females and we have very few clients of ethnic you know, origins. We have very few sort of black clients and very few Asian clients. So I’m not sure whether that’s about people just aren’t coming forward or if it’s a cultural thing where you just don’t do it. I don’t really know. (staff member in drug treatment agency) …you know evidence has shown that there was a number of ethnic minorities out there that are using the variety of drugs and are very active in the drug field. But in the 18 years that I’ve worked here and we’ve not seen a lot of [BME communities] at all. I think it could be that the services are not conducive to the culture for them. We’ve had a few people through here and they’ve not lasted that long and I don’t, I’m not sure whether it’s a cultural thing (Manager in drug treatment agency) The interview respondents were encouraged to offer suggestions as to why they thought black and minority ethnic communities were not accessing the few services that existed. Several issues were raised and the most commonly held view was that employing staff of minority ethnic origin may help services to gain the trust of and secure access to ‘visible minorities’. …there’s not that good spread of ethnic minority team members here… They see white people and they just think these people they can’t communicate with me, I mean there would all be some black users that prefer a white worker than a black worker, but that’s probably more, not the norm you know. (Staff member in drug treatment agency) Most of the drug agencies have no Asian staff. The projects look is important. They may feel uncomfortable there. They’ve done a bit to get Blacks on board, but nothing has been done to involve Asians. (Manager in project working with excluded young people). There was also the perception that there was a lack of adequate knowledge about minority cultures and community priorities, which manifested in a reluctance to ‘have a go’.

I think you have to have a certain knowledge base about the community that you work in and how that community operates. (worker in voluntary organisation) A few agency representatives echoed findings within existing research literature, which suggested that traditionally drug treatment services promoted their services in terms of offering help with a well-defined and restricted range of drug problems, such as opiate dependency (for example, Sangster et al67). Consequently it was this ‘medical model’ approach which was seen to deter the take up of services by ‘visible minorities’ and vulnerable young people more generally. It was also implied that crack cocaine misuse has become a pressing problem in the Birmingham area, which was seen disproportionately to involve people from black and minority ethnic communities. This had resulted in some experts calling for specialist crack services to attract referrals from ‘visible minorities’. One of the complaints amongst service providers was the fact that they were unable to dedicate resources to seeking out specific black and minority ethnic communities. There was a general belief that positive outreach work could help to improve visible minority groups’ access to drug treatment services. This is where outreach is so important there's a lot of kids being missed and it’s all the kids that are being missed that we need to get to. (staff member in drug treatment agency) One final point of great importance raised by agency representatives specifically representing young people from visible minority groups (e.g. youth groups etc) was the tendency to treat black and minority ethnic communities as a homogeneous group. These representatives affirmed the many differences between the communities (cultural, religious etc) that existed within the umbrella ‘Black and minority ethnic communities’ term. Furthermore staff alluded to stating how it was false to assume that all young people within a group, for example, those born to Pakistani parents, share a cultural identity and have similar needs. The underlying thoughts were to treat young people from black and minority ethnic communities as individuals, to enable a comprehensive needs assessment which could then help to inform the design of future drugs services provision for these individuals who were ‘affiliated’ to a number of different ‘minority ethnic communities’.

3.4.2.4

Women

Some representatives commented that services could be more sensitive to the needs of women clients. A few services are specifically directed at 67

Sangster, D, M Shiner, K Patel and N Sheikh (2002) Delivering drug services to Black and ethnic-minority communities. London: Home Office. Sangster et al also discuss the focus of many services on heroin injecting, which is a method likely to be less prevalent among black and minority ethnic drug users.

women (for example, a mother and baby unit based in the ABC, which is predominantly a service geared towards adults, but through joint working with HIAH is also providing for the young age group). More generic services do not necessarily cater for the separate needs of women, however, particularly women with specific needs, as discussed below. Women with children or pregnant women may feel afraid to disclose drug problems because of fear of social services involvement and the possibility that their children will be removed from their care. While some services are sensitive to these issues (for example, one staff member in a drug treatment agency noted that ‘…just because you’re a drug user doesn’t mean that you’re a bad mother’), these fears may sometimes be justified. Examples were given during the research of situations in which agencies were seen to have over-reacted to such situations, as for instance in the anecdotal evidence below. I heard of a hospital recently, who when they found out a woman was pregnant, were automatically calling a case conference. So of course they’re going to stay away. (Manager in a criminal justice agency) The situation is often compounded when young parents are also perceived to be exposed to other risks, such as women working in the sex industry. More generally, workers in the sex industry were seen as less likely to access services because fear of discrimination if they revealed details of their lifestyle. It was recognised by some staff in treatment agencies that sex workers were not accessing their services. Similarly, young women experiencing domestic violence are less likely to access mainstream services, in part because they may have encountered unsympathetic responses to their situation, and also in some circumstances as a result of lack of self-esteem and confidence due to a history of abuse. This was echoed by some workers in relation to drug and alcohol services.

3.4.2.5

Other groups

Other groups mentioned included disabled young people: both in terms of physical access, which is not yet provided by all services, but also in terms of individual preconceptions and institutional structures and processes which may discriminate against those with disabilities. Hard-to-reach young people generally are less likely to access services, in part, it was observed, through a lack of self-esteem, but also because of lack of knowledge of ‘what is out there’. The issue of whether they actually want help at that particular time also needs to be considered. Finally, some representatives referred to looked-after young people, who may encounter a range of problems and yet have difficulties in accessing services.

More generally, there is a huge issue with excluded young people and social services kids (looked after young people) â&#x20AC;&#x201C; the most vulnerable have the least access from the prevention/harmonisation services. (Manager in voluntary sector agency).

3.4.2.6

General issues

The examples above point to the need for further education and training for staff working in agencies in the drug and alcohol field, to ensure that they are sensitive to the issues presented by different groups. It is also important to develop greater links with organisations working directly with specific groups, particularly in the voluntary sector, to ensure that agencies draw upon their expertise and to facilitate cross-referrals and joint working on individual cases.

Implications for future practice and recommendations

4.1

Provision for young people in Birmingham

4.1.1 Range of provision Many of the comments in this report relate to the range of services currently provided to young people in Birmingham and often echo concerns expressed elsewhere. While HIAH already provides specialist services for young people aged 18 and below, including complementary therapies, there is perceived to be a more general need for continued development of holistic approaches to substance misuse treatment and prevention services, as advocated in the Models of Care report68. A wider range of interventions will result in more choices being available to young people to suit their needs at particular times. This may include the â&#x20AC;&#x2DC;one-stop-shopâ&#x20AC;&#x2122; approach to provision. One of the main problems encountered was that of waiting lists, particularly for the older age groups. This is partly related to existing staffing resources, but is not a problem that can necessarily be dealt with on a short-term basis, as agencies may not have the structures in place to be able to tackle the issues. While additional funding is important, a longer-term strategy also needs to be in place to ensure that agencies can recruit staff with the requisite skills and have the appropriate organisational systems in place. A further issue raised was the geographical spread of services, with the main providers being based in the city centre. While this is being addressed in some instances through outreach and detached services, consideration should be given to whether further satellite services might be required in particular areas of need. Concerns were expressed regarding the extent to which services currently address problematic alcohol use among young people, particularly since the evidence suggests that consumption of alcohol by young people has been increasing69. This is also noted by Williams70 when considering services to young people in her report and is a concern echoed in the Models of Care report.

4.1.2 Education and training Gaps in education and training, for young people, their parents and professionals working in agencies, were identified in our research, echoing 68

Department of Health (2002) Models of Care for substance misuse treatment: promoting quality, efficiency and effectiveness in drug misuse treatment services. Full report for consultation. London: DoH. 69 For example, see Balding, J (1998) Young people in 1997. Exeter University. 70 Williams, N (op cit).

needs that have been expressed elsewhere. In particular, further information, advice and guidance is required at Tier 1, to ensure that young people and parents are aware of the effects of different drugs and the dangers associated with them. This is an especially important issue for young people who are not in mainstream education. A further concern expressed was in relation to staff in agencies working with vulnerable young people, who often feel that they are not sufficiently briefed themselves to advise young people on substance use or to recognise signs of problematic use. While training is provided by the Health Education Unit, there was seen to be a need for a wider range of education and training to encompass different needs and to enable professional development. This requires a co-ordinated multi-agency approach.

4.1.3 Working with vulnerable groups In addition to greater variety in training offered to staff working with young people in different settings, it is important that mainstream treatment and service agencies are sensitive to the needs of different groups and issues faced by them. This requires close liaison with those organisations working with groups such as homeless people, young people leaving care, vulnerable young women and others at risk of social exclusion, as recommended in recent good practice guides71. Accessibility to services was noted as a serious problem for vulnerable young people and attention needs to be paid to the differing needs of particular groups, such as homeless young people. The integrated model of care proposed in the Models of Care report may go some way towards addressing these concerns. Our research identified the problems faced by young people leaving home, who may often come into contact with drug users in temporary accommodation. This points to the need to target drug prevention and treatment services at hostels and other temporary accommodation providers. In addition, consideration needs to be given to ways in which to support problematic drug users in social housing, to reduce the risk of losing their tenancy and being placed in a more vulnerable situation72. The need for early intervention was also raised by many stakeholders. It was also noted that this needs to be approached with caution, as in the case of children of substance-misusing parents or young drug-using parents, to avoid counterproductive over-reaction to concerns. Clear joint protocols for dealing with child protection issues in relation to problematic substance use, as recommended in Models of Care, are necessary to ensure that there is proper assessment of risk, but that drug misusing parents are not deterred from seeking help from services . New recommendations for co-ordination 71

For example, Randall and Britton (op cit). This is discussed in depth in Robinson, I and K Flemen (2002) Tackling drug use in rented housing: a good practice guide. London: Home Office/DTLR.

of children’s services arising from the Cross Cutting Review of Children at Risk for the 2002 Spending Review aim to ensure that preventive approaches are in place in services for children and families from 2003, to support young people at risk. A particular concern raised in the research was the need for longer-term support and aftercare for problematic drug users. Short-term funding for initiatives aimed at vulnerable groups can often create problems for provision of ongoing support and this issue needs to be addressed through an integrated multi-agency strategy.

4.1.4 Involvement of communities and service users The need for ‘bottom-up’ services was raised on several occasions in our interviews and the need to involve service users in planning of provision is highlighted in a number of policy documents, particularly those emanating from the Children and Young Person’s Unit. Agencies representing minority ethnic communities approached during our research expressed the concern that their views have frequently been solicited and yet do not appear to have been acted upon in development of services to young people from those communities. The report by Sangster et al identifies a number of mechanisms that may be put into place to develop drug services which are accessible and appropriate for minority ethnic drug users. These include greater involvement of black and minority ethnic representatives in management, planning and delivery of services, ensuring that services have the ability to meet the distinct needs of different communities and the development of services that are ‘in, and for, the community’. 4.2

Role of Birmingham Drug Action Team

The DAT clearly has a crucial role to play in relation to the development of services to young people in Birmingham. From the research undertaken, there are particular areas where action might be taken. These include taking a central role in dissemination, ensuring integrated strategies through a multi-agency approach to young people and substance use and involving local communities and organisations in service planning. These are discussed below.

4.2.1 Communication One key area that was identified was the lack of knowledge on the part of many organisations about the different treatment and other service agencies in the city and the circumstances under which it is appropriate to refer to particular agencies. The DAT could usefully play a role in co-ordinating information and dissemination about the availability and functions of prevention and treatment agencies in the city, as well as those aimed at

vulnerable or excluded young people which have an element of substance misuse prevention. A directory of services is already being developed. The issue of confidentiality and information-sharing between agencies was raised as a serious issue which often impeded the work of agencies. The development of information-sharing protocols between statutory and other agencies working with young people is another area where the DAT might take a lead. The recent conference organised by the DAT was a useful arena for developing organisational networks and discussing issues of concern, for example, around the appropriateness of methadone prescription. This type of event, or smaller seminars, can be helpful to initiate debates around particular issues or perceived problems. For example, our research highlighted a number of misconceptions amongst representatives concerning substance use and misuse by different ethnic groups, which might usefully be addressed in such a forum. Finally, a large number of agencies interviewed were not fully aware of the role of the DAT itself and there was limited knowledge of the Annual Plan and recent developments in drugs prevention initiatives. This signals a need for the DAT to promote itself more widely, which again has already started to take place, for example through the recent conference.

4.2.2 Involvement of local communities The importance of involving organisations and individuals based in local communities in development of services has been stressed in a number of contexts, including policy documents produced by Government departments referred to earlier. Particular groups consulted in our research included organisations representing homeless young people, members of minority ethnic communities and vulnerable young women. The Communities Against Drugs initiative is a recent development which aims to assist local communities in combating substance misuse, but there is an additional need to involve communities in planning and design of services. Many of the organisations consulted who worked directly with particular groups, such as minority ethnic young people, stated that they require closer, more direct links with the DAT, for example representation on a consultative/ advisory group, to ensure they are involved in the decision making process on commissioning drug services in accordance with their knowledge of the needs and services of these specific groups of young people.

4.2.3 Co-ordination of activities This has been discussed under the headings above, but it is worth emphasising the role that the DAT can play in developing inter-agency working, particularly at a strategic level. For example, in addition to taking a central role in the commissioning and co-ordination of provision for

treatment and prevention, the DAT might also play a vital part in other initiatives such as the development of an education and training strategy around young people and substance misuse, as discussed earlier. The courses for drugs workers being developed by Matthew Boulton College will make an important contribution to an overall education and training structure. 4.3

Conclusion

This report has outlined some of the main concerns of stakeholders in regard to substance misuse prevention and treatment services to young people. Together with the report produced by the Consultancy Partnership, it presents an overview of problematic substance use by young people and use of alcohol, drugs and other substances more generally, as well as the needs of young people and agencies working with them. A number of recommendations have arisen out of the research findings. It should be noted that in response to the recent increase in resources and the updating of the Governmentâ&#x20AC;&#x2122;s Drugs Strategy, the DAT has recently revised its structures and forward plans73 and many of the issues raised here are already starting to be taken into account.

Details of current and future activities are given in the Birmingham Drug Action Teamâ&#x20AC;&#x2122;s Annual Report 2001/2002 and forward plan.

Appendix I

Organisations consulted during the research

Addictive Behaviour Centre, including specific projects Azaadi Treatment Agency Birmingham Partnership against Racial Harassment Birmingham Voluntary Services Drug Foundation Connexions Focus Housing Girlspace GOWM Health Education Unit HIAH, including consultant GP Kingstanding YIP Lifelong Learning Division Maypole Centre Midland Life Education Centre Trust Parents for Prevention Probation Saltley Gate Project Schools (including those participating in the survey of young people and individuals interviewed) Sikh Youth Forum Social Services SRB4 Community Safety Co-ordination Team SRB5 representative St Basils Hostel Turning Point Washwood Heath YIP West Midlands Police Youth Offending Service and individual Youth Offending Teams