ResearchIntoTheProvisionOfAlcoholRehabRecovery_May2006

Research into the Provision of Alcohol Rehabilitation and Recovery for the Heart of Birmingham Primary Care Trust

Prepared by Mike Ward with Mala Seecoomar For Consultancy@Alcohol Concern

May 2006

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Contents 1. Introduction 1.1 Definition of aftercare 1.2 Definition of the client group 1.3 Methodology 1.4 Acknowledgements 2. How many people will require aftercare services?

2.1 How Many People Have An Alcohol Problem in Heart of Birmingham?

2.2. Is Heart of Birmingham above or below the national average for long term chronic drink problems?

2.3 Drawing conclusions about the level of need for treatment services 2.4 Drawing conclusions about the level of need for aftercare services 2.4.1 Local data 2.5 Estimating the impact of people who are out of contact with services 2.6 Conclusions 3. Care Management and Care Coordination 3.1 Assessing the Local Situation 3.2 Reflecting diverse needs 3.3 Conclusions 3.4 Recommendations 4. Aftercare for clients who have made positive gains 4.1 National guidance 4.2 Examples of good practice 4.2.1 Advice and support helplines 4.2.2 Self help groups 4.2.3 Drop-in/social clubs 4.2.4 Rapid access back in to treatment 4.2.5 Housing 4.2.6 Training / Employment 4.2.7 Social skills development programmes 4.3 What is the evidence on the effectiveness of aftercare?

4.4 Assessing the local situation - service user views on effective aftercare 4.5 Assessing the local situation - comments from the interviews 4.6 Assessing the local situation - comments from the questionnaires 4.7 Conclusion 4.8 Recommendations 5. Aftercare for clients who have left treatment without making positive gains or in an unplanned way 5.1 Is Engagement Worthwhile?

5.2 Examples of good practice 5.2.1 Care planning 5.2.2 Engagement approaches 5.3 Assessing the Local Situation – Interview Data 5.4 Conclusions 5.5 Recommendations 6. Workers’ competence to undertake aftercare 6.1 Assessing the local situation – interview data 6.2 Assessing the local situation – questionnaire data

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6.3 Conclusions 6.4 Recommendations 7. The strategic level 7.1 Strategic framework 7.2 Strategic Planning 7.3 Operational planning 7.4 Purchasing activities 7.5 Monitoring and review 7.5.1 Learning Lessons – Critical Incident Inquiries 7.6 Conclusions 7.7 Recommendations Appendices

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Executive Summary The Heart of Birmingham Primary Care Trust (PCT) commissioned this research to identify the requirement for aftercare services for problem drinkers in the Heart of Birmingham (HoB) PCT area.

Data provided by local agencies suggests that 700 problem drinkers will require aftercare services each year in the HoB PCT area.

At least 40-50% of clients will disengage from services each year without successfully completing the programme. This equates to another 700 people per year. Research evidence suggests that the clients who drop out are likely to have higher levels of risk associated with them, e.g. risk of suicide or violence to others. Therefore any system of after care will need to address the needs of those who disengage as well as those who successfully complete treatment.

A key to successful aftercare is a system of care planning and care coordination. Although local agencies all undertake care planning with their clients, the more intensive, potentially multi-agency approach envisaged by the NTA’s care coordination model is not in place locally.

Aftercare for problem drinkers who successfully complete treatment in the HoB area is poorly developed. Service users are clearly stating the need for better aftercare. Existing alcohol services do not feel they have the resources to provide ongoing care. Those non-specialist services which could provide aftercare are not well-linked in to the network of alcohol treatment services or well-prepared to take on problem drinkers.

Models of Care identifies a continuum of aftercare services which runs from peer support groups to services which develop employment, training and social skills. Most of these are poorly developed in the area.

The absence of aftercare services is so stark that there are many possible ways forward. Local commissioners will need to choose between these options. However, it should be noted that education, employment and training opportunities for clients are the clearest gap.

The limitations on the range of services for problem drinkers locally inevitably mean that the response to clients who are difficult to engage in treatment services is also limited. There was recognition that disengagement from services is just as much of a local problem as it is anywhere else. However, the resources available to follow-up clients are limited.

No evidence was found that the lack of aftercare services or the lack of follow up for difficult to engage clients was due to a lack of competence on the part of specialist alcohol workers. Resources rather than training appears to be the key issue.

However, gaps were identified in the skills of non-specialist services who may take on aftercare responsibilities. Two key training needs emerged:

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 

Understanding the options offered by specialist services Working with problem drinkers who are unwilling to change / continuing to drink Just under a third of agencies had protocols on working with problem drinkers.

The commissioning system offers a number of opportunities to drive the importance of aftercare and following-up disengaging clients into the treatment system. These following opportunities are not being exploited locally.  Aftercare and engagement of problem drinkers are not featuring in key local strategies.  Commissioners are not identifying priority groups for follow-up and aftercare.  Risk assessment systems need to identify the clients who need to be prioritised for follow-up and engagement  Contracts and service level agreements should specify engagement and aftercare  Performance monitoring systems should set outcome targets which measure agencies success in these areas.  Lessons about failures of aftercare and engagement should be identified and disseminated from existing local inquiry processes and consideration should be given to undertaking reviews of serious untoward incidents concerning problem drinkers.

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Recommendations  Heart of Birmingham PCT should work with Birmingham DAT and local treatment providers to ensure that the care coordination model is in place across the PCT area for alcohol misusers. 

Heart of Birmingham PCT should ask local agencies to undertake an annual audit of case files to ensure that all clients who require it have an aftercare plan in place.



The DAT and the PCT should ensure that the framework within the NTA’s Care Planning Toolkit is used to structure planning both aftercare for those successfully completing treatment and engagement with difficult to engage clients.



Heart of Birmingham PCT must lead the development of a system of aftercare for problem drinkers in the area.

The PCT will need to choose between one or more of the following options:  Appointing an aftercare development officer to oversee the development of aftercare through the better use of existing resources and by seeking new resources to develop other services.  Appointing aftercare workers in the key alcohol services.  Developing a specialist aftercare service.  Developing the capacity of non-specialist service to take on problem drinkers and improving their links with specialist services. 

The PCT should give a priority to providing the need for education, employment and training aftercare opportunities for problem drinkers.

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The PCT should agree a set of procedures for alcohol agencies to pursue with regard to clients who disengage from services. Such procedures should recognise the need to assertively follow-up risky or vulnerable clients who disengage.

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The PCT should consider whether specialist outreach services are required to follow up clients who are difficult to engage.

The PCT should work to improve the links between specialist alcohol agencies and potential non-specialist providers of aftercare. This work should embrace:  Information provision about the services offered by the various specialist and non-specialist agencies Aftercare

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



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A programme of training for non-specialist, tier 1 services which enables them to understand the range and function of local specialist services and work effectively with difficult to engage clients.

The development of protocols and procedures to support non-specialist agencies in working with problem drinkers.

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The PCT should ensure that aftercare and engagement of problem drinkers are featuring in key local strategies.

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The PCT should ensure that commissioners identify the priority groups for follow-up and aftercare.

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The PCT should ensure that risk assessment systems are in place in alcohol services and that these identify the clients who need to be prioritised for follow-up and engagement.

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The PCT should ensure that contracts and service level agreements should specify the local requirements for engagement and aftercare.

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The PCT should ensure that performance monitoring systems should set outcome targets which measure agencies success in engagement and aftercare.

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The PCT should ensure that lessons about failures of aftercare and engagement should be identified and disseminated from existing local inquiry processes and consideration should be given to undertaking reviews of serious untoward incidents concerning problem drinkers.

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1. Introduction The Heart of Birmingham Primary Care Trust (PCT) commissioned this research to:  identify the requirement for aftercare services for problem drinkers in the Heart of Birmingham PCT area.

1.1 Definition of aftercare This project is focused on those people “who require aftercare in the form of rehabilitation, recovery and community re-integration services to help them maintain reduction in the harm arising from their existing or previous alcohol misuse.”1 To move forward it is, therefore, necessary to have a clear definition of “aftercare”.

Aftercare is a word which means different things to different agencies. For prison based services aftercare is any programme of care beyond the sentence; a tier 4 residential rehabilitation would be aftercare for the prison system. Yet that residential service would regard aftercare as a move on house or a day programme. So what should be regarded as aftercare in the alcohol field?

The current guidance from the NTA on aftercare is in a fluid state. The consultation draft of Models of Care for Alcohol Misusers (MoCAM) does not include aftercare as part of the four tiers. Instead it talks about a separate process of “Helping individuals maintain the gains they have made from alcohol treatment”. 2 Similarly, the original version of Models of Care for Drugs (MoCD) does not include aftercare as part of the four tiers. However, the consultation draft of the new Models of Care for Drugs (2005) changes that position: “Tier 2 interventions can be a key delivery mechanism for the provision of aftercare.

In this context aftercare is drug-related support following the completion of care-planned drug treatment. This could comprise support groups or individual support for those wishing to remain drug-free or access to user groups and advocacy mechanisms (such as Narcotics Anonymous or equivalent groups).”3 The new draft also suggests that “Tier 4 interventions comprise residential specialised drug treatment which is care planned and care co-ordinated to ensure continuity of care and aftercare.”4 This study is, therefore, focused on the ongoing support needs of clients with alcohol problems who have, either in their own view or the view of the providers, exhausted the use of services available within the four tiers described in Models of Care albeit that they may benefit from some of the aftercare envisioned in the new definitions of tier 2 and 4.

(NB It seems likely that the final draft of MoCAM will be brought in to line with the new MoCD framework, therefore this report will draw on the new MoCD framework alongside MoCAM.)

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1.2 Definition of the client group The clients encompassed by this study will be a very disparate group of people. They will vary in terms of ethnicity, gender, intensity of problem, support needs and many other features. No single model of aftercare can be provided to meet all these requirements.

However, one very clear and very important division in this client group needs to be identified which will help structure this report. There are:  clients who have completed their treatment programme and made positive changes which they will need to maintain; and  clients who have failed to make positive changes and are continuing to drink and experience problems.

The response to these two groups will be different and they will be the subject of separate sections of this report. However, one theme does unite the aftercare needs of these two groups and that is care management and care coordination which is addressed in section 3.

1.3 Methodology The project has undertaken its analysis through:  Desk research into national evidence and good practice guidance;  Interviews with local stakeholders;  An analysis of other local data collected from a range of sources e.g. agencies, public health, education and community safety reports.

Alongside these approaches the service undertook:  An audit of the capacity of specialist alcohol services to provide aftercare for problem drinkers. Questionnaires were sent out to the staff of the key specialist alcohol agencies in the area.  An audit of the capacity of non-specialist rehabilitation services to work with problem drinkers. Over 100 questionnaires were sent out to a range of potential providers of aftercare in the area. The list of agencies that responded is in Appendix 1.

1.4 Acknowledgements I would like to thank Mala Seecoomar who undertook many of the interviews, Sean Murphy, Sian Wilton and Don Shenker at Alcohol Concern for their support, Jak Lynch at Heart of Birmingham PCT, Hugh Tibbits at SIFA, the members of the steering group and all the interviewees and respondents for their help with this project.

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2. How many people will require aftercare services?

This section seeks to make some estimates of the number of people in Heart of Birmingham who will require aftercare services. This will embrace both the needs of those who will successfully complete treatment and those who will require follow up because they have dropped out of care.

A previous study has looked at the numbers of problem drinkers in the Birmingham local authority area. This section looks at the more restricted Heart of Birmingham area and uses more recent data from the Department of Health’s ANARP (Alcohol Needs Assessment Research Project) published in 2005.

2.1 How Many People Have An Alcohol Problem in Heart of Birmingham?

There are two key sets of national data on the prevalence of alcohol problems.  ONS general household survey data (2001)  The Department of Health’s Alcohol Needs Assessment Research Project (2005) The ONS general household survey (2001) identifies the following six groups of drinkers. If these are extrapolated to Heart of Birmingham’s adult population (16 and over) of 171,938 this gives the following pattern: Non-drinkers (12% of population) Low-risk drinkers (67.1%), Hazardous drinkers (16.3%) - no apparent problems but taking risks with their longer-term health through regular excessive drinking or intermittent sessions of heavy drinking.

Harmful drinkers (4.1%) - already experiencing physical, social or psychological ill-effects from their drinking but are not severely dependent.

Moderately dependent drinkers (0.4%) Severely dependent drinkers (0.1%)

Estimated Number in HoB 20,632 115,370 28,025

7,049

688 172

Some in the alcohol field dispute the accuracy of the calculation of the two highest categories in this list. It has been argued that these categories significantly underestimate the number of dependent drinkers.5 The Alcohol Needs Assessment Research Project (2005) used the ONS data but enhanced it with other research and comes up with a higher prevalence of problems and, in particular, dependency. This data is focused on the population from 16-64 (147,326) and, therefore, under-represents the small but growing number of older problem drinkers. However, this study does move far more people into the dependent category.6 Aftercare

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Estimated Number in HoB 33,884 5,304

Hazardous/Harmful drinkers (23%).

Dependent drinkers (3.6%)

These national figures can be adjusted by using data on regional drinking patterns to make them more relevant to Heart of Birmingham. ANARP indicates that the West Midlands has the fifth highest level of hazardous and harmful drinking and the fourth highest (both out of nine) level of dependency.

If the figures for the West Midlands Region are extrapolated to the local population the changes are small but the following picture emerges7: Estimated Number in HoB Hazardous/Harmful drinkers (23%) 33,884 Dependent drinkers (4%) 5,893 However, it is also necessary to make adjustments to these figures for the area’s population characteristics. Two so called “protective factors” can change the likely drinking patterns in the community. These are:  An older than average population. Alcohol consumption declines with age. Therefore, areas with an older than average population have a small bias to lower levels of alcohol problems.8 Heart of Birmingham has a slightly older than average population. The mean age of the population is 39.6 as against 38.7 in England and Wales.

This will decrease the expected level of problems slightly.9  Muslim and other non-drinking communities. In some areas the level of drinking in the overall population is reduced by the presence of communities with a tradition of not drinking alcohol, most notably Muslim communities. 3.1% of England’s population define themselves as Muslim. In Heart of Birmingham the proportion is 35% and therefore this protective factor should be a major influence on drinking patterns in the borough.

The presence of a large non-drinking population will significantly reduce the level of hazardous, harmful and dependent drinkers in the Heart of Birmingham area. However, this is dependent on two hypotheses that cannot be easily tested. It is assumed that:  the Muslim population is non-drinking (there is no evidence of a significant pattern to the contrary); and that  the rest of the population shares the characteristics of the national population and will have the same proportion of low-risk and other drinkers.

Estimated Number in HoB 18,533 of which according to ONS data one fifth will be harmful drinkers (3,707) 3,300

Hazardous/Harmful drinkers (12.5%) Dependent drinkers (2.24%)

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All this data suggests that Heart of Birmingham is below the national, average for hazardous, harmful and dependent drinkers. It would suggest that approximately 18,533 people are hazardous or harmful drinkers and 3,300 are dependent drinkers in the borough.

However the key group for this study are the dependent and harmful drinkers who could benefit from alcohol treatment services and, therefore, aftercare.

On this data around 6-7,000 people fall into this category i.e. all the dependent drinkers and a proportion of the hazardous and harmful drinkers.

However, these data are all based on extrapolations of national and regional data. The next sections attempt to identify whether these are supported or contradicted by local data.

2.2. Is Heart of Birmingham above or below the national average for long term chronic drink problems?

This section focuses specifically on the dependent and harmful drinkers and attempts to gain a better understanding of the size of this group in HoB by looking at those local indicators known to be associated with the level of these problems in an area e.g. levels of violence or particular health problems. A single indicator, for example raised suicide rates, is not a reliable indicator of alcohol problems because its level may have been influenced by other factors. However, if a range of different indicators which are known to be linked to alcohol are all below average then this provides a more solid picture of the local scene.

It is generally agreed that the best indicator of the number of dependent and harmful drinkers in an area is the level of liver disease and cirrhosis. In Birmingham generally the level of these problems for all adults is above the national and regional average.

Indicator

Findings

Chronic Liver Disease including Cirrhosis Data City level data

Above the national, regional and county rate. (see appendix 2) Standardised Mortality Rate in England is 100 SMR in W Midlands Region is 110, and in Birmingham it is 128.

However, this data is for the City as a whole. It might be assumed that the make up of the local population, with its bias towards non-drinking populations would reduce the impact. The following table shows whether the individual wards in the borough are above or below average for various alcohol related problems.

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Gastro- Diabetes Alcoholic Alcohol Liver enteritis related Disease Hospital Alcohol Admissions Deaths 2003-4 ASTON BORDESLEY GREEN HANDSWORTH WOOD LADYWOOD LOZELLS AND EAST HANDSWORTH NECHELLS SOHO SPARKBROOK SPRINGFIELD

above

below

above

Below

above

below

above

above

Below

above

below

below

above

Below

below

below

above

above

below

Above

above

above

above

above

above

Below

below

above

above

above

above

Below

above

above

below

above

above

Below

above

above

above

below

above

Above

below

above

below

below

above

Above

below

below

above below

There is no evidence here that the PCT area is as below average as the population statistics would suggest. There is also no correlation between wards with higher Muslim populations and lower levels of alcohol related harm.

It is possible to check this data against a range of other data. However, it should be noted that most of this data is only available at City rather than PCT level and does not readily allow for the particular characteristics of this part of the City.

Indicator

Findings

Number of Licensed Premises City level data

Below the national average. (see appendix 3) There are 6.8 off licences per 10,000 population as against 8.7 in England and Wales.

There are 10.1 on licences per 10,000 population as against 21.2 in England and Wales.

Violent Offences City level data

Above the national and regional level (see appendix 4) 24.2 offences per 1000 population in Birmingham compared with 18.2 in England and Wales and 21.7in W Midlands. (2003/4)

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Toxic effect of alcohol mentioned

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Unemployment and Deprivation Data City level data

Consistent with above average level of alcohol related problems nationally (see appendix 5) In 2001 the unemployment rate was 5.7%., compared with an average for England and Wales of 3.4%

Suicide Data

Suicide rates for the borough are just below the national, and equal to the regional rate. (see appendix 6) The standardised mortality rate for suicide was the same as the regional rate of 98 and just below the national rate of 100.

City level data

Child Protection City level data

The number of children on the child protection register over the period 19992003 was above the regional and national average (see appendix 7) For England there were 25.2 registrations to the child protection register per 10,000 under 18s in 1999-2003, for West Midlands region it was 21.2 and for Birmingham it was 34.6. 10

General Health Data City level data

The census reports that general health is worse than the national average (see appendix 8 In the 2001 census, 10.9% of residents in Heart of Birmingham described their health as 'not good' against 9% for England & Wales

The health data, including that on liver disease suggests that harmful and dependent drinking is around the national average in the PCT rather than well below it as is suggested by the national extrapolations. The other city wide indicators suggest that alcohol problems are certainly approaching national average levels.

This analysis suggests that the number of people in the harmful or dependent drinker categories is likely to be around the national and regional average in Heart of Birmingham.

This contradicts the earlier finding and suggests that at least 12,000 people in Heart of Birmingham would benefit from alcohol treatment services i.e. those in the harmful and dependent categories.

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2.3 Drawing conclusions about the level of need for treatment services In order to estimate the need for aftercare service, it will be necessary to identify the numbers requiring treatment services. Only a small proportion of the people identified with alcohol problems will seek help at any one time. As a result, research has been undertaken to estimate how many and how often individuals will engage with alcohol services.

The best known of these processes was developed by Rush in Canada. The Rush model offers percentage figures which can be applied to local populations in order to estimate the likely numbers entering different types of service. The Alcohol Needs Assessment Research Project, drawing on Rush, suggests that 10% of the in-need population accessing services each year would be a low level of access. 20% would be a high level of access.11

12 13

This data indicates that it would be reasonable to expect at least 10% of the 12,000 people who could benefit to access services in the area each year.

The data suggests that 1,200-2,400 local people could seek help for an alcohol problem each year.

2.4 Drawing conclusions about the level of need for aftercare services To plan services t will be necessary to know how many alcohol service clients will successfully complete and require aftercare and how many will disengage before completion.

A study for the Home Office looking at both alcohol and drug services indicated that:  Disengagement from treatment services is a common feature of alcohol and drug services.  The rates of disengagement range from (at the lower end) 2% of clients disengaging from a private treatment programme to (at the higher end) 70% of clients disengaging from a brief intervention programme. The mean rate of disengagement appears to lie at around 40-50% of clients disengaging from a typical programme.

Particular studies related to alcohol provide even more useful data. For example Edwards A. & Rollnick S. (1997) identified an average 70.6% attrition rate for brief interventions for problem drinkers in primary care.14 Marques A. & Formigoni M. (2001) found that 47.7% drop out rate from an eight week programme of cognitive behavioural treatment.15 Data on the proportion of clients disengaging were sought from all local services.

Substance misuse service 20-40%16 17 IWIC Approx 79% leaving treatment unplanned18 SIFA Approximately 72.5% of clients leaving treatment in an unplanned manner. In 2005-2006 there were 660 discharges which were Aftercare

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Aquarius Social Services Care Management Team

thought to be from the HoB area, of these 181 were planned and 479 unplanned. This represents 27.42% planned against total.19 Around 40%20 About 20% don’t complete.21

The research questionnaires sent to the staff of the key specialist alcohol agencies in the area also asked about disengagement. Forms were received from SIFA, Aquarius, IWIC and the statutory teams. The forms were aimed at frontline workers who had responsibility for client caseloads, the majority working with over 50 clients per year.

The data gathered indicated that disengagement was a significant feature of the client work of most workers. The table below sets out the identified disengagement rates. Over half the workers estimated that they lost more than 40% of their clients through disengagement.

What percentage of these alcohol clients would you estimate have dropped out before the completion of treatment?

None 2 10-20% 2 203 40% 40-60% 5 60-80% 3 800 100% The cumulative impact of this evidence indicates that disengagement rates in the area are likely to match the 50% found in the national evidence. This leaves 50% of clients who complete the programme successfully.

If this data is applied to the potential activity data in the previous section this indicates that:  600-1200 clients will successfully complete treatment and require aftercare each year and a similar number will drop out.

2.4.1 Local data The extrapolated data in the last section indicates potential activity levels.

Actual client numbers were sought from local services.

Substance misuse service CAT saw 418 clients in 7 months from April 2005.22 This equates to 700 clients per annum IWIC23 65 clients in last year24 SIFA For the year 2005-6 SIFA saw 660 clients from the HoB area. 25 26 Aquarius 50-60 per year27 Data from services suggests that the number of clients in local treatment services is within the range suggested by the extrapolations in the previous section. It seems likely that local services deal with 1400 clients per year.

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If the national disengagement rate of around 50% is applied to these figures the activity data indicates that  700 clients will successfully complete treatment and require aftercare each year and a similar number will drop out.

2.5 Estimating the impact of people who are out of contact with services It could be argued that client disengagement reduces the burden on services and helps them to concentrate on clients who actually require help. This idea is based on flawed logic. It assumes that those clients who disengage are similar to those who stay engaged. This is unlikely to be true. It is probable that clients who disengage are significantly more risky and vulnerable than those who remain in services. (Appendix 2 – tabulates evidence supporting this position). Therefore those clients who drop out may impose an increased cost on society in terms of harm to self and others.

Client deaths are a commonplace of services. SIFA were able to identify four client deaths during 2005-2006 from the HOB PCT area. IWIC identified two people who had died among their clients. Aquarius identified three deaths.28 This section attempts to identify the proportion of violence and suicide which might be attributed to clients who have disengaged from services. This uses nationally extrapolated data and is indicative only The City of Birmingham had 153 suicides in the period 2002-4. That equates to 76 suicides per annum. National data suggests that at least 25% of these will be suicides of people with alcohol related problems. That equates to 19 per annum. The majority of these will be people who will be out of contact with services and a proportion will have lost contact with services in the last year.

The City of Birmingham had 23,465 violent crimes in 2003/4. According to government data 44% (10,400) of these crimes can be related to the misuse of alcohol. Not all of these 10,000 crimes will be committed by harmful or dependent drinkers, however, if the data in 2.1 above is extrapolated to this group at least one third of these 10,000 will committed by harmful or dependent drinkers. The majority of these will be people who will be out of contact with services and a proportion will have been perpetrated by people who have lost contact with alcohol treatment services in the last year.

2.6 Conclusions  Extrapolated national data suggests that potentially between 6001200 people per year could require aftercare services because they successfully complete treatment services. 

Actual data provided by local agencies suggests that 700 problem drinkers will require aftercare services each year in the HoB PCT area.



Actual data provided by local agencies suggests that at least 4050% of clients will disengage from services each year without

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successfully completing the programme. This equates to another 700 people per year. 

Research evidence suggests that the clients who drop out are likely to have higher levels of risk associated with them, e.g. risk of suicide or violence to others and therefore require aftercare in the form of follow up services.

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3. Care Management and Care Coordination A robust, local system of care coordination and care management should provide the ideal framework to manage the long term care of problem drinkers. It will embrace the needs of both those making changes and those who have dropped out of care and will provide the framework within which most aftercare should be considered.

The National Treatment Agency has given care planning a central role in its treatment effectiveness strategy: “Good care planning, good co-ordination of care, and frequent reviews of care plans with service users, is the vehicle to deliver improvements to individuals’ health and social functioning and reduce the public health and crime risk they pose to others.” 29 In 2005 the NTA published a consultative draft of its Care Planning Toolkit.

This outlines the role care planning and care coordination will play in aftercare. The toolkit recognises that the care coordinator must draw up: “an ‘aftercare plan’ or ‘post structured treatment plan’ to ensure that all support for the client that is already in place continues if necessary, and that any support not in place, is in place in time for the client leaving treatment. This plan may include access to adequate support networks, access to unstructured support, harm reduction, and rapid access back to treatment if the client requires it.”30 The same document also suggests that the care coordinator should: identify the engagement plan to be adopted with clients who are difficult to engage in the treatment system. 31 A care coordinator should ensure that aftercare occurs for those successfully completing treatment and ensure that those who leave care will be picked up.

However, care coordination cannot be applied to every client. Models of Care implies that care coordination is primarily to be applied to clients in tier 3 and 4 services: “the importance of all clients receiving regular keyworking is a crucial element of care planned treatment.”32 However, Models of Care also envisages the possibility of applying it to complex, risky or vulnerable clients in tier 2.33 In order for care coordination to work successfully a number of features need to be in place:  There needs to be clear guidance on which clients will be subject to care coordination.  There needs to be clear guidance on who should take on the care coordination role.  Care coordinators need training in the aftercare and engagement elements of their role.  There need to be resources available to provide the requisite aftercare.  There need to be services available to pick up the clients who disengage prematurely from services.  Supervision from line managers needs to ensure that aftercare plans are being drawn up

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 

Care managers will also have to recognise the differing aftercare needs of specific client groups, e.g. women, people from ethnic minorities, people with children etc.

Care management processes should also be able to draw on a multiagency network to ensure that clients, especially those who disengage are not lost to the system, have a range of care options and any risk is well managed.

3.1 Assessing the Local Situation In the survey of specialist services, most specialist workers asked about the extent to which care planning and care coordination were in place for problem drinkers responded positively. Care planning was reported to be a formal part of the work of the majority of those interviewed. 13 out of the fifteen workers responding said that their agency had a formal care planning system.

Does your agency have a formalised care planning / care coordination structure?

Yes 13 No 2 Don’t Know 0 However, this is an indication that individual agencies are care planning for clients not that there is a multi-agency system of care coordination as envisaged by the NTA. For example the detoxification nurses indicated that alcohol nursing care plans are working well;34 however, these are for brief interventions rather than long term engagement.35 Local voluntary organisations all indicated that they had their own separate care planning systems.36 Agencies agreed that while they assess clients, develop care plans and review them there is no formalised inter-agency care coordination system in place.37 38 39 40 Commissioners reported the same situation. The DAT reported that there is currently no uniform approach to care planning and that the current thinking is that they will adapt the drug assessment toolkit for use within alcohol assessment.41 Another said that there is “no management of people’s treatment journeys”.42 In the interviews, the extent to which aftercare was a part of these existing care planning processes was unclear. In part this depended on the definition of aftercare. The detoxification team insist on an aftercare plan to follow their intervention, however, this is inevitably different from the aftercare for someone who has completed a long term programme of rehabilitation. 43 44 Other agencies were less clear about how well their plans reflected structured aftercare needs.45 46 However, in the survey aftercare was a feature of the work of all the specialist workers that responded. Every respondent had prepared an aftercare plan for, at least, some of their clients.

For what percentage of these alcohol clients would you estimate you have developed an aftercare plan?

None 0 10-20% 4 202

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40-60%

1

60-80%

4

40% 80100%

4

The majority also felt that there was a formalised aftercare plan structure in their agency.

Does your agency have a formalised aftercare plan structure e.g. an aftercare plan format?

Yes 9 No 6 Don’t Know 0 However, again this is not a formalised DAT structure.47 48 Agencies were clear there is no multi-agency approach to the aftercare of clients, particularly those who may pose a risk to themselves or others. One agency described the situation as very limited49, another described it as “patchy – not as robust as we would like it to be”50 or that there was “not a lot” of follow up of clients who have completed. 51 52 The social services care management team offered the system which is closest to a formal care coordination structure – clients will have care plans prepared and reviewed during their treatment episode by a clearly identified care manager. The plans will cover the whole range of options e.g. jobs and education as well as care options.53 It was also pointed out that the lack of treatment services and aftercare options as well as waiting times for treatment made it difficult to undertake multi-agency care coordination.54 Agencies stressed that they tried to work with other agencies,55 56 but at least one found that non-specialist agencies were resistant to working with problem drinkers. 57 The greater concern was that there were only limited options for those care plans to draw on. 58 As one interviewee put it, there are: “Insufficient destinations for any care plan to be meaningful…insufficient volume of treatment options…writing care plans is a waste of time…nowhere to go.”

For care management to work successfully, it will also be necessary for clients to be able to easily return to structured treatment if they relapse.

Some, although not all, the voluntary organisations were able to provide this, 59 60 the statutory services were less clear about this. Waiting times of 5-6 weeks were a barrier and generally it depended on whether a client had already been discharged. If so, the process had to start again.61 62 63 64 One researcher noted that a system offering to pick up those who drop out would require a tripling of provision and that the current system had nothing in place for relapse prevention.65 Agencies also felt that line managers were both competent and willing to support workers in ensuring aftercare plans are in place. This would normally occur in clinical meetings66 or during clinical supervision. 67 68 69

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3.2 Reflecting diverse needs Generally agencies felt that staff could draw up care plans which recognise the needs of people with diverse needs, although it was recognised that this was a challenging area of work.70 71 72 73 74 75 76 77 78 However, there has been no previous work to ensure that these skills are in place.79 The absence of aftercare resources generally and the lack of a strategic approach to the aftercare needs of problem drinkers means that identifying particular failings related to for example women or ethnic communities was not possible. Aftercare was poor generally, it is not clear that it was particularly poor for one community more than another.

However, it was acknowledged that poor aftercare may pose a particular problem for clients who have a dual diagnosis of alcohol problems and a mental disorder. This group is characteristically hard to engage in services and suffer from problems of who is responsible for their care. Thus gaps in their aftercare are a double burden. 80 81 3.3 Conclusions  A key to successful aftercare is a system of care planning and care coordination. Care coordination, in particular, will provide a structure within which the long term needs of the client can be arranged. 

The NTA is laying great stress on care coordination in the latest draft of Models of Care Drugs (whose requirements will be reflected in Models of Care for Alcohol Misuse) and in its recently developed care planning toolkit. These identify a very specific system of care planning and care coordination.



The NTA’s Care Planning Toolkit provides a detailed framework for planning aftercare and engagement with difficult to engage clients.



Although local agencies all undertake care planning with their clients, the more intensive, potentially multi-agency approach envisaged by the NTA’s care coordination model is not in place locally.

3.4 Recommendations  Heart of Birmingham PCT should work with Birmingham DAT and local treatment providers to ensure that the care coordination model is in place across the PCT area for alcohol misusers. 

Heart of Birmingham PCT should ask local agencies to undertake an annual audit of case files to ensure that all clients who require it have an aftercare plan in place.



The DAT and the PCT should ensure that the framework within the NTA’s Care Planning Toolkit is used to structure planning both

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aftercare for those successfully completing treatment and engagement with difficult to engage clients.

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4. Aftercare for clients who have made positive gains 4.1 National guidance According to Models of Care Drugs 2005 the final stage in the treatment journey is the treatment maintenance or treatment completion phase. The goal of this phase is to assist clients in leaving structure treatment and maintain the changes they have achieved. This may involve helping the client to access a range of non-care planned community based services, such as mutual aid groups (e.g. NA, AA), housing support, employment or training and education opportunities. …Clients who are being discharged from treatment should then enter aftercare provision, aided by an aftercare plan.82 MoCAM similarly recognises that: “Individuals who have participated in alcohol treatment (will need to) receive information, advice and continuing support to help them maintain improvements in their health and social wellbeing and reductions in their alcohol consumption.”83 Good care management as outlined in section 3 will be crucial to this.

However, it will also be necessary to have a range of aftercare options which the client and care manager can access.

The nature of these aftercare needs will vary from person to person. People who have achieved successful change through tier 1 and 2 interventions may, for example, need less intensive forms of aftercare than those people who have made changes using tiers 3 and 4. It is therefore best to view aftercare as “a continuum of a range of activities, initially provided in a more structured way based on the individual’s assessed needs, but later delivered in response to the individual’s ongoing requirements.” 84 The following diagram outlines this continuum and the key aftercare services which it covers (sources of this information are identified in parentheses): Diagram 1- the Continuum of Aftercare Advice and support helplines

↓ Self-help groups (MoCD) ↓ Drop-in/social clubs ↓ Rapid access back in to treatment (Care Planning Toolkit) ↓ Housing (MoCAM) ↓ Training (MoCAM) ↓ Employment (MoCAM) ↓ Social skills development programmes (MoCAM)

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Clients emerging from tiers 1 & 2 are more likely to use self help and the advice line, drop-in or social club. The tier 3 & 4 clients may also benefit from these but may also, according to MoCAM, need help to  find housing  find employment  access training and education to develop employment and life skills  manage their personal finances  achieve lasting changes in their lifestyle. 85 The recent Addaction report on aftercare makes a similar point: “Aftercare is designed to offer a continuum of support to those who have been exposed to / involved in or have completed treatment or rehabilitative work... It aims to address the practical and personal developmental needs of clients and may include counselling, cognitive therapy, group work, family involvement and vocational training. Aftercare also includes aspects of resettlement helping those individuals in treatment integrate back into society by assisting with practical life skills, and offering support in finding accommodation, education, and employment. 86 Models of Care for Drugs 2005 indicates that at least some of these options should be available within the services provided by tier 2 and tier 4 services. 87 4.2 Examples of good practice In developing an aftercare response it is useful to identify examples of good practice from other areas. This section flags up examples from the various points on the continuum of aftercare. More detailed information on each of these is given in the appendices indicated.

4.2.1 Advice and support helplines

This is a model advocated in Models of Care but no models of such schemes have been found which are dedicated solely to aftercare have been found.

There are services such as Surrey Drug Care – a 24 hour helpline run by volunteers which would offer ongoing support to people with both alcohol and drug problems who called but it was not established specifically for that purpose.

4.2.2 Self help groups Self help groups are much more readily available and a number of models were identified:  Livin It Nottinghamshire (Appendix 3)  Bac-In Nottingham (Appendix 4) – for black and minority ethnic community  The Friends of Eastleigh, Basingstoke (Appendix 5) From 2000-2004 Alcohol Concern ran a project to help recovering problem drinkers establish self-help groups. 50 groups started and thrived within the programme. A guide How to start and run a self-help group – DIY with support for people overcoming alcohol misuse was published. It offers practical advice and guidance on setting up a self-help group and should be recommended to anyone attempting to start a group.

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Self-help groups generally provide ongoing support which will enable an initial change to become a long-term recovery. Some people may find that a selfhelp group helps them to give up alcohol; however, these groups will be most effective at supporting people who have already made that change.

Self-help groups can also help commissioners better meet the needs of a diverse community. Groups for women or Asian men can provide focused support.

The Alcohol Concern programme identified a number of benefits from selfhelp. Groups helped foster independence and a sense of belonging and provided the opportunity for members to start taking control of their lives. In particular, they enabled participants to:  Change their lifestyle by offering a bridge to “normal” life, learning how to socialise, undertake new activities and make friends without alcohol;  Take responsibility for themselves, their recovery and the group;  Regain confidence and self-esteem;  Reduce stress and increase the level of support in their lives;  Cease misusing alcohol and improve their health.

4.2.3 Drop-in/social clubs Barking Havering and Brent wood Alcohol Advisory Service offers aftercare via an open-ended weekly support evening (see Appendix 6).

4.2.4 Rapid access back in to treatment As with helplines, this is a model advocated in Models of Care but no models of such schemes have been found.

4.2.5 Housing There are a wide range of services offering housing to problem drinkers. A number of projects are available in Birmingham. Appendices 7 and 8 offer examples of two services from other parts of the country 4.2.6 Training / Employment Employment was clearly a priority for local service users. The single best example of a project facilitating these opportunities is Alcohol and Drug Services Manchester’s (ADS) Bridging the Gap - an innovative and awardwinning project based in Tameside whose strategy makes a difference to both workforce planning in the substance misuse field and the lives of former drug and alcohol users (see appendix 9).

4.2.7 Social skills development programmes In a separate project, ADS offers basic skills groups, teaching people maths English and I.T. These are followed by access to education, training, employment, social and leisure activities (see appendix 10). Similar services are offered by:  Rotherham Aftercare Service – a Drug Only Service  Liberty Aftercare Surrey

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(See appendices 11 &12) 4.3 What is the evidence on the effectiveness of aftercare?

There was no identified local evidence on the effectiveness of aftercare.88 89 90 91 92 93 However, there is national evidence of the effectiveness of aftercare.

Turnbull and McSweeney’s (2000) research highlighted that there was a common agreement that aftercare is an important factor to drug treatment success. The need to sustain any gains made with clients throughout their stay in custody or their residential stay was considered to be important. 94 Indeed, the effectiveness of aftercare in reducing re-offending and relapse rates was well documented in Fox (2000)95 and most importantly the National Treatment Outcome Research Study.96 4.4 Assessing the local situation - service user views on effective aftercare During the NTA’s consultation on the Models of Care for Alcohol Misuse service users were asked for their comments on the need for aftercare.

These are included to give a national perspective on users’ views on aftercare.

“Rather than discharge after relapse a person needs continual support.”

(Service user comment London) “Some aftercare programmes are too short or not available.” (Service user comment York) “A good aftercare system would include a phone service, regular contact and somewhere you can come back to and check in – a buddy system.” (Service user comment York) “Aftercare is part of ongoing treatment and should be available to everyone after rehab/treatment.” (Service user comment Banbury) “Not enough aftercare.” (Service user comment Leeds 1) “There must be aftercare or treatment is pointless.” (Service user comment Nottingham) “A good aftercare system would be ongoing and individually focused.”

(Service user comment Nottingham) “Need more resources/funding for appropriate continuous aftercare.” (Service user comment Nottingham) “Help with retraining” (Service user comment Nottingham) “Services do not provide aftercare or cannot afford it.” (Service user comment Leeds 1) “The need for safe places i.e. social club led by peers for out of hours support.” (Service user comment London) “Aftercare should include activities, courses, 24 hour support – in an ideal world.” (Service user comment Leeds 1) “I had detox but no follow up. Waste of time and money.” (Service user comment Leeds 1) Service users felt that aftercare was so important that treatment without aftercare was pointless. Where aftercare was offered it was only for a short period, the options they wanted to see were ongoing support or user-led aftercare with the support of a service.

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In the same way local service users were consulted on the need for aftercare as a part of this research.

1) Female Client SIFA – Drop in Doesn’t want to be abstinent – currently gets counselling from this service to help reduce drinking. Wants to reduce because she’s getting married in June.

Has been in supported housing for last 13 months, uses the drop in everyday in the morning. Goes home in the afternoon – no activities. Previous experience only with soup wagon, they did not really help just gave them soup.97 2) Male Client SIFA – Drop in Since his overdose and consequently being dual diagnosed he feels he is getting all the support he needs. Currently his care is being overseen by Aquarius and the CPT. Lives in private shared accommodation Has had detox recently after this had home treatment for 7 days from a CPN - saw different CPN and student everyday during this time. He has not been offered structured treatment since. He sees the Alcohol nurse.

Aquarius has hooked him into some kind of ‘Green Gym’ growing vegetables.98 3) Male Client SIFA – Drop in System lets people down that really need help. Need more alcoholics off the streets even if they haven’t got a problem.

Workers - 2 out of 10 workers will go out of their way to help – best people for this type of job are ex addicts.

Not much out reach work – but SIFA offer very limited service because they are a charity.

Race issues not taken into account – white people get more attention, mainly because staff are white.

Probation staff have been helpful – Got him his flat and counselling. Feels that you have to be a fighter to get anywhere.

‘What would you say about the gaps’? – ‘Fill them in’ Things need to be in place especially on release from prison.99 4) Male Client SIFA – Residential He has been in the service since November and has had two different counselling sessions including life skills. The approach here has been ‘encouraged to take responsibility’ – has tried giving up drinking before but for the wrong reasons – has tried to commit suicide twice before. Has had a consistent key worker for last 4 weeks has noticed a significant difference to be able to talk to one person. He will be here for 2 years – feels that SIFA are trying to equip him with the tools to continue life. Has been promised by SIFA that they won’t cast him adrift. However, he needs a lot of reassurance that he will not be “cast away”.

5) Male Client SIFA – Residential He is doing basic skills (e.g. literacy) and is hoping to get back into the work place, there are no specific schemes to help with this. SIFA will help him get

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voluntary work. He was detoxified about three years ago and managed to get a temporary job but then went back onto streets for about 21/2 years. In the past he has used AA but feels he would prefer not to use that kind of service again and would prefer to stand on his own two feet.

6) Male Client SIFA – Residential He feels that the isolation when he leaves SIFA will be difficult to handle. He will be helped to get a flat when he leaves but is not sure how he will fill his time. He hopes to sort out some courses but fears that his flat will be a dive and that this will turn him back to the drink.

7) Male Client SIFA – Residential He was homeless picked up by Snow Hill Hostel Outreach Team – in Birmingham city centre and was there for about a year. However, he had no organised help because of the size of the project. He left the hostel to live in bed and breakfast funded by his parents, however, he returned to the drink.

Referred to SIFA by friend. He then spent six months in a damp house followed by a move to SIFA. He has been there for four to five months. He wants to get into his own flat and get a job but is not sure what kind of support is available. He would look to get onto a college course and to be occupied.

Aquarius service users.

A group of service users were interviewed at Aquarius. This is a summary of the key points:  They were happy with the service they received from Aquarius, however, it was felt that there was very little Aquarius could do after they finished treatment, this was not unwillingness on their part – but felt it had to do with funding, they also felt that Aquarius places were very valuable and should be freed up to help people in greater need.  The structured after care that was offered was not tailor made for this group. It tended to be at a very low level e.g. attending a centre. They felt there was a real need for something at a higher level, specifically getting back into the work place.  One of them had found a self help group in the north of Birmingham run on a Saturday morning – but this comprised of people who were both drinking and abstinent. This was not acceptable to the users.  The provision of day centres if you had a psychiatric problem was available – but again this was mainly focused on simply ‘getting out of bed’  They would have liked to see easily recognisable projects catering for people with various needs.  They wanted to do something that gave back to the community. They felt that given their experiences they were the best placed to help others. 100

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Social work service users A group of service users were interviewed with their social worker. This is a summary of the key points:  Would have loved someone to meet them off the train when they came out of treatment.  Would have liked a safe place to stay and more handholding.  Felt a bit lost when first out of treatment and in fact still do. The 6-bed hostel/house set up by social services is seen as a lifesaver – as they can access as and when needed. All have been involved on a voluntary basis in setting the house up.  The group they attend (Wed & Sat) is very good and they all find it useful – They can access everything they need via this group (because it’s run by social services)  Would like better sign posting of services – god knows what other people do if they don’t go through the social services route.  Would like to see more service users involved as they feel these are really the only people that understand what cravings can be like at 3am.

There can be little doubt about the importance placed on aftercare by service users. The absence of aftercare is a clear gap which threatens to undermine the ongoing recovery of the user and reduce the value of any investment in treatment. In particular, isolation and meaningful occupation appear to be priorities.

4.5 Assessing the local situation - comments from the interviews Everyone interviewed was agreed that there is a limited range of treatment services which will be pressed to meet the current needs of problem drinkers in the area let alone ongoing aftercare needs.101 102 103 104 105 However, non-specialist providers of aftercare were also felt to be in short supply. As one interviewee said they are “very limited and not very local.”106 Another felt that it was “very hard for a service user to identify a clear pathway” into aftercare.107 108 Specialist services identified a range of gaps in the aftercare options.

Statutory services felt that there was a lack of drop in provision other than SIFA and no evening services apart from AA.109 In the main it was reported that “there are just not enough options”.110 Another concern was that if people have been for treatment outside Birmingham there is little coordination when they return.111 The lack of adequate aftercare was a message that was repeated and repeated.112 113 114 115 116 One positive element was that the social services care management team have 15 people attending an aftercare group – people that have gone through treatment and have not relapsed. If people do not attend the group they will have some kind of follow up via the alcohol care coordinators. 117 Aftercare

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Self help groups in particular were felt to be a gap, especially groups offering support at weekends and evenings.118 119 120 121 122 123 124 One interviewee suggested that a partial solution would be to ensure that there is good publicity about active AA groups 125 It was reported that there are too few appropriate housing options, too little done about service user involvement or creating volunteering opportunities and a lack of employment and training opportunities. 126 127 128 129 130 131 One interviewee pointed out that the system would work more effectively if there was a more strategic approach to treatment citywide. “There is a lack of communication between the various funding streams”. 132 This would be facilitated by a unified assessment process and a multi-disciplinary approach to treatment episodes. 133 There was particular concern that services were not appropriate to the diverse needs of local users. Interviewees felt that there was no clear focus on BME groups and that they are not receiving an adequate service.134 135 136 137 138 It was also suggested that the needs of women are not being met.139 Groups other than the BME communities were felt to be disadvantaged. In general, those felt to be socially excluded were felt to be less likely to receive an adequate service. “There is no service provision for people at the bottom of the scale.” 140 The IWIC felt that they had difficulties getting help for people with dual diagnosis and this was especially the case if they were Irish when their problems would be put down to alcohol alone.141 It was felt that the provision for alcohol is very middle class and does not take into account the chaotic clientele. 142 Another interviewee asked whether the number of people in asylum services really get the services and representation they need.143 4.6 Assessing the local situation - comments from the questionnaires In the survey of specialist workers the majority of respondents felt that the available aftercare provision was either “poor” or “non-existent” with only one respondent describing it as “good”.

How would you describe the resources available for aftercare for problem drinkers?

Excellent 0 Good 1 Adequate 3 Poor 9 Non-existent 2 Comments about the state of aftercare included: More resources need to be available Would like to see more alcohol agencies generally More resources for alcohol clients No day care support, training support to help client to structure day and motivate. Clients need help with motivation, can relapse through boredom as self esteem is low

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Not enough day centres, drop ins, where clients who have had a detox can attend, this leads to boredom one of the main triggers for relapse There is only one dry day centre which is based in the north part of Birmingham The survey then looked at the need for particular forms of aftercare: education, employment and training, housing and finance administration.

Do you feel that there are adequate resources to help you to assist clients to explore education, employment and training opportunities?

Yes 1 No 14 Do you feel that there are adequate resources to help you to assist clients to access housing and accommodation?

Yes 7 No 8 Do you feel that there are adequate resources to help you to assist clients to administer their financial affairs?

Yes 6 No 9 In all three cases a majority of the workers felt that there were inadequate resources, however, the most striking gap appears to be education, employment and training opportunities where all but one worker perceived a gap.

Comments on these answers included: Needs to be one specific post for someone specialist in above. We do not have the time to access the services that are available because of client workload.

Some clients have lived in supported accommodation and suddenly got a flat, the problem arises when it comes to paying bills as they have never had to do this, it becomes problematic and ultimately leads to the loss of accommodation We tend to refer people on rather than deal with this issue. Usually to counsellors in Aquarius who we work in partnership with.

There is a need for a specialist support workers or social worker to deal with employment, housing or finance issues. There is a need for them to be an integral part of services.

Workers were also asked about whether they had had particular problems with local aftercare providers. The answers were very mixed, a couple focused on the problems of working with mental health services. Others simply focused on the problem of the lack of resources. It was not possible to identify problems with particular aftercare services.

Have you had problems working with potential aftercare services?

Yes 6 No 6 Not Known 2 Comments on these answers included: Problems with mental health services who tend to dump clients with alcohol problems There is one detox unit in Birmingham, resources are limited to help clients withdraw from alcohol before aftercare. Cannot detox single people as no home support Aftercare

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There are not enough facilities available to clients like rehabilitation units, day centres, drop ins, again the net result of this lack of facilities is a large percentage of clients relapsing Constant change of key workers in mental health teams and social services, lack of consistency for clients, limited education educational opportunities, day centres are often described as boring or soul destroying by clients Alongside the survey of specialist workers, the researchers contacted a sample of non-specialist agencies who might act as specialist providers of aftercare. The majority of services worked with problem drinkers, albeit some would only work with clients who were no longer drinking or only with support from an alcohol service.

Does your service take clients with alcohol problems?

Yes No Yes, if no longer drinking Yes, if with ongoing support from an alcohol service Yes, if no longer drinking and with ongoing support from an alcohol service

11 6 2 4 4

The survey asked about agencies’ current work with problem drinkers. 13 out of the 24 respondents had problem drinkers on their caseloads ranging in number from less than 5 to over 20 clients. 5 agencies were unaware of the number of clients.

How many clients do you currently have with an alcohol problem?

None 6 1-5 5 5-10 2 10-20 2 20+ 4 DNK 5 12 of the services had received referrals from local alcohol services, the majority receiving less than 10 such referrals per year.

How many referrals have your received from alcohol services in the last year?

None 12 1-5 7 5-10 2 10-20 2 20-50 1 50+ 0 Most importantly in the context of this report, 11 of the 24 services clearly felt that alcohol services could make greater use of them.

Do you feel that alcohol services could make greater use of your service?

Yes 11 No 4 Don’t know 9 Comments included:

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Our service is self referral and we have found clients who are still drinking are unable to use our service, usually it is because it has been suggested by a 3rd party We feel that our resettlement team could work effectively with other services to provide a comprehensive package to individuals No capacity Unsure because to refer to project the service user must have more than one presenting need e.g. alcohol/mental health They could refer to us more frequently for accommodation Yes if they meet our care support under mental health One potential problem in the provision of aftercare by non-specialist agencies may be the lack of adequate ongoing support from alcohol agencies. A number of services, just over a third, felt that they did not receive adequate support from local alcohol services when they had a client with an alcohol problem. This was balanced by the third of service who did feel they received adequate support.

Do you feel that you receive adequate support from alcohol services when you have a client with an alcohol problem in your service?

Yes No Don’t know

8 9 7

Comments included: Should provide follow up support after discharge from their services Services tend to support clients in accommodation The alcohol services recognise a client has to be in the right place to receive face to face support Haven't tried this out yet but I do not know of any local services Haven't used them We have referred clients to SIFA with success Can access support / advice when needed Rarely applies There appear to be issues around working across disciplines re dual diagnosis Where we need help generally good but we could do with better formal partnership links SIFA provide excellent support Not able to accept or action new referrals to alcohol services as their case load is too high Too long a time delay in receiving support. Lack of emergency/early support.

Never approached However, only one service identified a specific problem with alcohol services.

Have you had problems working with specialist alcohol services?

Yes 1 No 10 Not 13 Known

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The particular problem was identified as services withdrawing support once someone has been accommodated within their scheme.

Alongside the support of alcohol agencies, another feature which will aid the ability of non-specialist agencies to work with problem drinkers is the existence of protocols and procedures which guide staff on the management of this client group. Just under a third of agencies surveyed said that they had protocols.

Does your agency have protocols or procedures on working with problem drinkers?

Yes 7 No 15 Don’t know 2 Agencies were also asked for general comments about working with problem drinkers. A range of views emerged.

If someone has a drink before a session it is explained that we are unable to work with them, and suggest they come back without having drunk We see a lot of problem drinkers but our work isn't as co-ordinated as it could be. Some training / dialogue would be good As a voluntary agency we are viewed as just a bed and not included in the treatment. Exchange of information is problematic. We also experience difficulties in resettling problem drinkers who do not wish to address their issues. Accessing rehab when motivated is also an issue.

We have completed a year long study of drugs and alcohol in our community. The DAT are trying to help us to develop a service but no-one is working with us on the alcohol services which are shown as the bigger problem in the research!

4.7 Conclusion  Aftercare for problem drinkers in the HoB area is poorly developed. 

Service users are clearly stating the need for better aftercare.



Existing alcohol services do not feel they have the resources to provide ongoing care.



Those non-specialist services which could provide aftercare are not well-linked in to the network of alcohol treatment services or well-prepared to take on problem drinkers.



Models of Care identifies a continuum of aftercare services which runs from peer support groups to services which develop employment, training and social skills. Most of these are poorly developed in the area.

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The absence of aftercare services is so stark that there are many possible ways forward. The PCT could:  Appoint an aftercare development officer to oversee the development of aftercare through the better use of existing resources and by seeking new resources to develop other services.  Appoint aftercare workers in the key alcohol services.  Develop a specialist aftercare service following the model of, for example, the Rotherham Aftercare Service.  Developing the capacity of non-specialist service to take on problem drinkers and improving their links with specialist services. 

Local commissioners will need to choose between these options.



However, it should be noted that education, employment and training opportunities for clients are the clearest gap.

4.8 Recommendations  Heart of Birmingham PCT must lead the development of a system of aftercare for problem drinkers in the area.

The PCT will need to choose between one or more of the following options:  Appointing an aftercare development officer to oversee the development of aftercare through the better use of existing resources and by seeking new resources to develop other services;  Appointing aftercare workers in the key alcohol services;  Developing a specialist aftercare service;  Developing the capacity of non-specialist service to take on problem drinkers and improving their links with specialist services. 

The PCT should give a priority to addressing need for education, employment and training aftercare opportunities.

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5. Aftercare for clients who have left treatment without making positive

gains or in an unplanned way There is a strong strand of argument that says that alcohol services can only be provided to those who are ready to change. There is a logic to this argument. Resources can be focused on those who are showing a desire to change.

The limited follow up of those who disengage and the focus on those ready to change can also be justified therapeutically. Both treatment providers and commissioners can argue that clients may need to continue to drink until they reach a point where they are ready to change.

Many agencies in the substance misuse field arguably use this approach as an unwritten workload management system. If all the clients who sought help maintained their contact, services would be unable to cope.

However, as highlighted earlier, this ignores two key issues: ďƒ˜ those who are least engaged are likely to present the greatest risk to themselves or others (e.g. homicide inquiries, Confidential Inquiry Into Homicides And Suicides et al.) ďƒ˜ many, if not the majority, of clients who are central to the concerns of the national alcohol strategy - persistent offenders in the criminal justice system - are likely to fall into this category.

Sections 2.4 and 2.5 have already highlighted that approximately 40-60% of clients who enter alcohol treatment services will drop out within as little as a couple of sessions.144 There is also evidence that the most risky and vulnerable clients will be more likely to disengage than the rest of the substance misusing population. These risky and vulnerable groups will include: those with criminal justice histories145, personality disorder146, and / or mental illness147.

As far back as the 1960’s the alcohol literature was identifying that those who dropped out of treatment were likely to be different from those who remained.

"There are pointers to the types of patient who are most likely to succeed in treatment. Men do better than women, and older men better than younger men. Social stability, especially having a job is associated with a good outcome from treatment. Married people do better than those who are single or divorced. Patients with psychopathic personality disorder, anti-social people who experience little subjective distress themselves but cause others to suffer respond poorly to treatment." Kessel (1969) Thus the people who are most likely to fall out of treatment are the most vulnerable e.g. the unemployed and socially isolated and those who pose the greatest risk those with personality disorders.

More recent literature seems to confirm that those who disengage are likely to be a more needy and more risky group. Magura (1998), an American study, looked at predictors of retention in treatment. It studied a group of over 1,000 clients of substance misuse services in New York. Those who were more

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likely to drop out included those with multiple problems and those with greater criminal justice involvement.

Mental disorder, and personality disorder in particular, seem to be indicated as features of those who are likely to disengage. In terms of client attributes, the presence of psychiatric co-morbidity in substance misusers entering treatment has been linked to poorer outcomes by Marsden (2000). Hansen (1997) also indicates that substance misusing psychiatric patients have poor treatment compliance.

Joe (1998) indicates that older ages, low criminality, employment, and (interestingly) having never married are associated with positive treatment retention. The converse is, therefore, true for poor retention.

MoCAM also recognises that not all drinkers will achieve positive change after their first encounter with treatment services. The document says that it will be necessary to plan for multiple alcohol treatment episodes.148 It is often a specific concern of tier one services that specialist alcohol services do not work well with difficult to engage substance misusers.

Alcohol Concern’s Commission on the Future of Alcohol Services recommends that: “The network of alcohol services needs to have the ability to reach out and maintain engagement with, at the least, those who are identified as posing the greatest level of risk. Not all services will need to have this capacity but appropriate services must exist in the local area.

These services will include assertive outreach, floating support, wet services and services for brain damaged drinkers”.

The next sections outline the evidence for engagement approaches and possible models of working with this client group.

5.1 Is Engagement Worthwhile?

Underpinning this section of the report is the question – is engagement worthwhile? Clients who drop out may be more risky and vulnerable but if attempts to engage them are doomed to failure then the resources are better invested elsewhere.

The key evidence on the effectiveness of engagement comes from the mental health field. Behind the current government mental health strategy is the view that while attempting to engage difficult to engage clients may not lead them swiftly to a point of permanent change, it is likely to reduce the risk they pose to themselves or to other people.

Three key sources of evidence support the benefits of engagement:  The Government’s Confidential Inquiry into Suicides and Homicides by Mentally Ill People149  Individual Homicide Inquiries e.g. Buchanan or Aslam (see below)  Independent Research e.g. The Sainsbury Centre’s Keys To Engagement

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Homicide inquiries Since 1994, it has been a government requirement that whenever a person with a mental health problem kills someone there needs to be an independent inquiry set up to examine how the person’s care broke down to such a dangerous extent. A key feature of these inquiries has been the failure of services to maintain contact with potentially dangerous clients. e.g.: ďƒ˜ The Report of the Independent Panel of Inquiry Examining the Case of Michael Buchanan - November 1994 - Commissioned by NW London Mental Health NHS Trust - this report shows a cyclical pattern of chaotic breakdowns, hospitalisation, stabilisation, discharge, loss of contact with services and treatment and consequent breakdown. or ďƒ˜ Report of the Inquiry into the Treatment and Care of Naseer Aslam Bradford Health Authority September 1999 - This report is critical of the follow up of NA after he left hospital or failed to attend appointments. The follow up is described as inadequate. The inquiry is critical of simply following up NA with a letter when he failed to attend for an appointment. NA was aggressive and violent and should have been given much more extensive follow-up.

Both of these men had patterns of substance misuse and mental disorder.

Confidential Inquiry The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness was established at the University of Manchester in 1996. It is funded by the Government to collect data on suicides and homicides by mentally ill people and make recommendations about improving care.

The section of the most recent report on suicide highlights a number of characteristics of people who commit suicide. These identify that isolation and loss of contact with services are key features of those presenting a suicide risk: Social characteristics - social adversity and isolation were prominent. Most were not currently married and were either unemployed or long-term sick.

41% lived alone. 3% were homeless and 1% in prison.150 Alcohol and drugs - this report highlights the role of substance misuse in suicide and homicide. 14% of suicides in contact with mental health services had a primary diagnosis of substance misuse. 38% had a history of alcohol misuse and 26% a history of drug misuse.151 Antecedents of suicide - the report looks at the sequence leading up to the suicide. The first point was often a life event such as a bereavement (4% of cases). This was then followed by self harm or suicidal ideas. Noncompliance and alcohol or drug misuse occurred early in the sequence.152 Suicide after discharge from mental health services - 41% of post discharge suicides occurred before the first follow-up appointment. They were at their peak in the first week after leaving hospital.153 Non-compliance with drug treatment - 26% of suicides were known to be non-compliant with drug treatments in the month before death. 30% had also missed their final appointment with service.154 Homeless people - These suicides were mainly young, single, unemployed men. They were more likely to have either schizophrenia or alcohol Aftercare

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dependence and showed higher rates of alcohol / drug misuse and violence.

Increased alcohol use was more often noted at last contact before the suicide.155 The inquiry concludes that because of the significant levels of contact with mental health services, particularly among suicides, much can be done to prevent suicide. Recommendations include:  Written policies on non-compliance;  Assertive outreach to clients who disengage;  48 hour follow up of all discharged patients who are at risk of suicide. 156 Independent research A range of independent studies emphasise the importance of engagement with services for promoting stability and compliance with care. Two representative examples are quoted below:  A study of residents in a bail hostel for mentally disordered offenders. “It is also striking that in a group with such high rates of psychiatric morbidity, unemployment and homelessness, only six percent were recorded as being actively in contact with the social services. This may suggest an association between a breakdown in contact with psychiatric and social services and offending in such individuals.”157  Evidence on arrest referral schemes for drug misusers show that clients are far more likely to engage with services in schemes which actually take clients to facilities than when arrestees are left to contact services on their own initiative. 158 There is no certain evidence that engagement is the answer. However, developing engagement focused approaches does have clear support in the evidence.

5.2 Examples of good practice This section outlines models of engagement focused approaches from other areas.

5.2.1 Care planning Good practice suggests that a care plan for a difficult to engage client will have a number of key features:  Simple and Realistic Goals and Objectives  Client and Carer Involvement, if possible  Risk Assessment and Management Plan  Communication Strategy  Strategy for Engagement  Regular Reviews  A Contingency Plan Most of these features will be very familiar to practitioners and should form a standard part of care planning. However, four in the list may need emphasis or explanation in the context of engagement:

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Carer involvement – there is evidence that carer involvement in a care plan is associated with increased likelihood of completing treatment and increased compliance with treatment requirements such as taking antabuse or attending aftercare.

The NTA’s Care Planning Toolkit encourages services to:  “(engage) with significant others to support the client in treatment.”

This is seen in the toolkit as a means of improving client engagement.159 Communication Strategy – all the published documentation on working with severe mental illness, dual diagnosis and anti-social personality disorder highlight the need for good communication of information. However, for the individual worker faced with a moment of crisis in a client’s life it may be very difficult to know who should be told about or consulted for advice. Will a particular contact breach a client’s confidentiality? Who is the best person to help? Good practice guidance recommends that these issues are resolved, as far as is possible at the care planning stage and a clear communication strategy forms part of the care plan.

Contingency Plan – in recent years contingency plans have become far more common features of care plans. Many care plan forms now carry a section in which to indicate what will happen in the case of a breakdown.

Most mental health services, for example, would now have these as a standard part of all care plans for difficult to engage clients.

Strategy for Engagement – Too often care plans rightly identify the client’s needs and lay out a series of plans for meeting those needs. What the plan fails to identify is how the worker is going to persuade the client to open the front door, attend an appointment or cooperate with the care plan. With many chaotic clients this may still be the case even if the client has been involved in agreeing the plan. Not to have a strategy for engagement alongside this plan is like having an exquisitely designed car without any petrol to make it run. The engagement with the client is the fuel which makes the care plan run. The NTA care planning toolkit is emphasising the need for care plans to have a strategy for how workers will engage the client.160 5.2.2 Engagement approaches The government’s mental health strategy, Modernising Mental Health Services, has identified assertive outreach as a key element of its approach.

Assertive outreach teams have been established in order to follow up the most risky clients in the community.

The assertive outreach model has also been tried successfully with substance misusers. In Surrey the Epsom Community Drug and Alcohol Team established an assertive outreach worker to follow up all problem drinkers who either failed to attend for their first appointment or prematurely disengaged from services. Over 80% of clients followed up were reengaged into services. This highlights both the benefits of outreach and the inappropriateness of the model which views non-attendance as a sign of poor

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motivation. On the contrary, poor attendance appeared to be the result of low self-esteem, low self-worth or depression.

Assertive outreach is not the only approach. The North East Council on Addictions is using a system aimed at increasing client engagement. At assessment, NECA will identify clients’ consent to different methods of contact in case the client drops out e.g. do they want to be contacted by text, letter, phone, via a relative etc. Clients also have a lapse and relapse plans which identify what they want the agency to do if they relapse e.g. in some cases they go round and knock on people’s door.

The appendices contain a number of examples of engagement focused approaches which might be considered:       

Appendix 13 - Omni Assertive Outreach Team Appendix 14 - The Elmore Team Appendix 15 – The Revolving Door South Bucks Link Worker Scheme Appendix 16 – The Rotherham Alcohol Advisory Service Street Drinkers Project Appendix 17 – Fife Alcohol Advisory Service Befriending Project Appendix 18 – The Surrey Social Services Response to Adult Substance Misusers Appendix 19 – Aspinden Wood – Wet Centre

5.3 Assessing the Local Situation – Interview Data Generally there was a recognition that disengagement is a significant issue for local alcohol services161 162 163 164 165, however, for services such as SIFA this was their client group - all their service users are classified as difficult to engage.166 For others the recognition was tempered by the fact that their response was limited by the lack of resources.167 There are no specific care pathways which identify what services should do to follow-up clients who are difficult to engage or who fail to complete treatment programmes, in some cases follow up is limited to a single letter.168 169 170 171 172 One agency felt that an adequate response would rely on services being better coordinated than is currently the case.173 The social services care management team have the most complete approach to following up clients who disengage174, however, generally there was seen to be a “huge gap”175 in the response to difficult to engage clients.176 Assertive outreach has become the standard approach to re-engaging difficult to engage clients but this is not a formal feature of local services for problem drinkers.177 178 179 180 Some services undertake a small amount of outreach e.g. the community alcohol team181 or IWIC.182 183 184 SIFA have developed a rolling appointment system so that the clients know they will see someone from Mon – Fri – between 9 –11am. 185 Other responses involve writing to the referrer if the client drops out. 186

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It was argued by one interviewee that a wet house would help those who do not want to get into treatment.187 5.4 Conclusions  Research has highlighted that approximately 40-60% of clients who enter alcohol treatment services will drop out within as little as a couple of sessions. There is also evidence that the most risky and vulnerable clients will be more likely to disengage than the rest of the substance misusing population. These risky and vulnerable groups will include: those with criminal justice histories, personality disorder, and / or mental illness. 

MoCAM also recognises that not all drinkers will achieve positive change after their first encounter with treatment services. The document suggests that it will, therefore, be necessary to plan for multiple alcohol treatment episodes. It is often a specific concern of tier one services that specialist alcohol services do not work well with difficult to engage substance misusers.



The limitations on the range of services for problem drinkers locally inevitably mean that the response to clients who are difficult to engage in treatment services is also limited. There was recognition that disengagement from services is just as much of a local problem as it is anywhere else. However, the resources available to follow-up clients are limited.

5.5 Recommendations  The PCT should agree a set of procedures for alcohol agencies to pursue with regard to clients who disengage from services. Such procedures should recognise the need to assertively follow-up risky or vulnerable clients who disengage. 

The PCT should consider whether specialist outreach services are required to follow up clients who are difficult to engage.

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6. Workers’ competence to undertake aftercare DANOS does not have specific units on aftercare. However the four units in section AK are those which relate most closely to aftercare:

6.1 Assessing the local situation – interview data There was a view on the commissioning side that the main gap in aftercare was a lack of awareness, competence or understanding of how to re-engage clients with the community after treatment.188 However, the general agency view was that local specialist workers are competent in the skills outlined in DANOS units AK1-4 and have the competencies to draw up care plans for those who drop out of treatment. In part, this was the result of formal training courses and in part because of the skills workers brought with them in to the role or acquired as part of their daily work. 189 190 191 192 193 194 195 196 6.2 Assessing the local situation – questionnaire data The survey of specialist staff asked workers about their training in these key areas. There was far less concern about a lack of training than the lack of resources (see section 4.6). In both financial affairs and accommodation, the majority of workers felt that they had sufficient training. Only in the case of employment and training was this contradicted and in that case more workers felt they had adequate training than had believed there were adequate resources.

Have you had adequate training in assisting clients to explore education, employment and training opportunities?

Yes 5 No 10 Have you had adequate training in assisting clients to access housing and accommodation?

Yes 9 No 6 Have you had adequate training to help you to assist clients to administer their financial affairs?

Yes 8 No 7

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The non-specialist services were asked about the extent of staff competence and training on working with problem drinkers. Three quarters felt that either a minority or none of their staff had the competence to work with problem drinkers.

What proportion of your staff has received training on working with problem drinkers?

All 1 A minority 7 A majority 4 None 11 What proportion of your staff has sufficient competence to work with problem drinkers?

All 1 A minority 11 A majority 4 None 7 When asked about specific training needs two key themes emerged:  Understanding the options offered by specialist services  Working with problem drinkers who are unwilling to change / continuing to drink These exceeded the demand for courses on identifying problem drinkers or providing one to one work. The latter theme emphasises the need to work with clients who are difficult to engage.

Are there any training issues that you have identified in relation to working with problem drinkers?

Tick One Identifying problem drinkers 3 Assessing problem drinkers 4 The options offered by specialist services 15 One to one work with problem drinkers 5 Groupwork with problem drinkers 1 Working with problem drinkers who are unwilling to change / 13 continuing to drink Health issues 1 Accommodation availability 1 Just under a third of agencies had protocols on working with problem drinkers.

6.3 Conclusions No evidence was found that the lack of aftercare was due to a lack of competence on the part of specialist alcohol workers. Resources rather than training appears to be the key issue.

However, gaps were identified in the skills of non-specialist services who may take on aftercare responsibilities. Two key training needs emerged:  Understanding the options offered by specialist services

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

Working with problem drinkers who are unwilling to change / continuing to drink Just under a third of agencies had protocols on working with problem drinkers.

6.4 Recommendations The PCT should work to improve the links between specialist alcohol agencies and potential non-specialist providers of aftercare. This work should embrace:  Information provision about the services offered by the various specialist and non-specialist agencies 

A programme of training for non-specialist, tier 1 services which enables them to understand the range and function of local specialist services and work effectively with difficult to engage clients.



The development of protocols and procedures to support nonspecialist agencies in working with problem drinkers.

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7. The strategic level Models of Care for Drugs 2005 recognises that the development of good systems of aftercare will be a strategic as well as an operational imperative.

“This approach will require treatment systems to be configured both to create effective exit routes out of specialised drug treatment, including through efficient access to Tier 4 provision, and to be well integrated with primary care and other systems of support and care for those in maintenance treatment and for those who wish to be drug free. This may require some drug treatment system or service redesign, including: ...investing in strategic partnerships with housing, education and employment, together with bespoke initiatives for drug misusers aimed at reintegration.” 197 In order to analyse the strategic response to aftercare, it is helpful to have a model of the commissioning role. The NTA uses the “Commissioning Cycle” in order to identify what needs to happen at each point in the commissioning process. This section of the report will follow this framework.

7.1 Strategic framework There is no existing PCT specific alcohol strategy.198 A strategy is being developed at the City of Birmingham level, but this is still in draft form. It was reported that the draft strategy does reflect the need for aftercare.199 A number of other local strategies impact on alcohol. These include:  The Licensing Policy,  The Community Safety Strategy  The Local Strategic Partnership’s Community Strategy,  Housing and Homelessness Strategies,

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

The Primary Care Trust Local Delivery Plan.

It should be expected that these strategies will address the impact of alcohol and that any recommendations should be in harmony with other local strategies. Of these the housing and homelessness strategies will be of the most relevance to aftercare.

Alcohol services should also be involved in the strategic process which leads to the formulation of these strategies, in particular the local housing and supporting people strategy. This may involve either membership of a forum or, at the least, consultation on the content of the strategy.

Given the significance of housing to aftercare for problem drinkers this has to be seen as an essential requirement on both parties. Alcohol agencies need to be prepared to contribute as much as housing / supporting people officers need to consult.

The local housing strategy makes no mention of alcohol, however, the local Supporting People Strategy has significant sections on alcohol. It is interesting to note, in the context of this report, that the strategy identifies that: “We currently have six times the amount of accommodation-based provision for people with alcohol problems per head of population as the region and the country, while our level of floating support based provision is about equitable.”200 As a result the Supporting People Strategy is proposing: “Reduce the number of accommodation-based units by 200.  Convert some existing schemes to houses in multiple occupation via the removal of support contracts.  Ensure strategic relevance and linkages of remaining accommodationbased units.  Develop an additional 200 units of floating support for people with substance misuse problems to address the issues of tenancy breakdown, antisocial behaviour and dual need for those in other forms of supported housing.”201 However, it was reported that this is based on faulty data and is being rectified.

It was generally agreed that local strategies and strategic structures were not responding well to aftercare.202 203 204 205 It was argued that this was not because commissioners did not understand the need for aftercare206 207 but because there was neither the money nor a strategy to meet the need.208 209

210

7.2 Strategic Planning Intensive aftercare or follow up is not for everyone. While aftercare such as helplines or support groups should be available to anyone recovering from an alcohol problem, more intensive outreach or long term aftercare could not be applied to all problem drinkers. Commissioners will need to decide at which particular client groups these strategies need to be targeted. Such strategies Aftercare

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are most necessary with those who present a significant risk to themselves or to society, or who present a significant burden. This requires that commissioners agree that certain high risk / complex groups are particularly targeted for containment. Who will they be?

In order to determine which client groups should be the priority for follow-up when they disengage or intensive aftercare, the commissioners need to determine which issues they are most concerned about. It is likely that those which will have top priority will include clients who threaten:  Harm to self or others;  Patterns of prolific offending This section contains a list of possible priority client groups. They are not in any order, and may not be exhaustive. It is simply a starting point for the debate.

People with a dual diagnosis of alcohol misuse and mental illness these clients appear to be high need groups that the government’s mental health strategy is attempting to address. Evidence from the homicide inquiries reveal that at least three quarters of the killers in these reports have a dual diagnosis.

Homeless alcohol misusers - there is evidence that homeless people are much more chaotic and more prone to harming self or others.

People with a history of violence to self and others - the Government has set the reduction of suicide and the prevention of harm to self and others as part of its health and mental health strategies.

Problem drinking parents with children - the need to protect children would appear to make this a high priority client group.

This list is not in any sense absolute. It merely suggests the type of categories which might be regarded as appropriate for long-term aftercare or assertive engagement. The exact make-up of the group is a matter either for national government guidance, or negotiation at local level.

7.3 Operational planning In order to identify the clients who need to be engaged or followed up commissioners need to ensure that agencies have risk assessment procedures in place. The need for risk assessment in mental health services has been heavily stressed over the last decade; however, the same pressure has not been always been in placed on substance misuse services.

Commissioners need to ensure that:  All substance misuse agencies use a risk assessment system;  The systems in place are as similar as possible across the area;  Training on risk assessment is in place for all staff;  That they are auditing the use of systems to ensure that action follow up and aftercare is provided when a high risk client is identified.

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7.4 Purchasing activities At the heart of the commissioning process is the purchasing of services and the contracts or service level agreements that specify the services to be provided. This provides a key means of driving aftercare and engagement with non-engaging clients into the treatment system. Contracts and service level agreements are not currently doing this.211 212 213 214 215 216 217 218 219 220 7.5 Monitoring and review Models of Care recommends that there should be performance indicators that focus on effective care planning and aftercare outcomes.221 Performance indicators for alcohol services were acknowledged to be poorly developed in the city.222 223 224 225 226 227 228 229 230 231 Where they exist they tend to focus on outputs rather than the outcome targets which are required to measure aftercare for problem drinkers.

In considering which performance indicators to adopt commissioners should look to examples beyond the alcohol field. The Audit Commission's report "Changing Habits" suggests a number of performance measures for drug agencies.232 These can be usefully adopted and adapted for alcohol misusers:  Numbers of clients accepted from different agencies;  Drop-out rates among clients;  Number of clients who drop out that are re-engaged into services;  Numbers of clients who complete a treatment programme and receive an aftercare programme;  Numbers of clients who complete an aftercare programme.

7.5.1 Learning Lessons – Critical Incident Inquiries The need to investigate when things go wrong is a well-established principle in health and social care. Inquiries into homicides by mentally ill people, Local Safeguarding Children’s Board’s Child Death Serious Case Reviews and Serious Untoward Incident Inquiries have all established the principle of learning lessons.

This principle has not yet been so clearly articulated in the substance misuse field. The NTA has issued guidance on holding inquiries into drug-related deaths which encourages (rather then requires) DAT's to undertake investigations into deaths in order to learn lessons for treatment and care (see Appendix 20). However, there is no reason why commissioners of alcohol services should not instigate inquiries into any untoward incidents.

The evidence about the impact of alcohol on suicide and violence and the number of deaths identified in section 2.5 provides ample justification for such an approach. Judging by the evidence of the homicide inquiries it is likely that such inquiries will highlight failures of follow-up, aftercare and engagement in a significant number of cases.

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7.6 Conclusions The commissioning system offers a number of opportunities to drive the importance of aftercare and following-up disengaging clients into the treatment system. These opportunities are not being exploited locally.  Aftercare and engagement of problem drinkers are not featuring in key local strategies.  Commissioners are not identifying priority groups for follow-up and aftercare.  Risk assessment systems need to identify the clients who need to be prioritised for follow-up and engagement  Contracts and service level agreements should specify engagement and aftercare  Performance monitoring systems should set outcome targets which measure agencies success in these areas.  Lessons about failures of aftercare and engagement should be identified and disseminated from existing local inquiry processes and consideration should be given to undertaking reviews of serious untoward incidents concerning problem drinkers.

7.7 Recommendations The PCT should ensure that  Aftercare and engagement of problem drinkers are featuring in key local strategies.  Commissioners identify the priority groups for follow-up and aftercare.  Risk assessment systems are in place in alcohol services and that these identify the clients who need to be prioritised for follow-up and engagement.  Contracts and service level agreements should specify the local requirements for engagement and aftercare.  Performance monitoring systems should set outcome targets which measure agencies success in engagement and aftercare.  Lessons about failures of aftercare and engagement should be identified and disseminated from existing local inquiry processes and consideration should be given to undertaking reviews of serious untoward incidents concerning problem drinkers.

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Appendix 1: List of Agencies Responding to the Audit of the Capacity of Non-specialist Rehabilitation Services to Work with Problem Drinkers Ji-ra House Birmingham Shelter Homeless to Home St Basils Link Cruse Victim Support St Peters Housing Association Time out Bloomsbury Children's Centre Unidentified

Residential care for older adults Tenancy Support Housing Advice 16-25s Bereavement Care

The Fireside Charity Banardos Arch Project FSU - Investing in Families Nechells Green Community Centre Shelter Multiple Needs Project St Martins Centre for Health and Healing Satnam Training and Education Project Birmingham City Mission Ladywood Healthy Living Project Zambesi Servol Community Trust Bangladesh centre Crossover William Booth Centre St Anns Hostel Welfare Benefits and Advice Centre Free at last

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Victim support General needs accommodation Young People's service Family support Housing Drop-in service for homeless and socially excluded Children and their carers Family support Community work Housing advice Houses men aged 25-45 who have been excluded from direct access hstels in Birmingham Advice and counselling After School Club, Adult Education, Health Promotion Brief access hostel Prevention of inequalities support from prenatal on Supported accommodation / resettlement Acommodation, floating support etc for people with mental health problems Blank form Advice and guidance on how to access employment and training Accommodation with support to single homeless men Resettlement service for single homeless men Benefits Advice Support and opportunities for anyone living in Nechells - whatever the problem/circumstances

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Appendix 2 - Summary of Identified Vulnerabilities / Risks Associated with Non-Engagement with Services STUDY Personality disorder

IDENTIFIED VULNERABLITY / RISK Kessel & Walton (1969) , Dean (1995) Ravndal (1999)

Suicide

National Confidential Inquiry into Suicide and Homicide by People with Mental Illness – University of Manchester – 1999

Opiate overdose (women)

Quaglio (2001)

Psychiatric morbidity

Geelan 1998/9; O'Connell 1990; Hansen(1997); Marsden J. 2000.

Dixon (1999); Lang (2000) Geelan 1998/9; Kavanagh (1996); Joe (1998)

Unemployment Homelessness

Geelan 1998/9

Younger clients

Del Rio (1997); Kavanagh (1996) ; Joe (1998)

Unstable incomes

Del Rio (1997)

Lower educational attainment

Kavanagh (1996)

Criminal history

Joe (1998); Magura (1998); Lang (2000)

Those with multiple problems

Magura (1998)

Socially disadvantaged

Monti (1997)

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Appendix 3 – Livin It Nottinghamshire Livin it is a service user led group established by Nottinghamshire DAAT. It provides ongoing support to people who have completed a programme of alcohol or drug treatment. It is run by employed ex users and offers a range of support to ex –users including group support and support in finding training and employment opportunities.

Appendix 4 – Bac-In Nottingham Bac-in is a user led support group for people from BME communities with substance misuse problems. It is led by former service users from those communities and has been running for four years.

Appendix 5 – The Friends of Eastleigh, Basingstoke The Friends of Eastleigh is a registered charity which was founded in 1989.

The charity is run by volunteers who are ex-clients, relatives and friends of exclients of the Basingstoke Community Alcohol and Drug Services.

Its aim is to give support to people who are experiencing alcohol or drug problems. This support extends not only to the client themselves but also to their friends and relatives. It also support the alcohol and drug services by providing funds for education material and items that improve the quality of time for people attending for treatment.

It holds monthly support groups - one for ex-clients and one for relatives. It provides a place for people to go and enjoy themselves, in an alcohol free environment and the opportunity to talk to a counsellor should they feel the need.

It raises money for its supportive work through various events during the year ranging from sponsored walks and raffles to jumble and tombola stalls.

It also offers a befriending service as many clients have problems with loneliness. It is also concerned about the lack of facilities in the Basingstoke area for people who need rehabilitation and detoxification and is lobbying until more is provided.

Since its formation in 1989 it has worked very hard at trying to promote a greater awareness and understanding of the illness of addiction.

Appendix 6 – Drop-in/social clubs Barking Havering and Brent wood Alcohol Advisory Service offers aftercare via a number of routes. There are two six-week aftercare group programmes, one more advanced than the other. Clients who have

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completed both aftercare groups can make use of an open-ended support group which meets weekly. There is also a users group which is a client run body aimed at raising funds for the agency. This will also offer a form of support to some former users of the service. In addition, many clients are encouraged to attend AA meetings for additional support.

The system of aftercare is, however, dependent on clients coming to AAS premises. Consideration should be given to a system of aftercare which offers peripatetic support in people’s homes. This could be particularly valuable for people with poorly developed social and domestic skills.

Appendix 7 - Southampton ‘second stage’ move-on shared accommodation and independent flats provided for homeless substance misusers Southampton City Council has provided a small amount of move on accommodation for people who are recovering from alcohol and drug problems but are homeless. These will encompass people who have been in residential rehabilitation and need to find accommodation at the end of their stay as well as people who are homeless for other reasons.

Appendix 8 - Hart and Rushmoor (Hampshire)Tenancy support and floating schemes For drug and alcohol misuse. Funded in 2002 in the second round of the Safer Communities Supported Housing Fund – Partnership with Rushmoor Council, Acorn substance misuse team, Emmaus Projects and Hyde Housing Association – for two specialist floating support workers.

Appendix 9 – ADS Bridging the Gap – Developing Employment Skills Best in Category and Overall Winner 2004 Community Care Awards Bridging the Gap is an innovative and award-winning project based in Tameside whose strategy makes a difference to both workforce planning in the substance misuse field and the lives of former drug and alcohol users.

Bridging the Gap trains former substance misuse service users to work within the drug and alcohol field. In the first round of training 25 participants were offered:  six month DANOS linked training in substance misuse work,  practical work based placements within local substance misuse agencies,  post training support and vocational guidance.

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as they are not for a violent crime.

The training, which takes place in different community centres around Tameside, consists of a one-week induction followed by a structured sixmonth training programme. This gives a broad foundation in drug work including communication skills, drug treatment and assessment options, harm reduction, diversity and child protection. Six hours each week are spent learning the core skills, and in addition students receive two hours of mentoring or supervision and spend up to seven hours working in placements.

The course is not simply about skills training. It enhances the chances of former service users making change permanent. 19 people completed the first programme and 10 are now in permanent employment in the caring field.

Appendix 10 Case Study – ADS Higher Bridge ADS has built a new service in partnership with the Bolton Substance Misuse Service. Aimed at clients who are abstinent or committed to achieving abstinence, Higher Bridge offers:  Supported Home Detox,  Day Care Programme,  Intensive and Long-term Support and  Referral to Specialist Agencies All of these are offered within a strictly abstinent environment which ensures safety and stability with likeminded individuals.

The Day Programme offers one to one counselling and groupwork on relapse, anxiety and anger management. Alongside these are complementary therapies including acupuncture, EST, reiki, and Indian head massage.

These approaches are vital in the first stages of recovery, but to make a permanent difference it is necessary to reintegrate people into the community.

ADS offers basic skills groups, teaching people maths English and I.T. These are followed by access to education, training, employment, social and leisure activities.

This scheme is working with over one hundred serious substance misusers each year.

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Appendix 11 – Rotherham Aftercare Service – a Drug Only Service The Rotherham Aftercare Service provides a range of support services for individuals who are attempting to move away from drug use and its associated lifestyle. The Service offers individualised packages of care to consider the need to maintain stability beyond treatment.

The Service is aimed at people who are either drug free or who have achieved some stability in treatment for their problem. Medical prescribing may be available for people who have become drug free from opiates (heroin/methadone etc). For people who still require Substitute prescribing (Methadone/Subutex etc.), the Service will work in partnership with agencies providing this treatment (e.g Community Drug Team or Shared Care) One to one sessions may be provided by a range of staff and there are also a number of group sessions looking at both therapeutic and lifestyle issues.

Medical clinics are also offered for individuals wishing to receive Naltrexone to help them stay opiate free. Anyone wishing to access this Clinic should contact the Service, as assessments and tests may be needed prior to seeing the doctor.

Other services on offer to the individual are: 

Relapse Prevention

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Various relaxation techniques

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Education enhancement

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Employment/careers opportunities

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Parenting skills

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Debt/ financial advice

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Leisure activities

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Help with healthier lifestyle changes

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Rehabilitation

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Help with housing problems

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Complementary Therapies

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Appendix 12 – Liberty Aftercare Surrey The key aim of the services is to offer a Through and Aftercare (TCAC) service to help drug users develop pragmatic skills, which will enable them to live in the community after an episode of treatment/rehabilitation or after leaving the criminal justice system. Such skills will include: using spare time constructively, cooking, budgeting, developing meaningful activities and preparation for work. Clients will be assessed by the TCAC outreach staff and offered places on the programme as appropriate. Clients failing to attend will be followed up by outreach and re-engaged or referred back to and reengaged into treatment (as appropriate).

Appendix 13 - Omni Assertive Outreach Team The Omni Team is part of Surrey Alcohol and Drug Advisory Service, a voluntary organisation based in Guildford. At the time of writing, the team had seven staff and a manager. At any one time the team is working with about 40-50 clients. The clients are selected against a very rigorous set of risk criteria and only very risky or vulnerable clients are taken on. The aim of Omni, is clearly to engage people who are otherwise difficult to engage and then act as a bridge in to other services, e.g. a Community Drug and Alcohol Team. It is not the team's general intention to act as a community support service although at times it is inevitable that the team will operate in that way.

Referrals generally come from Drug and Alcohol teams, although there is no limit on who can make a referral.

The Omni team was set up in 1999 with a particular remit to attempt to keep dually diagnosed (mentally ill / substance misusing) clients engaged with treatment. The background to this development was concern within Surrey Social Services, the primary commissioners of the service that many dually diagnosed clients were a particularly risky or vulnerable group. Moreover it was felt that traditional substance misuse and mental health services were allowing these chaotic clients to disengage without adequate follow-up. Thus Omni was set up to rectify this concern. More recently the Omni brief has been widened to encompass risky and vulnerable substance misusers generally.

The team operate a very strict set of risk criteria and after assessment there is always an extensive team discussion as to whether the client should be taken on. Omni feel that one of the problems that stops statutory services engaging with clients is that they take on too many lower risk clients and thus do not have the time for engagement.

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Appendix 14 - The Elmore Team The Elmore Team is a voluntary organization based in Oxford. It offers a team of peripatetic workers who support difficult to engage clients. It is a well respected service that has been mentioned as a model of good practice in both the Keys to Engagement and a recent Homeless Alliance report.

The team consists of 6.6 workers and a manager. Staff do not need to have a qualification, however some staff have either nursing or social work qualifications. Irrespective of background, the workers are all called support workers. The key requirement is viewed as being a creative approach to clients.

Each worker carries a caseload of about 15-20 clients at any one time.

These will vary between very active clients who may be being seen on a daily basis and those who are simply being monitored. Functions include helping people find accommodation, assisting them to keep the place, helping with benefits, money management and accessing other helping services.

In general, those taken on by the team will tend to be people with multiple problems who fall between the remits of a number of agencies. They will usually have a chaotic presentation. More recently they have been funded by the rough sleepers initiative to undertake outreach to street homeless people.

The clients are individually key worked rather than team worked. Each worker has monthly supervision with the manager. In these sessions staff go through each client on their caseload in great detail. Informal support from colleagues is a key feature of the approach. However, this has never been formalised into a formal support group structure. Instead, the manager seeks to create an atmosphere in which people give and receive support from each other.

Over the last three years they have introduced a system of monitoring outcomes on four axes:  Stability of accommodation;  Quality of the engagement with the team;  Level of chaos presented;  Appropriate use of other agencies.

Keyworkers make annual assessments about how well clients are doing against these measures. This is inevitably a subjective process but is felt by the team to be a useful step forward.

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Appendix 15 – The Revolving Door South Bucks Link Worker Scheme The Revolving Doors Link Worker Team was established in 1997 in High Wycombe in Buckinghamshire. Revolving Doors is a London based organisation with similar schemes in Islington, Bethnal Green and Ealing. The scheme has four workers of whom one is a team manager. Workers do not need to have a professional qualification. Instead the skills of the worker are evaluated e.g. do they have the capacity to work with people who are chaotic?

This is explored through the use of case studies and group interviews.

It then works to engage the clients in the service and ultimately enable them to access other services in the community. As a subsidiary role the service works with local agencies to advocate for the needs of this client group.

Although set up primarily for mentally disordered offenders, from its inception most of its referrals were of street drinkers already known to local alcohol and drug agencies. 70-80% of the scheme's clientele have alcohol and drug problems. As a result, in 1999 a specialist substance misuse workers was appointed as a member of the team. Approximately 33% of the clients are diagnosed with borderline personality disorder. Most of the clients will have used services in the past but have not engaged.

The team has 30 people on its long term caseload and is also assessing or working on a short term basis with another 20 clients.

The emphasis in the service is on building relationships with the client and working with them over a long period of time. As a result it is very client led with the workers looking for windows of opportunity to move the clients in a more positive direction.

Working in an assertive outreach style means that the workers will often come into contact with a whole network of clients. This is useful in identifying other risky clients and the staff will sometimes undertake one-off sessions with other network members.

The service operates on the team approach so there are no individual key workers. At the start of each day they have a half-hour planning meeting to decide who will visit which clients and other such issues. At the end of the day the team have a feedback meeting to discuss what has happened.

Client notes are not taken by the worker who made the visit. Another member of staff attending the feedback meeting makes a summary after the discussion at the meeting. This facilitates workers keeping in touch with the needs of a wide range of clients and encourages the visiting worker to be clear about what has happened.

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Appendix 16 – The Rotherham Alcohol Advisory Service Street Drinkers Project The project has been in existence for three years. Its main focus is moving people from rough sleeping to a tenancy. The project only has one worker working on these issues but he is part of the larger Alcohol Advisory Service staff team. The worker has a caseload of about 40-45 clients, but of these only about 15 will be active at any one time. The clients, on top of being homeless, will tend to have both criminal justice histories and mental health problems. Many of these clients will be the victims of violence from other people or subject to extortion from protection rackets. The ratio of alcohol to drug problems is about 60-40. A small proportion of the clients are women (approx 15%).

The work involves intensive individual work to encourage clients to take up tenancies and then to move in to and maintain the accommodation. Success is measured on three scales:  The number of clients obtaining accommodation;  The numbers maintaining accommodation;  The numbers cutting down their drinking.

The project uses earnings attachments to prevent clients from being financially exploited or to help them mange their money. As soon as a client goes in to arrears the project will put attachments on clients’ earnings so that they control the client’s money and can then give it to the client on a daily basis and ensure that bills are paid.

Clearly, being a lone worker is a risky position. The project worker takes a number of safety precautions such as the use of a mobile phone, or alerting police and colleagues to his whereabouts at all times. However, a significant safety factor is that the town centre of Rotherham is entirely covered by close circuit television. Thus street work is protected by this added surveillance.

The worker pays significant attention to keeping clients safe in their new accommodation. For example the following issues are considered: smoke alarms should always be fitted; clients are discouraged from having gas appliances which are more likely to cause fires; even electric bar fires can be a fire hazard so the worker encourages the use of storage heaters.

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Appendix 17 – Fife Alcohol Advisory Service Befriending Project In April 1995 Fife Alcohol Advisory Service secured funding to establish and operate a three year Befriending Project for problem drinkers living in Kirkcaldy. The Project is the only one of its kind in Scotland and is innovative in its approach in that it recognises many problem drinkers may not change their drinking behaviour despite having received hospital detox, lengthy counselling programmes, psychiatric intervention or other forms of care.

The initial aims and objectives of the Project were: to befriend problem drinkers, their friends and families; to provide crisis support and a home visiting service to clients who were house bound, disabled or unable to call into the office; to provide problem drinkers with as much information as possible about sources of help for an alcohol problem in order that they could make an informed choice of help available; to give volunteers an opportunity to support problem drinkers, particularly where they themselves had experienced such a problem and could empathise; to give isolated clients an opportunity to share their problems with someone who had time to listen and care; to match befrienders and clients, wherever possible, in such a way that clients could relate easily to their befrienders; to provide volunteers with training and practical experience in order that they became effective befrienders.

The project was based at the FAAS office and had two paid workers within the project, a part-time Co-ordinator and admin support. By October 1997 there were 30 active volunteer befrienders in the Project.

The main aim of the Project is to improve the quality of life for problem drinkers by matching them to a skilled befriender who, through listening and offering non-judgmental support, assists and encourages them to rebuild their self-esteem, self confidence and social contacts. The experience of the project demonstrates that it is possible to support problem drinkers and their families with the help of ordinary people, some of whom may themselves have overcome an alcohol problem.

Befrienders and clients normally met once a week - the day and time of the meeting being agreed between both parties. On average they would spend up to three hours per week in one another's company. Befrienders aim to build up clients' lost confidence and self esteem and to improve social contact in a variety of ways including leisure activities such as walking and swimming, etc. Befrienders are encouraged to meet their clients outside the home wherever possible. In some circumstances, however, home visits may be the most practical approach, for example if the client is house bound or agoraphobic.

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Appendix 18 – The Surrey Social Services Response to Adult Substance Misusers Surrey Social Services recognises that substance misusers with personality disorders or mental health problems (‘dual diagnosis’ clients) can represent a very high risk group. In order to protect both individual clients and the community, it has agreed that rehabilitation should be easily available to this group and that social services has a responsibility to re-engage high risk clients as soon as possible.

Two main measures have been introduced to achieve this: • Five specialist substance misuse social work/care managers, attached to local substance misuse teams, are employed to assess and manage clients and refer more complex cases to a local ’substance misuse panel’.

Membership of the substance misuse panel includes social services, NHS mental health trusts, criminal justice and housing representatives. The relevant substance misuse social work/care manager also attends. Managers from the assertive outreach team and a local assessment centre (which provides respite beds for drug misusers) attend in an advisory capacity.

Workers from partner agencies who are involved in cases coming before the panel are also invited to attend for discussion of their client. The structure ensures: • long-term, co-ordinated oversight of contact and engagement with identified high risk/vulnerable clients; • co-ordinated care of clients with dual diagnosis to avoid barriers between mental health and substance misuse services; • information exchange about these clients with relevant agencies; and • reduction and containment of risky behaviours through co-ordinated community support and assertive outreach

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Appendix 19 – Aspinden Wood – Wet Centre The Aspinden Wood Centre in South London is a purpose-built Registered Care Home for people with a long history of alcohol dependency who have failed to stop drinking. It accommodates 24 people (both sexes), under a condition of Licence Agreement.

The centre provides a safe and controlled environment where service users can drink, supervised by staff, as an alternative to doing so on the street. The centre operates a person centred and structured Harm Minimisation Programme to ensure that the vulnerable people can continue to enjoy their independence, a measurable quality of life and with dignity within the community.

The project provides 24hr cover. There will always be at least three staff on duty during day and two sleep in.

Clients will have a long history of alcohol dependency. They may have lost, or be experiencing difficulty in maintaining a tenancy or place in a hostel. They may have been unable to respond to rehabilitation programmes because of continuing alcohol use. They may be experiencing some form of mental health problems associated with alcohol or homelessness. All residents are over 40 years of age.

Referrals come from a wide range of areas, including Outreach Teams, Day Centres, Hospitals, Other Hostels, Social Workers and Local Authorities.

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APPENDIX 20

DRUG DEATH INQUIRIES In England there are currently two models of drug death inquiries: Brighton DAT, East Riding and Hull DAT. Interestingly they offer two very different approaches. Brighton - this system is a more typical confidential inquiry. The coroner's court notifies the DAT of any drug deaths. The DAT then send out a standard questionnaire to both those identified as being involved by the coroner and also to a wider network of agencies to determine whether they had any contact with the deceased. The information from these questionnaires is then collated by a research assistant who produces a composite report incorporating findings across a range of deaths.

A report on this process is being produced by a public health consultant, but neither the report or the questionnaires appear to be publicly available at present. However, discussions with the DAT coordinator did not suggest that this approach had managed to reduce drug deaths.233 East Riding and Hull - this approach is much closer to the homicide inquiry model. The coroner notifies the DAT of any apparently drug-related deaths prior to the coroner's verdict. The DAT then writes out to involved agencies seeking information about their involvement with the deceased. A small group of experts is convened to review the evidence and draw up a report on the lessons from this individual death.

This process has been going for some four years in the East Riding and the DAT coordinator believes it has contributed significantly to a fall in drug deaths, in particular, overdose deaths.234

1

Extract from original project specification - 2005 National Treatment Agency – Models of Care for Alcohol Misusers – 2005 (3.B.5) 3 National Treatment Agency – Models of Care for Drugs - 2005 4 National Treatment Agency – Models of Care for Drugs – 2005 p.18 5 Alcohol Concern – Consultation with the Alcohol Field on MOCAM – NTA - 2005 6 Department of Health - The Alcohol Needs Assessment Research Project - (2005) 7 Department of Health - The Alcohol Needs Assessment Research Project - (2005) 8 Ward M. – Caring in a Crisis – Age Concern Books - 1997 9 National Statistics - Neighbourhood Profile 10 Department of Health – Local Council Tables – 1999-2003 11 Rush B - A Systems Approach to Estimating the Required Capacity of Alcohol Treatment Services. Addiction vol 85pp 49-59 – 1990 12 Godfrey C et al. Assessing Needs for Alcohol Services: Guidance for Purchasers. Centre for Health Economics, York - 1993 13 Department of Health - The Alcohol Needs Assessment Research Project - (2005) 2

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Edwards A. & Rollnick S. - A problem in brief intervention studies - Addiction (1997) 92 (12), 1699-1704 15 Marques A. & Formigoni M. - Individual vs Group CBT for alcohol/drug dependents Addiction (2001) 96, 835-846.

16 Interview with SMS Manager – March 2006 17 Interview with Irish Welfare Information Centre– March 2006 18 Interview with Senior management team at SIFA – March 2006 19 Data supplied by SIFA – April 2006 20 Data supplied by Aquarius – April 2006 21 Interview with Social Services Officer – March 2006 22 Interview with SMS Manager – March 2006 23 Interview with Irish Welfare Information Centre– March 2006 24 Data supplied by IWIC – May 2006 25 Data supplied by SIFA – April 2006 26 Interview with PCT Commissioning Manager – March 2006 27 Interview with Aquarius Management – March 2006 28 Data supplied by Aquarius, SIFA and IWIC – April 2006 29 National Treatment Agency – Models of Care for Drugs - 2005 30 National Treatment Agency –Care Planning Toolkit - 2005 31 National Treatment Agency –Care Planning Toolkit – 2005 p.13 32 National Treatment Agency – Models of Care for Drugs - 2005 33 National Treatment Agency – Models of Care for Drugs - 2005 34 Interview with SMS Manager – March 2006 35 Team Leader for the Community Detox Nurses – March 2006 36 Interview with Irish Welfare Information Centre– March 2006 37 Interview with Aquarius Management – March 2006 38 Interview with Social Services Officer – March 2006 39 Interview with author of report on substance misuse services in Birmingham – March 2006 40 Interview with GP – May 2006 41 Interview with DAT Officer – March 2006 42 Interview with author of report on substance misuse services in Birmingham – March 2006 43 Team Leader for the Community Detox Nurses – March 2006 44 Interview with SMS Manager – March 2006 45 Interview with Irish Welfare Information Centre– March 2006 46 Interview with Senior management team at SIFA – March 2006 47 Interview with DAT Officer – March 2006 48 Interview with PCT Commissioning Manager – March 2006 49 Team Leader for the Community Detox Nurses – March 2006 50 Interview with SMS Manager – March 2006 51 Interview with Aquarius Management – March 2006 52 Interview with author of report on substance misuse services in Birmingham – March 2006 53 Interview with Social Services Officer – March 2006 54 Interview with Irish Welfare Information Centre– March 2006 55 Interview with Irish Welfare Information Centre– March 2006 56 Interview with Senior management team at SIFA – March 2006 57 Interview with Irish Welfare Information Centre– March 2006 58 Team Leader for the Community Detox Nurses – March 2006 59 Interview with Irish Welfare Information Centre– March 2006 60 Interview with Senior management team at SIFA – March 2006 61 Team Leader for the Community Detox Nurses – March 2006 62 Interview with SMS Manager – March 2006 63 Interview with DAT Officer – March 2006 64 Interview with Aquarius Management – March 2006 65 Interview with author of report on substance misuse services in Birmingham – March 2006 66 Team Leader for the Community Detox Nurses – March 2006 67 Interview with SMS Manager – March 2006 68 Interview with Irish Welfare Information Centre– March 2006 69 Interview with Senior management team at SIFA – March 2006 70 Team Leader for the Community Detox Nurses – March 2006

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Interview with SMS Manager – March 2006 Interview with Irish Welfare Information Centre– March 2006 73 Interview with Senior management team at SIFA – March 2006 74 Interview with DAT Officer – March 2006 75 Interview with Social Services Officer – March 2006 76 Interview with author of report on substance misuse services in Birmingham – March 2006 77 Interview with author of report on substance misuse services in Birmingham – March 2006 78 Interview with GP – May 2006 79 Interview with PCT Commissioning Manager – March 2006 80 Interview with DAT Officer – March 2006 81 Interview with SMS Manager – March 2006 82 National Treatment Agency – Models of Care for Drugs – 2005 p.27 83 National Treatment Agency – Models of Care for Alcohol Misusers – 2005 p.52 84 National Treatment Agency – Models of Care for Alcohol Misusers – 2005 p.52 85 National Treatment Agency – Models of Care for Alcohol Misusers – 2005 p.52 86 Addaction – Aftercare Report Year 1 – 2004 87 National Treatment Agency – Models of Care for Drugs – 2005 88 Team Leader for the Community Detox Nurses – March 2006 89 Interview with SMS Manager – March 2006 90 Interview with Senior management team at SIFA – March 2006 91 Interview with DAT Officer – March 2006 92 Interview with Aquarius Management – March 2006 93 Interview with author of report on substance misuse services in Birmingham – March 2006 94 Turnbull, P. J. and McSweeney, T. (2000) - Drug treatment in prison and aftercare: a literature review and results of a survey of European countries - Council of Europe Pompidou Group as cited on URL: http://www.pompidou.coe.int/English/penal/prison/dmop-e041.htm 95 Fox, A. (2000) - Prisoners’ Aftercare in Europe: a four-country study - The European Network for Drug and HIV/AIDS Services in Prison: London 96 Gossop, M., Marsden, J., and Stewart, D. (2001) - Changes in substance use, health and criminal behaviour during the five years after intake, Bulletin 5. - The National Treatment Outcome Research Study: London 97 Interview with Service User – March 2006 98 Interview with Service User – March 2006 99 Interview with Service User – March 2006 100 Interview with Aquarius Service users – March 2006 101 Team Leader for the Community Detox Nurses – March 2006 102 Interview with DAT Officer – March 2006 103 Interview with Aquarius Management – March 2006 104 Interview with Social Services Officer – March 2006 105 Interview with author of report on substance misuse services in Birmingham – March 2006 106 Interview with SMS Manager – March 2006 107 Interview with Senior management team at SIFA – March 2006 108 Interview with PCT Commissioning Manager – March 2006 109 Team Leader for the Community Detox Nurses – March 2006 110 Interview with SMS Manager – March 2006 111 Interview with Senior management team at SIFA – March 2006 112 Team Leader for the Community Detox Nurses – March 2006 113 Interview with Irish Welfare Information Centre– March 2006 114 Interview with PCT Commissioning Manager – March 2006 115 Interview with PCT Commissioning Manager – March 2006 116 Interview with GP – May 2006 117 Interview with Social Services Officer – March 2006 118 Interview with SMS Manager – March 2006 119 Interview with Senior management team at SIFA – March 2006 120 Interview with DAT Officer – March 2006 121 Interview with Aquarius Management – March 2006 122 Interview with Social Services Officer – March 2006 123 Interview with author of report on substance misuse services in Birmingham – March 2006 124 Interview with author of report on substance misuse services in Birmingham – March 2006 72

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125

Interview with author of report on substance misuse services in Birmingham – March 2006 Interview with SMS Manager – March 2006 127 Interview with Irish Welfare Information Centre– March 2006 128 Interview with DAT Officer – March 2006 129 Interview with Aquarius Management – March 2006 130 Interview with Social Services Officer – March 2006 131 Interview with GP – May 2006 132 Interview with Senior management team at SIFA – March 2006 133 Interview with Senior management team at SIFA – March 2006 134 Team Leader for the Community Detox Nurses – March 2006 135 Interview with SMS Manager – March 2006 136 Interview with author of report on substance misuse services in Birmingham – March 2006 137 Interview with Aquarius Management – March 2006 138 Interview with Social Services Officer – March 2006 139 Interview with DAT Officer – March 2006 140 Interview with Senior management team at SIFA – March 2006 141 Interview with Irish Welfare Information Centre– March 2006 142 Interview with Senior management team at SIFA – March 2006 143 Interview with PCT Commissioning Manager – March 2006 144 Ward M. - Research into Engagement in Substance Misuse Services - DPAS 2002 145 Joe (1998); Magura (1998) and Lang (2000) quoted in Ward M. - Research into Engagement in Substance Misuse Services - DPAS 2002 146 Kessel & Walton (1969); Dean (1995) and Ravndal (1999) quoted in Ward M. - Research into Engagement in Substance Misuse Services - DPAS 2002 147 Geelan (1998); Marsden J. (2000); O'Connell (1990); Hansen (1997); Dixon (1999) and Lang (2000) quoted in Ward M. - Research into Engagement in Substance Misuse Services DPAS 2002 148 National Treatment Agency – Models of Care for Alcohol Misusers: Consultation Document – Department of Health - 2005 149 University of Manchester – Safer Services: Confidential Inquiry into Homicide and Suicide

by Mentally Ill People – 1999 150 University of Manchester – Safer Services: Confidential Inquiry into Homicide and Suicide

by Mentally Ill People – 1999 p.25 151 University of Manchester – Safer Services: Confidential Inquiry into Homicide and Suicide

by Mentally Ill People – 1999 p.26 152 University of Manchester – Safer Services: Confidential Inquiry into Homicide and Suicide

by Mentally Ill People – 1999 p.36 153 University of Manchester – Safer Services: Confidential Inquiry into Homicide and Suicide

by Mentally Ill People – 1999 p.42 154 University of Manchester – Safer Services: Confidential Inquiry into Homicide and Suicide

by Mentally Ill People – 1999 p.47 155 University of Manchester – Safer Services: Confidential Inquiry into Homicide and Suicide

by Mentally Ill People – 1999 p.55 156 University of Manchester – Safer Services: Confidential Inquiry into Homicide and Suicide

by Mentally Ill People – 1999 p.95ff 157 Geelan S. et al - A Profile of Residents at Elliott House - Health Trends Vol 30 No.4 1998/9 p104 158 Edmunds M. et al - Arrest referral: emerging lessons from research - Central Drugs Prevention Unit - Home Office 1998 159 National Treatment Agency –Care Planning Toolkit - 2005 160 National Treatment Agency –Care Planning Toolkit - 2005 161 Interview with Senior management team at SIFA – March 2006 162 Interview with Social Services Officer – March 2006 163 Interview with PCT Commissioning Manager – March 2006 164 Interview with DAT Officer – March 2006 165 Interview with Social Services Officer – March 2006 166 Interview with Senior management team at SIFA – March 2006 167 Interview with SMS Manager – March 2006 168 Interview with SMS Manager – March 2006 126

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169

Interview with PCT Commissioning Manager – March 2006 Interview with Aquarius Management – March 2006 171 Interview with DAT Officer – March 2006 172 Interview with author of report on substance misuse services in Birmingham – March 2006 173 Interview with SMS Manager – March 2006 174 Interview with Social Services Officer – March 2006 175 Interview with SMS Manager – March 2006 176 Interview with PCT Commissioning Manager – March 2006 177 Interview with PCT Commissioning Manager – March 2006 178 Interview with SMS Manager – March 2006 179 Interview with author of report on substance misuse services in Birmingham – March 2006 180 Interview with DAT Officer – March 2006 181 Team Leader for the Community Detox Nurses – March 2006 182 Interview with Irish Welfare Information Centre– March 2006 183 Interview with author of report on substance misuse services in Birmingham – March 2006 184 Interview with DAT Officer – March 2006 185 Interview with Senior management team at SIFA – March 2006 186 Team Leader for the Community Detox Nurses – March 2006 187 Interview with Irish Welfare Information Centre– March 2006 188 Interview with PCT Commissioning Manager – March 2006 189 Team Leader for the Community Detox Nurses – March 2006 190 Interview with Irish Welfare Information Centre– March 2006 191 Interview with SMS Manager – March 2006 192 Interview with Senior management team at SIFA – March 2006 193 Interview with Social Services Officer – March 2006 194 Interview with Social Services Officer – March 2006 195 Interview with Aquarius Management – March 2006 196 Interview with author of report on substance misuse services in Birmingham – March 2006 197 National Treatment Agency – Models of Care for Drugs – 2005 p.21 198 Interview with Aquarius Management – March 2006 199 Interview with DAT Officer – March 2006 200 Birmingham Supporting people Strategy 2005-2010 p.41-2 201 Birmingham Supporting people Strategy 2005-2010 p.41-2 202 Team Leader for the Community Detox Nurses – March 2006 203 Interview with DAT Officer – March 2006 204 Interview with Social Services Officer – March 2006 205 Interview with author of report on substance misuse services in Birmingham – March 2006 206 Interview with Social Services Officer – March 2006 207 Interview with PCT Commissioning Manager – March 2006 208 Interview with SMS Manager – March 2006 209 Interview with Irish Welfare Information Centre– March 2006 210 Interview with Senior management team at SIFA – March 2006 211 Team Leader for the Community Detox Nurses – March 2006 212 Interview with SMS Manager – March 2006 213 Interview with Senior management team at SIFA – March 2006 214 Interview with PCT Commissioning Manager – March 2006 215 Interview with DAT Officer – March 2006 216 Interview with Social Services Officer – March 2006 217 Interview with DAT Officer – March 2006 218 Interview with Aquarius Management – March 2006 219 Interview with author of report on substance misuse services in Birmingham – March 2006 220 Interview with Social Services Officer – March 2006 221 National Treatment Agency – Models of Care for Drugs – 2005 p.25 222 Team Leader for the Community Detox Nurses – March 2006 223 Interview with SMS Manager – March 2006 224 Interview with Senior management team at SIFA – March 2006 225 Interview with PCT Commissioning Manager – March 2006 226 Interview with DAT Officer – March 2006 227 Interview with Social Services Officer – March 2006 170

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228

Interview with DAT Officer – March 2006 Interview with Aquarius Management – March 2006 230 Interview with author of report on substance misuse services in Birmingham – March 2006 231 Interview with Social Services Officer – March 2006 232 Audit Commission - Changing Habits - 2002 p.70 233 Interview with Brighton DAT Coordinator - March 2002 234 Interview with East Riding DAT Coordinator - March 2002 229

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