Research into Alcohol Treatment and Recovery Services to inform retender of services in 2015

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1 Research into Alcohol Treatment and Recovery Services to inform retender of services in 2015 Tom White Oxfordshire County Council Public Health Team V 0.9

2 This report is intended to inform a part of the tender specification for the September 2015 Oxfordshire County Council Public Health procurement of Drug and Alcohol processes. A thank you to everyone who contributed to this report and gave their time freely at short notice. Limitations of methods used Due to the relatively short time frame, the sample size of qualitative analysis is small. Every effort has been made to pick out core themes from responses to key questions. The sample size for the qualitative analysis is small and thus the conclusions drawn may not reflect every professional or service user s within the current services. Every effort has been made to present a balanced and logical analysis of people s thoughts and opinions and inevitably this has included some of my own interpretation when doing the write up. 2

3 Contents Page Title Page Summary 4 Introduction 5 Which population demographics are accessing 6 Oxfordshire services currently? Barriers to a more efficient treatment experience for service 9 users Characteristics of an excellent future service 11 References 15 3

4 Summary The purpose of the report is to inform the retender of drug and alcohol services by Oxfordshire Public Health Team in This report focuses on the qualitative survey of alcohol treatment professionals, current and ex-service users in Oxfordshire. Where appropriate Quantitative data and academic journals have been used to strengthen points raised. The findings are discussed across 3 emerging key themes: Population demographics currently accessing alcohol treatment services within Oxfordshire. Barriers to a more efficient treatment journey for clients. Characteristics of an excellent future service. Recommendations for the retender are made throughout the report. Some of the main ones include; Outreach work with targeted organisations such as universities, community groups, probation service, police, colleges /schools, women s groups. Tender for 1 service provider of treatment services. One point of access for drug and alcohol users with specialist interventions for key vulnerable groups within the population as needed. This could involve groups specific for BME, women, alcohol users, drug users, students, men, families. One key worker who follows the client through their treatment. Use some resource to concentrate on promotion of services to relevant professionals, with clarity of referral routes and improved communication routes. Look at the efficacy of family treatment for alcohol treatment. Look at minimum training standards for staff in provider services. Look at longer contract length for future providers. 4

5 0 Introduction The purpose of this piece of work was to provide some on the ground research to inform the service specification for the drug and alcohol contract that will be let by the public health team in Specifically this research originally set out to find out if there is a demographic of alcohol users who need to access services but are choosing not to. It was proposed that the best methods of identifying these silent drinkers would be through 3 streams of work: Academic studies and research. Qualitative insight from local service providers and users. Data from treatment/ recovery outcomes in Oxfordshire and nationally. The emerging themes from the 3 streams of work are discussed within this report and brought together to form recommendations for future use Academic studies and research Literature searches were conducted using Google Scholar, Pubmed, Medline and other scientific journal search engines. All citations are referenced in the Harvard style, with the author s name and date of publication included in the main text and full details within the reference list Quantitative Data Data was provided by PHE from the NDTMS system. Some further analysis was done to protect identifiable data Qualitative Data A number of visits and semi structured interviews were done with professionals and service users in the treatment, recovery and rehab services. Responses have been anonymously reported here to protect the identity of everybody involved with this part of research Layout of Report The discussion has been broken down into 3 key themes that emerged from researching the original brief and from subsequent qualitative work. Is there any disparity in the access to services for alcohol treatment? Is there a particular demographic that is under represented? What are the key barriers to a more efficient treatment journey for clients? What are the characteristics of a successful/ more efficient alcohol service in the future? At the end of each section, recommendations for the retender have been made. 5

6 1-Which population demographics are accessing Oxfordshire services currently? This theme was initially discussed with professionals within the provider services as an opened ended question. Professionals on the whole felt that people accessing the alcohol services did vary in age and social backgrounds. It was felt that you get a whole range of people here and that it (treatment) is down to the individual and their personality, rather than where they re from or how old they are. One professional did feel that more could be done to engage with the universities, colleges and employers to catch clients sooner into their addiction, as a typical client tended to be slightly older sometimes with a family or a job and other responsibilities. 1.1-Age Fig 1 (shown below) seems to partially back up this assertion in showing that there is a marked increase from the numbers of year old males accessing the service compared to year olds. The increase is more linear in females, building towards a peak at years old. ONS self-reported data shows that 27% of people aged had drank heavily in the week before the survey, though just 3% of this age group reported drinking on 5 or more days of the week compared with 18% of over 65 s. These figures show that it is difficult to classify drinking patterns by age but may point to a culture of binge drinking when at a younger age moving towards enjoy a nightly tipple when older Graph to show the number of males & females entering Alcohol treatment in Oxfordshire during 2013/14 broken down by age range Males Females Fig 1- Ages of people accessing alcohol treatment in Gender Fig 1 also shows that there is still a disparity between the numbers of men and women accessing alcohol treatment services- 62% were men. One service user said that Women s only treatment groups helped me a lot because I felt a lot safer in that environment than I did in mixed groups. Now though, it doesn t bother me as I m a lot more confident. When asked further whether these groups influenced her decision to access treatment she replied No, because I didn t know about them until after my 6

7 assessment. Whilst these groups are key for some individuals, other felt they weren t as important as other factors within the services like consistency and transparency. These responses from service users show that specialist groups/ interventions will perhaps help people remain within a service for longer but not necessarily aid initial engagement. Another reason for the 62/38 gender split could be cited in the lifestyle data collected in the census. 26% of men self-reported exceeding the government guidelines of 3-4 units per day on a regular basis, whilst the figure for women is lower at 17%. Men (60% of total) had more admissions for alcohol related health problems than women. 1.3 Ethnicity One service user did hypothesis that the services weren t seeing many people from BME communities. It is hard to establish drinking patterns broken down by ethnicity with any reliability in any large data sets. During the last year 90% of all people in treatment were White British. The other 10% were of other ethnic origins. The few professionals who felt able to comment were not sure whether the numbers they were seeing in services were representative of the wider population. In Oxfordshire as a whole 16.4% of people are not white British, though it is impossible to draw any conclusions as to the prevalence of alcohol misuse/ dependence within different communities Socio-economic group There is no data breaking down individuals accessing services by socio-economic group. The issue of people who are functioning, i.e. with jobs and families, alcoholics not accessing treatment services was discussed with professionals. Professionals who were interviewed did feel that the services saw more people who were of a lower socio-economic demographic. They felt that the majority of clients were chaotic, unemployed and lacked a family support network. One professional felt that services for treatment and rehab were best placed to assist those with complex needs when compared to other available help such as Mutual Aid. Professionals did feel that people who were middle class alcoholics were put off by traditional services as they would have to mix with drug users, who often have to commit crime to fund their addiction. One professional summed up the issue: People with a drinking problem feel that they are at the top of the hierarchy when it comes to drug and alcohol users. They feel they are not doing anything illegal and that they cannot relate to drug users and they certainly don t see their addiction as the same. The thought of mixing with people who are offending and/ or homeless is not something they want to do. It is not until the latter stages of treatment that people have learnt to accept all addictions and are more able to empathise. Service users and professionals were in agreement that there is a hierarchy among service users and this contributes to alcohol users sometimes failing to access services Recommendations 7

8 The issues around certain demographics of people not accessing services are not clear cut. Opinion from service users and professionals was wide ranging and difficult to consistently categorise. The data from the treatment services does show that the typical person will be male, aged and white British. However it is difficult to say whether this is simply reflective of drinking habits and population splits, i.e. men self-report drinking more alcohol than women and the majority of the population in Oxfordshire is white British, or whether it is to do with services being more appealing and accessible to that particular demographic within the wider population. Looking at more middle class drinkers in detail would possibly be useful, though that is not to say that the current service does not see some of this demographic currently. However the feeling among professionals is that catering for people who are possibly homeless, with no education and lacking a social support network is more important. The reasons behind this relate to market position of treatment services and the 3 capitals behind recovery. Firstly market position of current treatment services means that they are best placed to help those people who are more chaotic- such as homeless people. Mutual Aid services do not provide the intensive harm minimization and rehab services that can provided in the current model. In trying to cater further for more middle class clients, the services could easily link with mutual aid groups particularly at the initial contact and rehab points. Secondly middle class people tend to have more personal, social and community capital. Personal capital is where some of the biggest differences lie. Middle class drinkers tend to have better education, better skills and a better diet. Diet is particularly important to alcoholics as it helps to reduce the harm that alcohol does to the body. An established eating pattern is one of the first steps taken in recovery. Family and other support networks are more likely to be present in middle class alcoholic, which increases the chance of successful outcomes. Finally the ethos of public health is to focus services on those most in need. Middle class drinkers undoubtedly have a great need when compared to the general population, however a homeless alcoholic will be at a much greater risk of dying younger. It would seem that a common sense approach would be required to increase the profile of services in certain populations such as BME communities and young people. This can be done via: Outreach work with targeted organisations such as universities, community groups, probation service, police, colleges /schools, women s groups. Produce promotional material in other languages as appropriate. Target specific age groups with awareness materials using relevant market research to use messages that speak to different demographics. As further data becomes available on a national and local level about drinking habits then more targeted work can be done to target services at particular groups of people. It should be noted here that one service user in particular did not feel that traditional public health campaigns (such as don t drink and drive) are enough when trying to promote services to people misusing alcohol. They (service user) felt that it was more important to invest money in making sure that the services were easy to find on the internet and phone directories. 8

9 2- Barriers to a more efficient treatment experience for service users When talking to both professionals and service users there were a number of issues cited that potentially inhibit the treatment process. Though individual opinions varied slightly, the common issues are discussed here. It should be noted here that the small sample size may mean that these barriers are only pertinent to the individuals involved and would need thorough investigation before making changes to the service provision. 2.1 Timeframes A number of people thought that the timeframes involved in service s processes were a key barrier. This related to both the timeframe between initial contact and assessment and the timeframe involved in transferring between treatment services. A selection of quotes are included below: and when clients do know who to go to, there are often long waiting periods. Don t drag out treatment- it is a key time and it (the will to change) can fade quickly if things don t move quickly For me, things seem to take forever but I was lucky that my family were able to chase things up for me. It is clear that this was a complex issue and needs further investigation with providers. The service users who provided their opinions are only a small sample of all those who pass through treatment in Oxfordshire and as such may not be reflective of what is happening Paperwork Linked to this were feelings that paperwork processes hamper both the professionals ability to engage with the client and also the client s journey through treatment. One professional described it as The client gets their first appointment and they are very scared/ nervous but all they get to see is the top of my head! 3 of the service users also mentioned that paperwork had gone missing for them at various points in their journey. Again this will need further investigation with providers as there has been a huge amount of change in the services recently that is likely contributing to these issues. It would seem a logical approach to review the systems in place and try to streamline paperwork where possible Process Service users also cited confusion with the overall process and a couple felt that it would be beneficial to have some kind of journey card or reference sheet explaining each step or option available to them. One service user expressed this as As I realised I had a problem I tried to get help but I was drinking so much that by the afternoon I couldn t string two thoughts together. On days where I had to leave the house I would drink more as I was nervous. This meant that meetings and groups were a haze to begin with and I really needed something to refer back to when I was a bit more lucid. Another service user had a parent who was able to take notes from 9

10 meetings to help recall and they felt that this was beneficial but it would ve been great to given something by the service at the initial contact point. A professional also said that clients are often confused and don t know what it is going to happen next. Another stated that Clients, like all of us, want different things but most consistently they want to know what the service does, how it does them and that they will actually do them. Clients generally understand the limitations. From this it can be inferred that service users are accepting of things not going to plan but really want to be communicated with. Some recommendations around the responses here will be picked up in section 3 s recommendations. 2- Recommendations It is difficult to make direct recommendations relating to barriers as it is unclear as to the prevalence of them. A review of paperwork within services and the transfer process between services would be a good first step. A focus group of current/ previous service users to discuss the client facing literature and other things that could be done to aid understanding of their treatment journey would be a possibility. Specific aspects of the retender specification could look to address some of these barriers via regular audits or quality control as part of the contract management process. 10

11 3- Characteristics of an excellent future service Service users and professionals were each asked what would an excellent service look like in the future? It should be noted that some of these point may already exist in the service and that they are reported here as it was felt strongly that they should remain. 3.1 One service provider A clear message from everybody that was spoken to was the need for a unified service under one organisation. Professionals spoke of easier transfers and quicker assessments. Service users spoke of consistency and clarity as being the main key benefits. This idea is already flagged for the retender in 2015 and there is a great deal of support for it from clients and professionals. 3.2 Separation of Drug and Alcohol Treatment Provision The responses to this varied across individuals. There is no conclusive academic research into this particular issue. Some individuals supported splitting the treatment services for drugs and alcohol: I think that some alcohol users are put off by having to be in group with drug users. Certain functioning alcohol dependent people who have jobs and families are horrified at the thought of interacting with people who are committing crimes and injecting. After all they don t see themselves as doing anything illegal and this is important to them However other people didn t support the split;.this would lead to more confusion and passing of people around. People often have a secondary addiction or have had an issue with drugs in the past and this requires a joined up approach to tackle. In fact 22% of people in alcohol treatment in Oxfordshire in 2013/14 had secondary drug use. I think splitting the service would promote the hierarchy that already exists where alcohol users look down on drug users. People need to see addiction as all the same and it is an important step in recovery to be able empathise with other people s addictions. Splitting services would contradict the model of having one unified service and may also interrupt consistency for people presenting with secondary drug use. A compromise of a single access point for drug and alcohol users backed up by specialist interventions is already being used by provider services. Future service development should look to identify user groups that would benefit from separate groups or provision within services. Women s only groups are running and were well supported by previous service user; women s only groups really helped me as sometimes women can be exploited in a mixed group. They especially helped me at the start as I felt very vulnerable then. When I was getting ready for rehab it didn t bother me as I had more confidence by then. It seems that a continuation of the current model with some development to further identify groups in need would be a good inclusion in future services. Research done by Haringey Council as part of their 2013 retender of services found abstinent clients wanted separate services, though not necessarily in separate 11

12 buildings (taken from a survey of 90 service users, 40% of whom were alcohol dependent). This shows the importance of some separation dependent on the need and stage the client is at in their treatment, which is reflected in current services in Oxfordshire. 3.3 Key Workers Current and previous service users highlighted the need for one key worker who follows them right through their treatment journey..it is not effective for someone to be assessed and then immediately reassigned to another worker. Marlatt & Witkiewitz (2002) said that individualisation of treatment is vital to success, as the needs of people accessing services will vary hugely. It was suggested that the only way to achieve this is through developing the trust and rapport with the individual. Professionals also supported this idea; having one key worker would enable a smoother transition to rehab and back again...consistency is key and could help cut down drop outs. One professional discussed how this could work in practice, suggesting that clients could be categorised according to how much support they would need and what stage they are at. From there suggested caseloads could be used to balance group and individual work for professionals. Provision of an individual key worker from assessment onwards would obviously require one service provider to allow for cross cutting work. Further investigation into the feasibility of a battery of training for key workers to promote consistency of approach may be needed too. 3.4 Profile of services- transparency and promotion Both professionals and current/ ex-service users felt that promotion of the services was key to people knowing where to go. It was widely discussed that the changes that have occurred over the past year within treatment services have been the deciding factor in some of the confusion. Linked to this was some ambiguity of understanding of the process, which was cited as a key barrier in treatment. Service users didn t feel confident in knowing what was going to happen next and sometimes professionals felt processes were unclear. Again this is probably due to the changes within the services and will be addressed by having one unified service. On speaking to service users, it was found that the majority of people were referred to services via their GPs or by hospital staff. 3.5 Links with other outside agencies Some professional were very keen to promote more links with outside organisations and make this a formal requirement on any future contract. Links with Mutual Aid are key- there should be drop in sessions run by them every week at treatment services. Some people are going to prefer Mutual Aid settings to other treatment and it should be as easily available as possible. Service users are also keen to see more practical help based within the services I went to see the housing person but it took a long time to get an appointment- also 12

13 there is some information on the walls etc but an organised notice board would be great. 10% of service users had a housing need in 2013/14, so this option certainly needs exploring further. 22% of people were still living with children and it would make sense to look at the feasibility of family based therapy, with links to appropriate support workers within the community. Stanton et al (1997) found that family based therapy for drug treatment is more effective than individual counselling and it had higher retention rates, which made it more effective from a commissioning perspective. However this study only looked at drug users and thus may not be applicable to alcohol users. 3.6 Outreach work It was felt by professionals that outreach work has been the primary casualty of the changes in the past year. We do offer some home visits but this is on an ad hoc basis and not a requirement (of the contract). It is essential to get out and cover the whole of Oxfordshire. Service users were mainly from the Oxford area, though a few did travel significant distances (> 1hour) to go to groups and other services. Without my family pushing me. Taking me to the train station.i probably wouldn t come. Especially to start with when I really struggled. Professionals linked this issue back to consistency, saying that it takes a long time to get trust from the local area and that it needs to be the same person going in. This wasn t a well explored issue as the majority of service users were from Oxford and therefore it is difficult to conclude firmly from the responses. However covering the whole of Oxford is a requirement for any county council service. There is also some evidence that rural alcohol users are at a greater risk of health complications. Booth et al (2000) found that rural drinkers had more barriers to treatment and had much more severe co-morbidities compared to urban drinkers. 3.7 Other ideas/ issues emerging Professional understandably felt that there had been too much change and this had caused a higher than expected turnover of staff. This has a great deal of uncertainty within the workforce over jobs and work conditions. Suggestions such as TUPE of existing staff and minimum training standards before deployment were noted. The other key message was around the length of contract let to the provider, which was summed up very well by one professional: The service in Oxfordshire used to be very strong as you had consistency over a long period of time. Recently there has been a lot of change and I think that has caused a lot of confusion. What would help would be if there was stability over a long period by having a longer contract. 13

14 3.8 Recommendations One service provider of treatment services. One point of access for drug and alcohol users with specialist interventions for key vulnerable groups within the population as needed. This could involve groups specific for BME, women, alcohol users, drug users, students, men, families. Look at building in flexibility to meet changing needs for home visits and assessments. One key worker who follows the client through their treatment. Use some resource to concentrate on promotion of services to relevant professionals, with clarity of referral routes and improved communication routes. Requirement for drop ins by relevant agencies such as housing, mental health and others such as family support workers. Look at the efficacy of family treatment for alcohol treatment. Look at minimum training standards for staff in provider services. Look at longer contract length for future providers. 14

15 4. References Stanton, M. Duncan; Shadish, William R.(1997). Outcome, attrition, and family couples treatment for drug abuse: A meta-analysis and review of the controlled, comparative studies. Psychological Bulletin, 122(2),, Booth, M. et al.(2000). Rural at risk drinkers: correlates and one year use of alcoholism treatment services. Journal of studies on Alcohol and Drugs Marlatt, A.G. & Witkiewitz, K. (2002) Harm reduction approaches to alcohol use: health promotion, prevention and treatment. Addictive Behaviour Office of National Statistics. Census data from Retrieved on 13 th May

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