Independent review into the impact on employment outcomes of drug or alcohol addiction, and obesity

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1 Independent review into the impact on employment outcomes of drug or alcohol addiction, and obesity St Mungo s Broadway response to the call for evidence September 2015 About St Mungo s Broadway Our vision is that everyone has a place to call home and can fulfil their hopes and ambitions. As a homelessness charity and housing association our clients are at the heart of what we do. We provide a bed and support to more than 2,500 people a night who are either homeless or at risk, and work to prevent homelessness, helping about 25,000 people a year. For any queries regarding this submission, please contact Catherine Glew in the Policy, Public Affairs and Research team. Tel: , or catherine.glew@mungosbroadway.org.uk. St Mungo s Broadway provides services to many clients affected by long term health problems. In this response, we focus on people affected by drug and alcohol addiction. This reflects the scale of impact of addiction among our clients, and our expertise in providing substance use services and support. This response collates evidence from St Mungo s Broadway staff and clients and internal data. It includes references to documents that may be of additional interest to the review team. Further information on all points raised is available on request. We would also like to invite Professor Dame Carol Black and the review team to visit the services mentioned and speak with our clients. Summary and recommendations: St Mungo s Broadway works to help our clients affected by addiction to recover and rebuild their lives. We welcome government attention to the challenges facing people affected by addiction. To effectively address these challenges, St Mungo s Broadway calls on Dame Carol Black and the review team to recommend the following: That an understanding of multiple interrelated barriers to employment including addiction, mental health, learning disability, physical health, relationships and trauma should underpin the government s response That the government makes significant and sustained investment in joined up addiction, health, skills, employment and housing services that work for people with multiple related needs at different stages of their recovery That benefit entitlements are not linked to take up of treatment for drug and alcohol addiction. Question 1 St Mungo s Broadway supports thousands of men and women with employment, health and welfare as part of their sustainable recovery from the issues that underpin their homelessness. Many struggle with issues relating to drug or alcohol use. According to our latest Client Needs Survey of 1,940 clients in May 2015, 56% of those being supported by our residential services are currently using alcohol problematically and/or currently misusing prescribed drugs or using illicit drugs. Drug and alcohol use makes it harder to engage with mainstream employment support, health care and benefits systems. a. Experience of employment support services Our research and experience shows that the vast majority of homeless people want to work. However, they face numerous barriers to entering employment. Only 8% of St Mungo s Broadway residents are in work, this falls to only 4% among our residents with substance use needs. In 2012, St Mungo s Broadway, Crisis and Homeless Links published a joint report outlining the experiences of homeless people on the Work Programme and evidence of the many problems that needed to be addressed in order for it to be more effective, including failure to address barriers to employment such as substance use needs and homelessness. 1 Our recent joint briefing with ERSA gives recommendations for the future of government led employment support for people who are homeless, including those with multiple and complex needs. 2 These recommendations include ensuring conditionality and sanctions better tailored to individual circumstances. 1 St Mungo s Broadway, Crisis and Homeless Link (2012) The Programme s Not Working: Experiences of homeless people on the Work Programme 2 ERSA, Crisis, Homeless Link and St Mungo s Broadway (2015) Supporting homeless people into work: recommendations for the future of Government-led employment support

2 b. Experience of health care People who are homeless often find it hard to access the healthcare they need, particularly if they have multiple health problems. Health services are usually designed to treat one condition at a time. Support must be accessed from different parts of the health system, and may be difficult to navigate for people managing substance use issues. People who are using drugs and alcohol often face barriers to managing or improving their mental health. Many mental health services exclude those who are currently using drugs or alcohol. Our experience shows that clients often need to deal with their mental health problems in order to reduce their substance use. Without proper mental health support, treatment and recovery from addiction is unlikely to be sustainable. [I ve been trying to get help with my mental health] but they won t, because I drink. I said well, I drink because of my issues, she said which way are we doing this? I went through detox, after detox, after detox, then I was thrown back out onto the street. Well, what s the first thing I m going to do? I m back out on the street having another drink. St Mungo s Broadway client 3 St Mungo s Broadway recently submitted evidence to the NICE consultation on severe mental illness and substance misuse (dual diagnosis). Our submission contains case studies illustrating the experiences of clients with substance use issues engaging with mental health services. 4 c. Experience of the benefits system Many of our clients experience problems with benefit delays and errors. 5 People who are homeless are more likely to be sanctioned than other claimants. 6 These experiences causes anxiety and physical hardship for people who are homeless, including those with substance use issues. The client case study in Appendix A illustrates some challenges faced by people who are homeless and have multiple needs when engaging with the benefits system. Questions 2, 4 & 5 This response will consider these questions together, providing evidence on the following points: Treatment services for people with drug or alcohol addictions; Specialist employment support services for people with drug and alcohol addictions; The effectiveness of integrated services. a. Treatment services for people affected by addiction St Mungo s Broadway runs a range of substance use services, including specialist workers based in our hostels and as a partner in local drug and alcohol pathways (e.g. Haringey, Wandsworth). Our work is based on the recovery approach, which structures the service around the client and offers positive choices and opportunities to work towards their own recovery. A key lesson from our experience as a service provider is that one approach will not suit everyone. While we welcome government prioritising recovery from addiction, we are clear that any treatment services provided alongside employment support should be flexible, accessible and offer appropriate levels of support for individuals. We believe in every client s potential, and we are committed to every individual s sustainable recovery. Often, however, this work is not quick or easy. Some people are able to resolve substance use issues independently or with brief support. However, a good number of St Mungo s Broadway clients require intensive intervention to resolve drug and alcohol addiction. Many will present with concurrent, complex issues (such as mental health, learning disabilities, physical health issues, experience of complex trauma, or very early onset of substance misuse which makes diagnosis of other issues more problematic). This work is personal and requires patience and flexibility to build motivation for formal treatment. 3 St Mungo s Broadway (2014) Homeless Health Matters: The case for change (p.11) 4 St Mungo s Broadway (2015) Submission to the NICE consultation on dual diagnosis 5 St Mungo s Broadway (2015) Submission to the Work and Pensions Selection Committee inquiry on benefit delivery 6 St Mungo s Broadway (2014) Submission to the Work and Pensions Select Committee inquiry on benefit sanctions policy

3 For some, abstinence based services are important in providing the right environment to quit drug and alcohol use. For others, the appropriate intervention reduces harm where addiction is addressed over a long time period. There is no one treatment approach that will allow everyone affected by drug and alcohol addiction to be able to work. Key elements of successful treatment services for people affected by drug and alcohol addiction No wrong door approach to access Peer support, developing relationships, client involvement in service design and delivery Involvement in meaningful activity (e.g. volunteering, group work, courses) in a safe environment Access to psychotherapy support to understand mental health and addiction Gender specific services for women who have suffered domestic violence b. Specialist employment support services for people affected by addiction St Mungo s Broadway provides education, training and employment (ETE) services for our clients. All our ETE services are open to those who are actively using drugs and alcohol and those in recovery, but there is a clear expectation that clients will be sober when they attend sessions and behaviour that compromises safety will not be tolerated. We also provide specialist employment support targeted at people with substance use issues. Our ETE work with clients is part of a broader range of work on health, housing, relationships that contributes towards a client s recovery from the issues behind their homelessness. This broader recovery also supports people to move towards work, volunteering and meaningful activities. ETE services are available to clients in London, with some provision in Bristol. St Mungo s Broadway ETE related services a journey 7 Different types of support are appropriate for clients at different stages of their recovery. The first stage may be building relationships and attending group activities in accommodation projects. Other ETE services include: Basic Skills provides group and one-to-one tuition in English, maths and IT skills. 34% of St Mungo s Broadway residents with a substance use need do not have the literacy skills to read a letter or complete a form without support. STRIVE is a pilot pre-employment programme targeted at single homeless people, delivered by Crisis and St Mungo s Broadway and funded by DCLG, BIS and the Skills Funding Agency. The programme supports clients to the point at which they can benefit from mainstream ETE provision. Evaluation has been commissioned by DCLG, with final reporting due in Recovery College is an inclusive adult learning programme where courses are designed, delivered and attended by St Mungo s Broadway clients, staff and volunteers people attended courses at our London college in 2014/14. Work and Learning and Employment teams provide information, advice and support for clients with a range of support needs, from those close to work to those furthest from the job market. In 2014/15 our teams in London helped 211 clients get jobs. Train and Trade provides vocational training in bricklaying, plastering, tiling, painting and decorating, gardening, music, and bike maintenance. 306 clients took part in 2014/15 achieving 61 qualifications. Key elements of successful ETE services for people affected by drug and alcohol addiction Clear policies on drug and alcohol use, anticipating triggers for relapse and working to provide a supportive space that minimises risk Joint work and links to drug and alcohol treatment and support Awareness of a client s stage of recovery from addiction, working at a pace that suits the client Understanding of client aspirations and abilities e.g. areas of interest, literacy, skills etc. Positive social networks and peer support, mentoring before and when in work Links with employers, particularly for clients with offending histories See Appendix A for a specialist service case study, including outcomes. Question 3 a. What other physical and mental health conditions are these groups likely to face? Our 2015 Client Needs Survey provides information about 1,940 St Mungo s Broadway residents, a 98% response rate for clients in our residential services on 1 May Further information about all our services is available on request. 8 For information and outcomes, see

4 56% (n=1,077) of our residents have substance use needs, defined as currently using alcohol problematically and/or currently misusing prescribed drugs or using illicit drugs. It should be noted that these figures do not distinguish clients that are addicted to drugs or alcohol from the broader group of clients with substance use needs. Of the 1,077 residents identified as having substance use needs: 56% use alcohol problematically. 71% misuse prescribed drugs or use illicit drugs, most commonly cannabis (40%), crack cocaine (35%) and heroin (30%). Two thirds are engaging with St Mungo s Broadway or an external provider around their substance use needs. 50% cited drug use and 45% alcohol use as a factor contributing to them becoming homeless. The majority of our clients with a substance use need also experience problems with their physical and/or mental health. 49% of our 1,077 residents with a substance need also have a significant physical health condition that has a substantial effect on their health and which requires ongoing treatment/medication. 72% also have a mental health need (including those with a diagnosis; who have experiences which could meet the threshold for diagnosis; who self harm and who exhibit compulsive hoarding behaviour). 21% of our 1,940 residents experience all three problems: substance use need, mental health need and physical health condition. Only 9% have a substance use need without any physical or mental health problems. b. How do these interact with non-health related barriers to employment? Homelessness itself is a barrier to employment. The lack of a stable and settled home makes it extremely difficult for people sleeping rough, sofa surfing or living in hostels, temporary accommodation projects, night shelters or refuges to find and keep a job. Many people who are homeless face multiple barriers to employment, created or exacerbated by their homelessness. These extend beyond immediate housing issues. In addition to health related barriers to employment, other challenges for our residents with substance use needs include: Literacy: 34% of St Mungo s Broadway residents with substance use needs do not have the necessary literacy skills to read a letter and/or to complete a form without support. Qualifications: 22% have no UK qualifications. Internet access: 34% do not have access to the internet. Transport: 18% need support to travel and/or use public transport. Disability: 26% have a disability; 11% have a diagnosed learning disability. Offending history: 65% have an offending history. 47% have been in prison. Our evidence also shows that the more needs our clients have, the less likely they are to move on from homelessness into independent accommodation. 9 c. What additional support or interventions might be required to help people overcome these barriers to employment? For people who are homeless, it will be important to address housing needs which act as a barrier to employment. Evaluation of mainstream employment support indicates that stable housing can underpin (re)entry into work. 10 For details of other interventions to address mental health, literacy and for those with complex needs, please see our response to questions 2, 4 and 5. Question 7: St Mungo s Broadway opposes proposals to link benefit entitlements to the take up of treatment for drug and alcohol addiction. We support the aspirations of our clients to recover from addiction, develop skills, and move towards work. We welcome government attention to the challenges facing people affected by addiction. 9 DCLG call for evidence: Addressing complex needs - Improving services for vulnerable homeless people 10 DWP (2014) Work Programme evaluation: the participant experience report

5 However, we anticipate that linking benefit entitlements with treatment would have an unacceptable human and financial cost. These comments are based on input from expert staff and St Mungo s Broadway clients. High quality treatment services are not universally available. As discussed above, sustainable treatment and recovery from addiction involves not only drug and alcohol services, but also concurrent support for other related issues including mental health, learning disabilities, physical health issues, relationships and experience of complex trauma. These services are not available for everyone. People with multiple needs find it particularly challenging to access several service pathways from different providers. Accessing and engaging with services is a particular problem for people with a dual diagnosis of substance use and mental health needs, who are often excluded from both types of provision. These systemic barriers to treatment can be addressed through significant investment in joined up addiction, health and housing services that work for people with multiple related needs. We would welcome significant, sustained investment from government to meet this challenge. Linking benefit entitlements to take up of treatment puts the most vulnerable most at risk. Without appropriate services, conditionality that requires claimants to enter treatment will not support them to recover from addiction or enter employment. Requiring claimants to enter inappropriate or incomplete treatment pathways puts vulnerable people at risk of relapse and cycling through services repeatedly. This is harmful for individuals and costly for the public purse. Claimants who are not able to comply with treatment requirements for example because services are ill equipped to work with people with multiple needs will face increased risk of rough sleeping, destitution, offending behaviour, begging and exploitation. Isolating people from the benefits system will leave them further from accessing the treatment and support that they need. Linking benefits entitlements to treatment does not create the right conditions for sustainable recovery. Even where people are able to access treatment and support, requiring people to enter treatment when they are not ready to make the choice of their own accord will not produce sustainable outcomes. Successful recovery involves individual choice, motivation and action. The choice between treatment or sanctions and the threat of extreme hardship is not a choice that will allow people room to enter treatment for its own sake, with the motivation to recover. Measuring outcomes will be challenging. There may be challenges in defining and measuring success around addiction treatment. Abstinence is unlikely to be an appropriate outcome for many claimants, and physical testing may undermine relationships between some clients and staff. St Mungo s Broadway has worked with thousands of clients affected by drug and alcohol addiction. Addiction cannot be treated quickly or simply with a brief medical intervention. Similarly, recovery from addiction will not guarantee that someone is ready and able to work. Our approach is to offer focus on people s assets rather than their problems, offering accessible opportunities to tackle the full range of barriers faced by individual clients including housing, health, substance use, skills, relationships and employment. Helping people with their own sense of purpose and progress is likely to lead to a reduction in drug and or alcohol use, as many of our own skills and employment services can testify. being here at Recovery College has given me the confidence to put it [my experience of domestic violence] on paper. It's lifted a weight off me, as I've shown others what I've written. It's a form of therapy by writing it down. To sum up, I've gained a life, and it s given me a life, and kept me off the drink. London Recovery College client The starting point for supporting people with substance use needs into work is to understand that often those needs are connected to, and overlap with other problems. People need to be engaged in the right way in order to realise that change is possible and to feel sufficiently motivated to reduce their substance use. This requires a broad-based recovery approach. A punitive approach would at best be ineffective, but is also like to increase hardship and destitution.

6 Appendix A client and service case studies Client case study L s story L is HIV positive and has a diagnosis of emotionally unstable personality disorder. She lost her entitlement to ESA following a work capability assessment (WCA), and appealed the decision. L has a chaotic lifestyle and is addicted to heroin and crack cocaine. She struggled with the appeal process, which took 4 months. She cannot read or write, and required significant support from St Mungo s Broadway to correspond with the Jobcentre Plus. Her mental health worsened due to stress. She often went several days without food and was too weak to attend appointments. Food bank vouchers were provided, but she was only entitled to 3 per year. Her anti-retroviral medication should be taken with food and the side effects of the medication became worse without it. She often failed to take her medication because of the negative effects. Her health and immune system deteriorated. L s housing benefit payments were also stopped, and she accrued 1000 in service charge arrears. She was at risk of eviction and homelessness, and would have faced barriers to accessing other housing due to her arrears had she been evicted. After 4 months, L s ESA claim was reinstated and she received a large backdated payment. Staff felt that L s experience could have been avoided if the Jobcentre Plus had better protocols and support in place for vulnerable people who have complex needs. Specialist service case study London Borough of Hammersmith & Fulham (LBHF) Jump Start 11 As well as our ETE provision for all clients, St Mungo s Broadway provides specialist services for people who are homeless and affected by substance use. The Jump Start Programme is in its 5 th year and provides ETE advice and guidance to clients engaging with substance use services in LBHF. The service accepts referrals from LBHF substance use providers, and also works closely with local Jobcentre Plus. The service focuses on increasing employability and creating employment, training and volunteering outcomes for clients at various stages on their journey to recovery. The service works to directly identify and address the obstacles to each client s individual progress and to link this with the support provided by their key worker/recovery worker. Outcomes for 2014/15: 220 new clients referred 83 clients gained places on training course, of which 16 were accredited. 11 gained a qualification. 37 clients gained volunteering/unpaid work/work-based training placements 29 job starts were achieved 10 full time and 19 part time Clients are also offered in-work support with issues like work clothing and payroll. 11 Further information is available on request.