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This entry is our analysis of a study considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original study was not published by Findings; click Title to order a copy. Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text Unfold supplementary text The Summary conveys the findings and views expressed in the study. Below is a commentary from Drug and Alcohol Findings.

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Evidence-based practice? The National Probation Service's work with alcohol-misusing offenders.

McSweeney T., Webster R., Turnbull P.J. et al.
[UK] Ministry of Justice, 2009.
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This report on work in England and Wales describes a system creatively grappling with a huge drink problem among offenders, but one undermined by lack of evidence about what works and by under-resourcing linked to a dispute over whether health or probation should bear the core funding burden.

Summary Conducted by the Institute for Criminal Policy Research, this study examined how the probation service in England and Wales works with alcohol-misusing offenders. In particular:
• procedures for identifying and intervening with problem-drinking offenders;
• how far these complied with the principles set out in national guidance; and
• arrangements for the commissioning and delivery of sentences which involve alcohol treatment requirements.

Main sources were a telephone survey completed with the substance misuse policy or delivery lead in 41 of the 42 probation areas, and alcohol treatment requirement records for 2007/08. Additionally, Offender Assessment System (OASys) data The study analysed 17,183 assessments completed on 15,082 offenders during a three-month period in 2007. was obtained from six 'case study' drug action team areas selected to represent the range of such areas. Completed by criminal justice services at key stages in an offender's OASys is only mandatory for tiers 2, 3 and 4 community sentence offenders. In some cases up to half of all inmates are discharged from prison without being sentenced or after serving sentences of under 12 months so are never assessed using OASys. Also, though OASys is mandatory for prisoners serving more than 12 months, the assessment is often only undertaken about three months in to their sentence. prosecution and sentence, these assessments include whether drinking influenced offending, how much and how often the offender drinks, whether this has been linked to violence, and their motivation to tackle any drink problems. Each case study area was also asked to select 30 case files In the event 185 files were made available. for analysis. About two thirds documented offenders consecutively sentenced to an alcohol treatment requirement, the remainder offenders assessed as problem drinkers but not sentenced to a requirement. Also 64 in-depth interviews were conducted with stakeholders and with professionals involved in alcohol-related sentences and services in the six areas. The results of this work are summarised below under similar headings to those used in the report.

Probation work nationally with alcohol-misusing offenders

Based on responses to the national survey and stakeholder interviews, it seemed that the commissioning and delivery of alcohol services had been hampered by lack of: resources and dedicated funding; guidance on the targeting of interventions; appropriate and accessible treatment; probation staff's relevant confidence, skills and knowledge; and the prioritising of alcohol-related work by local commissioners. Relevant data below.

Half Compared to a quarter for drugs. of the OASys offender assessments identified alcohol as an influence on offending. In around a third the offender admitted to having drunk too much and just under one in four linked this to their offending. Despite the frequency of such problems, OASys data from sentence plan reviews revealed that 43% of alcohol interventions had yet to begin four to six months after probation supervision had started. In just 4% of cases had sentence planning objectives relating to alcohol been fully met by the first review. These findings are consistent with observations that in many areas offenders are increasingly 'stacked' awaiting the availability of programmes or elements of sentence requirements, and with records on OASys-identified dependent drinkers during 2007/08. These showed that by the end of a community sentence just 44% of alcohol-related interventions were continuing or had been completed. Despite the widespread drink problems revealed by the study, one in three of the surveyed probation areas had not completed an assessment of the level of need for alcohol-related services among their caseloads.

Compliance with national guidance on alcohol screening, advice and treatment

The national survey and in-depth interviews in the case study areas were used to assess the degree to which alcohol interventions were carried out and conformed to Models of Care for Alcohol Misusers (often abbreviated to 'MoCAM'), best practice guidance produced in 2006 by Britain's Department of Health and National Treatment Agency for Substance Misuse.

Survey responses indicated that OASys assessments were the main way of identifying offenders whose crime was linked to drinking. Three fifths of probation areas also said they routinely screened for risky drinking, primarily using the AUDIT questionnaire developed for primary care settings, one of several recommended in the guidance. Once screened the aim was usually then to intervene, signpost or refer on as appropriate. To aid this many probation areas had developed criteria for different intensities of intervention based on OASys and AUDIT scores. Casting doubt on how widely AUDIT actually was used, Or at least, its use was recorded. in the six case study areas just under half the alcohol-problem offenders on alcohol treatment requirements had been assessed using AUDIT and none who were not on requirements, resulting in an AUDIT screening rate of under one in three, even among this group with known drinking issues.

Commonly voiced concerns included the quality and accuracy of screening and assessments (such as whether AUDIT cut-off scores were sufficiently diagnostic), whether screening was consistently and routinely implemented, and delays in completing assessments and meeting court deadlines because of limited community-based provision, especially alcohol treatment services, a problem exacerbated by the limited purchasing power of probation areas. There were concerns too about the extent to which probation staff involved in delivering, managing or directing alcohol interventions were trained and competent to the relevant (ie, DANOS) benchmarks. Probation alcohol leads nationally seemed largely unaware of the level of accredited competence of staff involved in alcohol interventions, and in at least two of the six case study areas staff stressed their lack of alcohol-related training. The quality and continuity of provision offered to recently released prisoners was considered variable and inconsistent.

In terms of the specific programmes on offer, the Drink Impaired Drivers intervention was practically universal, and most areas ran named substance abuse courses and also courses on domestic violence. Most also offered brief interventions in a way consistent with the MoCAM guidelines, though rarely at every opportunity; three quarters of probation leads surveyed nationally said their areas delivered brief interventions during at least one of the five stages of the supervision process, but only six claimed to do so at all five stages. Some interventions Aggression Replacement Training (ART); Controlling Anger and Learning to Manage it (CALM); Addressing Substance Related Offending (ASRO); Lower Intensity Alcohol Programme (LIAP); Community Domestic Violence Programme (CDVP); Programme for Reducing Individual Substance Misuse (PRISM). however were usually not on offer at all, constricting the options available to match the profile of the offender.

The commissioning and delivery of alcohol treatment requirements

Available from 2005, alcohol treatment requirements can be imposed for up to three years as part of a community-based sentence or two within a suspended sentence. The offender has to have a drinking problem considered susceptible to treatment, which should reflect the severity of their drinking and offending, be acceptable to the offender, and locally available. The study found these requirements massively under-used but also that those which are imposed facilitate engagement with alcohol treatment services and may help resolve drinking problems more than sentences without a requirement. Under-use was linked to under-resourcing, itself partly due to a dispute over whether health or probation should bear the core funding burden. Details below.

Routinely collected data for England and Wales in 2007/08 suggests that demand for these sentences considerably outstripped supply. In that financial year 5145 requirements started, up nearly 50% on the previous year, but this still represented just 8% of offenders starting community sentences who had been assessed via OASys as 'dependent' Officially defined as achieving a section 9 (alcohol) score of six or more. Scores can range from zero to 10 and are based on five alcohol specific questions with possible responses ranging from zero (no problems) to two (significant problems). In the six case study areas AUDIT scores were found in just under half the files for offenders on alcohol treatment requirements. Scores ranged from six to 40 and averaged 27. The WHO AUDIT manual says "scores of 20 or above clearly warrant further diagnostic evaluation for alcohol dependence". drinkers. Amounting to a third of all offenders starting community sentences, had these roughly 24,000 Of the 71,373 offenders assessed at the start of community sentence between April 2007 and March 2008 across England and Wales, a third were assessed as dependent drinkers. dependent drinkers been treated, it would have more than doubled the national alcohol treatment caseload. Most areas reported targeting requirements at offenders posing the highest levels of risk and/or with high levels of alcohol dependence, a pattern confirmed in the six case study areas.

Treatment requirements do seem to facilitate engagement with alcohol treatment services and perhaps also to contribute to reducing alcohol-related needs. Of the 3129 requirements which ended during 2007/08, 56% had been completed and 35% revoked (meaning the offender may be resentenced for the original offence). Completion rates varied considerably (from 31% to 60%) between probation areas. A more fine-grained indication of progress was gained by analysing the 119 offenders serving alcohol treatment requirements among the 185 problem drinker case files made available in the six case study areas. Over the first six months of their supervision orders, offenders on requirements attended alcohol treatment services on average six times compared to less than once for the other offenders. One in seven offenders on requirements did not attend services at all, but this was the norm among their non-requirement counterparts.

OASys drinking severity scores for these offenders recorded later in their sentence had on average declined slightly (by 1 out of a possible score of 10), reflecting the progress made by the half of the offenders whose scores had fallen. More (59% v. 38%) offenders on than not on requirements had reduced severity scores, but even among requirement offenders, for a third their scores had remained unmoved.

Low usage of alcohol treatment requirements (and their unavailability in a third of probation areas at the time of the study) was related to funding and commissioning The locally funded system for alcohol treatment of offenders was commonly contrasted with central funding of equivalent sentences for offenders with drug problems. structures. Probation argue that (as for any local resident) health authorities should pick up the bill, but health argues that the criminal justice system is responsible for funding services to meet the demand it creates. As a result, three in five probation areas nationally which delivered requirements paid for these mainly or exclusively with their own money. In some case study sites, limited alcohol treatment capacity impeded the monitoring of attendance, making courts less willing to impose new requirements and rendering many existing sentences for a time unenforceable. Differing degrees of constricted access to treatment also seem to have contributed to wide regional variations (from 1% to 26%) in the proportions of OASys-assessed dependent drinkers sentenced to alcohol treatment requirements.

Funding issues may also have affected the quality and intensity of the treatment provided in pursuance of the requirements, which usually amounted to six hourly sessions over a six-month period. Among the 28 probation areas offering requirements, only eight described interventions consistent with the specialist treatment recommended in national guidance. Another four offered only low intensity brief interventions. The remainder varied intensity depending not just on the needs of the offender, but also on treatment availability – a pattern replicated in the six case study sites, where the distinction between brief interventions and treatment was often blurred. It was generally agreed that there was scope for better targeting of requirements, more accurately assessing motivation, and offering more timely interventions.

The evidence base and emerging best practice

Little British research is available to guide the provision of alcohol interventions in a criminal justice context. However, the National Offender Management Service which includes probation services is funding projects to help identify, develop and disseminate best practice.

The featured study itself found four examples of good practice in the six case study sites which warranted further exploration and possibly replication:
• the integration of dedicated alcohol workers in probation offices was universally seen as particularly positive. With routine use of feedback forms, it helped ensure direct and regular communication between offender managers and partnership staff, without obscuring the delineation of roles and responsibilities;
• in one area integration had reached the point where alcohol treatment staff routinely had direct access to probation case management systems, reportedly common in Wales;
• at one site, three-way meetings between the offender, their offender manager, and their alcohol treatment worker at the start, middle and end of an alcohol treatment requirement, were reportedly working well as a way of establishing the aims of the requirement and monitoring progress;
• new arrangements in one area aimed to ensure that treatment services measured the impact of interventions by routinely asking questions from the alcohol section of the probation service's OASys assessment system. It meant that both services were measuring and recording impact in a consistent way.

Apart from these highlighted practices, the focus on dedicated provision for alcohol-misusing offenders was universally welcomed. In line with national guidance, four sites had arrangements in place to ensure that offenders whose problems were severe enough to warrant an alcohol treatment requirement were referred for specialist assessment. Staff found that provider inputs into pre-sentence assessments helped them make more appropriate referrals. In all the case study areas staff were routinely applying motivational interviewing and 'cycle of change' skills with alcohol-misusing offenders. Probation staff at one site also reported having access to an alcohol intervention practitioner who offered a brief intervention and outreach service for risky but not dependent drinkers. On the whole, alcohol treatment services and probation managers had good working relationships, often built on historical links between services.

Recommendations

Probation settings offer important opportunities to identify actual or potential drinking problems and to address these through brief interventions and referral to specialist provision, opportunities only partially grasped. English and Welsh probation areas do offer a broad range of alcohol-related interventions to some of the offenders they supervise. However, convergent data from several sources show there remains a high level of unmet need. A key policy priority should be to increase the use of evidence-based alcohol interventions with offenders whose criminality is related to drinking, in the short term, by sharing and disseminating best practice and identifying strategies for ensuring more offenders start and complete current programmes; in the longer term, by developing the evidence base and using it to formulate new guidance. Whatever the interventions adopted, it is important to increase the range, capacity and funding of the probation service's alcohol-related work.

In more detail, improvements are required in: alcohol screening and specialist assessment; the accessibility of specialist treatment; and training for offender managers in alcohol issues generally and delivering brief interventions in particular. In many areas, upgraded training could be built in to existing arrangements. For example, one case study site was negotiating with its treatment providers to ensure they were involved in training probation staff in brief interventions. Such training plus dissemination of emerging best practice from elsewhere could help ease bottlenecks.

The prevalence of serious drinking problems gives considerable scope for increasing the number of alcohol treatment requirements, but uncertainty and inconsistency around funding, targeting, and the form treatment should take, urgently need to be resolved. Resolving the impasse between probation and health authorities over which should fund which elements of alcohol interventions for offenders will however be difficult because health resources are stretched and substantial cuts are expected in probation budgets. Expanding the remit of centrally set drug treatment allocations to include alcohol is one possibility. The new Alcohol Interventions Guidance will need to further clarify these important issues. It should help that having been provisionally accredited, probation services can now refer many less problematic drinkers to the Lower Intensity Alcohol Programme, enabling the scarce resources required to implement requirements to be yet more sharply targeted at the greatest level of alcohol-related need.


Findings logo commentary The featured report describes a system creatively grappling with a huge drink problem among offenders, but one substantially undermined by the lack of evidence about what works to reduce those problems and curb re-offending, and by under-resourcing linked to a dispute over whether health or probation should bear the core burden of addressing these problems through brief interventions and treatment. The new Alcohol Interventions Guidance for criminal justice services which the featured report hoped might help resolve this issue describes the problem without offering definitive solutions. It is however usefully specific about which interventions should be targeted at which offenders depending on the severity of their problems and the nature of their offending, another issue the featured report thought in need of resolution.

Much of the recent policy impetus has focused on increasing the number of offenders who complete accredited crime-reduction programmes, including those which address substance use. A key weakness with this reliance on set programmes is that these have rarely been scientifically evaluated. They may meet accreditation criteria, but this is no guarantee that they reduce crime or improve health any more effectively than routine non-accredited work. Also the programmes themselves are accredited, yet much depends on how well they are implemented and the overall offender management process within which they are located. A short-lived move to accredit these systems as a whole was abandoned in the mid-2000s as too complex.

Alcohol Concern's news bulletins and the updating service provided by the Alcohol Policy UK web site will help readers remain up to date on developments in alcohol interventions for offenders. See for example the latter's entry on the featured report.

Thanks for their comments on this entry in draft to Tim McSweeney of the Institute for Criminal Policy Research at King's College London and Libby Ranzetta of Ranzetta Consulting and the AERC Alcohol Academy. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 22 July 2010. First uploaded

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