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Skellington Orr K., McCoard S., Canning S. et al.
NHS Health Scotland, 2011.
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Though drinking problems were widespread, Scottish probation and community service staff were unconvinced of the appropriateness of screening their offender clients for risky drinking and (if indicated) offering brief advice. Not a priority, was the common feeling.
Summary This research report presents the findings of an independent evaluation of the feasibility and potential effectiveness of screening for risky drinking and offering brief advice as required to adult offenders in community justice settings in Scotland. It describes the set up and operation of pilot schemes in three local authority areas between January 2010 and April 2011. These offered training to 121 probation and community service staff supervising offenders to enable them to conduct screening for risky drinking using the AUDIT questionnaire during the initial appointment with an offender in day-to-day practice. A randomly selected half were also trained to offer a brief intervention based on motivational interviewing to offenders who screened positive Scoring 8 to 19, the range associated with hazardous or harmful drinkers. for risky drinking but did not exceed the threshold for probable dependence, using as appropriate an alcohol advice booklet as a supplement; the other half were merely to hand the offender the booklet in addition to usual care and supervision. Offenders who had in the past year been screened and offered a brief intervention in these or other settings, or whose sentences required alcohol treatment or education, were excluded from the pilot.
The featured schemes and study arose from a commitment in the Scottish government's 2009 alcohol strategy to fund research on the delivery of brief alcohol interventions in non-medical settings. Such interventions have been widely researched in primary care but not in community justice settings. The project aimed to help fill this research gap by testing the feasibility and effectiveness of screening and intervention during the routine practice of criminal justice staff working with clients newly sentenced to probation or community service orders. Staff views and responses were tapped via an online survey of the staff who conducted screening and intervention, their feedback on the training, and depth interviews with strategic, policy and operational staff. Views from participating clients were also to be obtained but in the end just one was interviewed. It was also planned to assess impact on drinking by repeating the AUDIT survey three and six months later, but this data was available at either stage for just 16 of 82 hazardous/harmful drinking clients.
Around 70% of the 295 eligible offenders said they were willing to take part in alcohol screening, encouraging as an indicator for uptake within this setting. However, this included only just over half (51%) the community service clients compared to 93% of probation clients. Overwhelmingly they were white men and averaged 31 years of age.
Among those not eligible to take part, for around two thirds this was because they were already receiving alcohol advice and support from another source, so the incidence of drink problems in those who did take part is likely to underestimate the level of need among offenders in probation and community service settings.
Among those who were screened, the results showed that:
• Around 59% of offenders on community service or probation orders in the pilot areas, and who fulfilled the eligibility criteria, screened positive for at least hazardous drinking.
• Of these, 42% fell into the hazardous/harmful rather than dependent category and might have benefited from brief intervention.
• Almost 1 in 5 scored as high risk drinkers who might be dependent.
• Those in the high risk/possibly dependent group were more likely to be on probation than community service orders.
• Although client numbers were small, men were almost twice as likely as women to register screening scores in the intervention range; almost two thirds of women fell below the threshold.
• Offenders in the 18–24 age band were more likely to screen positive than offenders in older bands.
Frontline staff were sometimes not committed to the pilot, feeling it had been imposed on them, but in one area ready access to and support from a coordinator allocated to the project bolstered enthusiasm for the work.
Pre-training questionnaire were completed by 34 staff compared to 89 who completed a post-course questionnaire, and it was not possible to match the pre- and post-course respondents, complicating interpretation of the results. After training, almost all the respondents (91%) who provided an answer thought it was quite or very relevant for them to be able to offer brief alcohol interventions. Large proportions said that whether they did so would depend on resources (time and a suitable intervention room) and administrative and management support. Also after training, 8 in 10 said they felt as able to work with risky drinkers as with other clients, over 8 in 10 felt clear about their responsibilities with drinkers and that with the right support, these clients can make good progress towards sensible drinking, and 9 in 10 felt confident about helping clients with their drinking problems. However, a quarter who answered this question did not agree they had a right to ask clients about drinking, and in-depth interviews revealed some feeling that the training had been too low-level and longer than was needed for staff already familiar with addressing problem drinking.
In practice though, staff often felt the pilot was not suited to their client groups, largely because they faced more serious issues such as money problems and housing, and addressing their drinking was not a high priority. Some said if it was a priority it would already have been incorporated in sentence planning, that they would have dealt with it anyway in normal practice and perhaps more adequately than through five minutes of brief advice, that their clients were often too extreme in their drinking to be suitable for a brief intervention, and that excessive drinking was too intertwined with other problems to be dealt with in isolation. The AUDIT screening tool was generally seen as easy to apply and by some as a useful way to broach the issue of drinking, while other staff thought it was inappropriate to have to complete it even when drink was clearly not a relevant issue. Few staff felt offenders generally had engaged well with the brief intervention. Commonly, a post-sentence appointment was seen as too late to assess drinking because the results could not be used to inform sentencing decisions; the pre-sentence social enquiry report to the court was seen as a better stage.
The process of establishing eligibility, screening and delivering an intervention averaged around 25 minutes with an estimated cost of around £67 per person, including overheads.
Despite the challenges inherent in applying alcohol screening and brief intervention to this setting, the pilot has shown that community justice does afford an opportunity to identify and intervene with many people at high risk of alcohol-related harm who might otherwise not be identified as being in need. Screening results show a high level of need in this population. The training provided seemed necessary since most previous training had been delivered a long time ago, or had not been appropriately focused.
Due the lack of follow-up outcome data and the inability to adequately assess the reactions of the offenders, the evaluation could not assess the impact of the brief interventions delivered. In turn this was partly due to some lack of enthusiasm on the part of frontline staff. Although the AUDIT screening tool and the brief intervention seem to have been easy for them to administer, and were seen as useful tools in themselves, staff were in some ways negative about the appropriateness and likely success of screening and alcohol interventions in this environment. In particular, they felt that alcohol problems were of less immediate concern than other issues for their clients, perhaps one of the strongest themes to emerge from the analysis of staff views. There was a strong view that screening and intervention may capture more people and be of greater use in determining sentencing outcomes if undertaken before sentencing.
Learning points from the pilot include a need for greater involvement of operational staff during the planning and implementation of such schemes to ensure that models of working take into account workloads and client-staff protocols. Also, training should be targeted at the criminal justice setting and tailored to the participants, and regular refresher training arranged which can take advantage of actual experience of doing the work. Alcohol screening and intervention in this context would perhaps work better if a local manager/champion took overall responsibility for these processes and 'managed the managers' across (if appropriate) split sites, so that a consistent approach is adopted to allow for comparable data within and between areas. This is the main workforce development requirement to improve engagement with frontline staff by providing education and evidence on the effectiveness of these interventions.
On administrative and resource grounds, there should be few barriers to introducing alcohol screening and brief interventions to community justice settings, although there is clearly some scope for reducing the time these take so that they do not impact too greatly on workloads. Time and costs might be reduced through better training and as staff become more practised and increasingly familiar with the process. Further uptake could also offer economies of scale in the form of coordinated central resources and training.
The total cost of alcohol misuse to Scottish society in 2007 has been estimated at around £3.56 billion, of which £727 million (about 20%) was related to crime. There is evidence to suggest that brief alcohol intervention are a cost-effective way of tackling alcohol misuse in some settings and have similar potential within community justice.
commentary This study and others to date leave Britain with no persuasive evidence that brief interventions are an effective way to curb drinking and crime among offenders in the criminal justice system, and with questions over the appropriateness of screening and whether it will be widely implemented under current systems.
The scepticism expressed by the criminal justice staff in Scotland who took part in the featured project echoes the feelings of probation officers in a similar trial in 20 probation offices in England. Of the nearly 200 staff in the trial, about a fifth did not recruit any offenders to the study, and only about a quarter were able to implement screening and brief intervention as intended without extra help from researchers and specialist alcohol workers. Despite apparent staff enthusiasm, barriers to implementation cited by staff included workload pressures, lack of knowledge, and lack of follow-up treatment services. Compared to staff in two other settings (primary care and emergency departments), screening and brief intervention was felt to meld more naturally with routine probation work, but staff were less convinced these procedures would be useful and tended to feel they were best reserved for offenders with obvious drinking problems.
That study and a preparatory study which also included prisons and police station custody suites found that the FAST Alcohol Screening Test broadly duplicated results from the AUDIT screening tool, yet generally required just a single question. With the AUDIT averaging ten minutes in the featured study, this could save considerable time and make screening more acceptable because it would be less likely to be seen as overshadowing more pressing concerns.
There may remain however the perception of staff and offenders too that drinking levels which are almost normative among young Scottish men are not worth bothering with in the context of the other concerns facing newly sentenced offenders, and that more serious problems would in any event be exposed during the criminal justice process. Such perceptions limit implementation in criminal justice settings more than in health settings, because in the latter there is a credible argument that even low-level excessive drinking poses long-term risks to health and that routine screening and brief intervention are justified on public health grounds. When crime is the primary concern, this justification carries less weight, even though both Scottish and English studies highlight the high frequency and severity of drinking problems among offenders.
These trials cast doubt on whether screening will be widely implemented in criminal justice settings, as did an audit of probation alcohol work in England which found that even among offenders known to be problem drinkers, under one in three had been screened using the AUDIT survey.
Last revised 26 July 2012
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