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Promoting recovery through employment

Almost wherever you look among the UK’s national drug policies (England, Scotland and Wales, but only peripherally in Northern Ireland), employment is seen as both a bulwark against relapse to dependent drug use and an obligation on drug users who can work and contribute to society rather than living on benefits. In contrast, in alcohol strategies employment is more likely to feature as a benefit of alcohol and allied leisure industries.

A realistic ambition?

The focus on reintegration in to mainstream society through employment is not new. In the 1960s it was fundamental to the original US methadone programme organised and evaluated by Vincent Dole and Marie Nyswander of New York’s Rockefeller Institute for Medical Research. When their treatment had become a mass programme the economic climate had changed and patients more often had multiple needs while their reintegration was impeded by diminished access to affordable housing and suitable jobs.

In today’s job market too, how realistic is competitive paid employment for multiply disadvantaged addicts who have spent a decade or more not honing their CVs, but chasing drugs, in the process often gaining a criminal record? Problem use of drugs like heroin and crack is concentrated in areas of high unemployment and deprivation, places where finding a job is even harder than the national average. For example, in 2011 the most deprived areas of Scotland saw over seven times more GP consultations for drug problems per 1000 of the practice population than in the most affluent areas, a differential not seen for non-drug misuse consultations. Unlike recreational drug use, addiction to illegal drugs thrives in areas distinguished by poverty, few job opportunities and a lack of community resources.

Though employment is at the heart of the government’s ‘recovery’ agenda, finding a job has been omitted from national payment-by-results criteria which determine how treatment services in some areas will be funded, perhaps an acknowledgement that in the recessionary times when the criteria were drafted, jobs were an unrealistic target for this patient group. At local level too, only a minority of areas have exercised their discretion to include employment-related criteria.

Reticence to set payment-by-results schemes up to fail is understandable given the barriers to employment faced by problem drug users, enumerated in a report commissioned by the Department for Work and Pensions: lack of education and skills; physical and mental health problems; low self-confidence; social disadvantage; drug use itself; inadequate access to support services; problems engaging with employers and support professionals; dealing with stigma; criminal records and spells in prison; the need to attend for (especially methadone) treatment; fear that job-related stress might precipitate relapse; reluctance of employers.

Under-resourced effort

Rather than more resources to help overcome these barriers, the recent picture has been one of the withdrawal of resources or the abandonment of support plans. Lost on the way were the Progress to Work scheme for problem drug and alcohol users and funding for dedicated JobCentre coordinators to organise support for drug using claimants. Lost too were the planned Welfare Reform Drug Recovery Pilots, a voluntary set of extra supports for benefit claimants being treated for their drug problems, relieving them of the need to look for work while they focus on their recovery. However, under the new Universal Credit benefit arrangements patients in addiction treatment can be relieved of the need to look for work for six months, though by the end of 2014 this benefit was available to few claimants and just 0.3% of the anticipated recipients were receiving it.

The decision whether to offer time free of the requirement to seek work for patients in addiction treatment lies in the hands of local JobCentre officials, a sign of the localism which has taken over in the JobCentre front line, anything more than the minimum being subject to the priorities and flexibilities afforded to district managers.

Work Programme

At national level the main initiative is the Work Programme launched in June 2011 for people at risk of long-term unemployment. As with other claimants, problem substance users on job-seekers’ benefits can be mandated to this programme after nine or 12 months depending on age or other circumstances.

Like some addiction treatment services, the Work Programme operates on a payment-by-results basis. The large companies responsible for delivering the programme are free to do more or less what they think best to achieve these results, including arranging addiction treatment for claimants. A prime disadvantage is the programme’s binary ‘working or not’ criterion for rewarding these companies, one out of kilter with the gradualist approach more suitable for people facing a steep climb before paid competitive employment is an option, who generally want and need to traverse education, training, job-finding skills, volunteering, and supported employment, and may get stuck at any of these stages. According to the (now defunct) national drugs charity DrugScope, the result is that the Work Programme “is delivering very little for people with histories of drug and alcohol use ... because the funding model has failed to incentivise the provision of specialist services”. Addicts and ex-addicts are among the jobseekers furthest from the job market who tend to be ‘parked’ by Work Programme companies, which gain more from lower hanging fruit. With little to prompt this, the partnership working between job centres, treatment services, and Work Programme providers expected to benefit problem substance users “is generally absent” said DrugScope. These shortcomings were also identified by the parliamentary Work and Pensions Committee as obstructing progress to work for the most disadvantaged jobseekers in general, and drug and alcohol users in particular. Seemingly acknowledging that routine arrangements were not working well for problem substance users, in January 2013 the Department for Work and Pensions announced two pilot schemes involving extra payments to Work Programme providers which help these clients find jobs or closer working between the Work Programme and addiction treatment providers.

Whilst acknowledging shortcomings, guidance published in 2012 by the National Treatment Agency for Substance Misuse (now part of Public Health England) determinedly accentuated the positive, highlighting examples of good practice developed locally, which support the rather limited conclusion that since 2009 there has been significant progress “in some parts of the country” in addressing the employment-related needs of people in drug and alcohol treatment. For this guidance, “progress” meant: partnership working between job centres, treatment services, and Work Programme providers of the kind (see above) DrugScope and the Work and Pensions committee found generally missing; good communication facilitated by a single point of contact in each treatment system, JobCentre Plus district office and Work Programme provider or local subcontractor; shared training; outreach in the form of JobCentre Plus and Work Programme staff in treatment and recovery services, and vice versa; three-way review meetings between client, treatment keyworker and either JobCentre Plus or Work Programme advisor; and continuity of care afforded by treatment, recovery and employment support providers working in a joined-up way.

Beyond the Work Programme

Outside and predating the Work Programme framework, addiction treatment services have tried to promote employment to progress and embed their clients’ recoveries. From Scotland there was evidence that treatment services may indeed be able to help, but not very much. If there was an impact of employment-related help, it was in the form of on-site help from familiar and trusted faces at the treatment service, not external agencies. Another approach trialled in England was to place treatment staff in job centres to facilitate referral to treatment, intended to help ready claimants for employment. In three high drug use urban areas, it did raise the treatment entry rate, but not enough to recommend a national roll-out. Generally across the world the evidence for employment-promoting initiatives is at best patchy. Among the studies is one from New York which found that even though it helped welfare applicants overcome substance use problems, intensive case management did not help men find a job; women did benefit to a small extent. The traditional ‘gradualist’ approach taken in this study has been contrasted with appropriate support targeted at rapid competitive employment, among which the most prominent is the Individual Placement and Support model. It has some important supporters in Britain and has helped substance users find employment in the open labour market rather than sheltered placements.

Though generally disappointing, the record of treatment promoting recovery through employment is not entirely bleak. Run this search to pick out the bright spots and, perhaps as importantly, get a feel for what does not work and what it is reasonable to expect.

Thanks to Paul Anders of Public Health England for bringing the Universal Credit arrangements to our attention.

Last revised 08 May 2015. First uploaded 01 January 2010

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