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Title and link for copying Comment/query to editor Drug Matrix Alcohol Matrix

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

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Alcohol Matrix cell E5: Treatment systems; Safeguarding the community

K Probation work with alcohol-misusing offenders ([UK] Ministry of Justice, 2009). National study in England and Wales describes a system creatively grappling with a huge drink problem among offenders, but undermined by lack of evidence and under-resourcing linked to a dispute over whether health or probation should be the core funders. See also similar report for Scotland (NHS Health Scotland, 2011).

K Alcohol services (or their lack!) in English prisons (HM Inspectorate of Prisons, 2010). Inspections and surveys of prisoners and staff reveal “very limited” services for problem drinking inmates, leaving them with poor prospects on release. See also similar report for Scotland (NHS Health Scotland, 2011).

K Challenges to collaboration between health and criminal justice (2010). Based on exhaustive consultations in South West England, diagnoses the blockages to providing alcohol-related services to offenders and recommends improvements in commissioning, coordination and practice. See also associated report (2011).

K Systemic barriers to employing problem drinkers ([UK] Department for Work and Pensions, 2010). Clearest lesson from interviews with alcohol service clients in Britain and with staff working in or with treatment agencies is that interagency working can result in better support for problem drinkers and better access to training and employment opportunities.

K Treatment alone did not cut drink-drive deaths (2005). Multi-million dollar attempt to equip US communities to tackle substance misuse only succeeded in reducing alcohol-related traffic deaths when treatment initiatives were supplemented by measures to limit the availability of alcohol.

R Managing drink-drivers (Health Canada, 2004). Canadian report based on reviewing evidence and expert opinion; includes recommended ways of coordinating treatment, rehabilitation and enforcement approaches to alcohol/drug impaired driving.

R Melding disparate objectives and systems is key to criminal justice treatment (Australian Government, 2005). Realistically acknowledges that criminal justice and treatment have different objectives and philosophies and don’t naturally see eye to eye, but argues that education and training can underpin collaboration to achieve the shared goal of effective service delivery.

G Offender management guidance ([UK] National Offender Management Service, 2010). Official guidance on the commissioning, management and delivery of interventions for alcohol misusing offenders in England and Wales; note this predates changes in targets and performance indicators and commissioning and service provision structures introduced since the change in UK government in May 2010. See also general health commissioning guidance ([UK] NHS Commissioning Board, 2013) issued after NHS England took responsibility for commissioning prison healthcare and local authorities for commissioning public health services for offenders under community supervision, in both cases including the treatment of substance use problems.

G Alcohol and offenders guidance for Scotland (Scottish Government, 2012). Guidance and support for commissioners and planners who have a responsibility for developing strategic responses to alcohol problems amongst offenders.

G Protecting the children (Scottish Government, 2013). Guidance for services and commissioners working with adult problem drinkers or drugtakers on protecting their families and children.

G A model system for responding to problem-drinking prisoners (World Health Organization, 2012). Based on UK experience, offers an integrated model of best practice care for problem-drinking prisoners from screening through brief intervention and more intensive treatment, depending on need and feasibility.

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What is this cell about? Constructing systems featuring screening, brief interventions and treatment to cater for problem-drinking offenders at various stages in the criminal justice system. Also other local area or national systems which benefit the community by identifying and/or responding to problem drinkers. Involves commissioning to meet population needs in the context of resource constraints and national policy. In these systems, treatment is usually offered or imposed not because it has been sought by the patient, but because it is thought that treating their substance use could cut crime or otherwise benefit the community. At this distance from the preoccupation with interventions, research is rarely of the gold-standard randomised controlled trial format. Whole areas and multiple coordinating agencies cannot easily be randomly assigned to implement experimental systems of care while others are told to stand still or do the conventional thing to form a comparator – and even if they are, communities have their own lives, politics and event-driven diversions beyond any individual’s control. It means research usually looks for patterns in what naturally happens rather than manipulating it to test the consequences; all this cell’s key studies use variants on this methodology. Emerging patterns may reflect cause and effect between the assessed variables, but may instead reflect unmeasured variables which randomisation would have evened up across experimental and comparison systems. Treatment systems developed for criminal justice purposes are often derived from those for treatment generally, so we can also refer you back to cells dealing with generic systems in respect of brief interventions, across different types of treatment, medical treatments, and psychosocial therapies.

Where should I start? Try turning to the chapter starting page nine of this review commissioned by the Australian state of Victoria, published jointly with the Australian government. It explains that criminal justice and treatment systems must collaborate to deliver treatment for offenders, but also that this is problematic due to radically different starting points: “Criminal justice systems are charged with carrying out justice and maintaining public safety; while ... treatment systems assume responsibility for assisting individual clients to recover. As a result criminal justice systems ... [require] the supervision and surveillance of offenders while treatment systems attempt to influence or modify clients’ behaviour in the least restrictive manner possible”. It means each sector can see the other as ill-informed, unrealistic and undermining – not a good basis for joint working. The remedy offered is education and training to foster mutual understanding of each other’s viewpoints and the recognition or forging of common or at least compatible goals. The chapter then unpacks this recipe into seven ingredients, such as both sides understanding that treatment and criminal justice goals differ and appreciating the need to negotiate confidentiality. One of the issues we will (below) invite you to think about is how these ingredients have manifested themselves in Britain.

Highlighted study Commissioned by Britain’s Ministry of Justice, a report from a leading research centre on probation’s alcohol-related work in England and Wales portrays a glass barely half full. Note the methodology: an extensive survey of all but one substance misuse policy or delivery lead in the 42 probation areas, allied with an intensive look at six case study areas. Such work can not only depict the general picture without selecting unrepresentative areas, but also dig deeper to see what produced these results. It is a story of bottlenecks within probation and in accessing external services and (perhaps as a result) a lack of priority given to identifying need. Among offenders who were identified and allocated to alcohol programmes, delays meant that by the end of their sentence, under half were continuing in or had completed their treatment. A flagship national initiative – the alcohol treatment requirement which enables courts to impose treatment – was massively under-used due to under-resourcing, itself partly due to a funding dispute between health and probation. Another theme was a lack of evidence on whether, even when adequately implemented, the interventions affect drinking or offending – particularly pertinent, since we now know that the one most commonly implemented has not been found to reduce offending. Here and in the corresponding report for Scotland there were bright spots of good practice, especially in the close integration of alcohol workers with probation, but overall this was a system not coping well under pressure and often failing at the first step of identifying need.

Issues to think about

Does Britain have the right partnership ingredients? Look again at our starting point review and its ingredients for partnership working between treatment and criminal justice services. They start on page 10 of the PDF file: Understanding the Intent of Sentencing; Understanding the Impact of Differing Goals; Understanding that Treatment Failure can Violate the Law; Communicating Clearly with a Common Language; Effective Case Management Strategies; Working with Indigenous AOD Clients (an issue more for Australia than the UK); Negotiating the Issue of Clinician Confidentiality in the Criminal Justice System. Ask yourself one or more of the following questions. Are you convinced these are realistic objectives, the right ingredients, and sufficient to establish good partnership working? If you have experience of such working, to what degree were these ingredients present and what was their effect? Leaf through some of the British key studies in this cell (especially this report but also these: 1 2) and ask yourself whether these ingredients were identified as (or as not) characterising the investigated systems and whether they were seen as important to partnership working and ultimately to benefiting offenders and the community.

Why is drinking so prominent in sending thousands to prison, but not in prison services? In both England and Scotland there is a striking disparity between the presence of drinking problems and their role in precipitating imprisonment, and the attention paid to these by prison services – so striking that for England the prisons inspectorate bluntly subtitled their report “an unmet need”, while in Scotland researchers listed more gaps than fillings in the alcohol problem identification and treatment system. If only because this could help cut their recidivist population, why aren’t prisons doing more? Is it a case of ‘see no evil’? Perhaps; the reports say that in England alcohol problems were not consistently or reliably identified, while in Scotland screening was generally limited to a yes or no question. Is it money? The English report spotlighted a scarcity of resources dedicated to alcohol, meaning the national alcohol strategy was merely “an illusion of action”. Is it that the authorities just don’t know what to do? The English report comments that very few treatment or offending behaviour programmes have been developed or accredited specifically for problem drinking offenders, and the Scottish report that evidence is limited for most alcohol interventions in prisons. But even if all these and other factors are involved, that still begs the question of why eyes are half closed, resources lacking, and evidence uncollected. It’s not that all such issues are under-managed; more has been done for problems related to illegal drugs. Does the relative absence of alcohol in prisons permit the issue to be set aside? Is it because drinking is legal so seen as ‘not our business’? Does it simply reflect what is often see as the relative lack of attention to alcohol (versus drugs) problems in the broader society?

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