[UK] Department for Work and Pensions, 2011.
In three high drug use urban areas in England, treatment staff were placed in job centres to facilitate the referral of unemployed substance users in to treatment. It worked, but not well enough to recommend a national roll out.
Summary Concerned that too few unemployed drug users were being referred to treatment to help prepare them for employment, in England the UK government's employment ministry trialled a system for enhancing the linkages between state employment services and drug addiction treatment services. The figures which concerned the authorities were that in 2006 an estimated 30,000 users of heroin and/or crack cocaine in England were not in treatment for their drug use problems and in receipt of state funding for people fit to work but unable to find employment, or unable to work because of illness or disability. Yet from April 2009 to the end of August 2010, 10,300 job centre customers were identified as having problems with these drugs, of hwom just 2400 were not already in treatment. In the same time period, 2500 referrals were made to addiction treatment services, which resulted in 861 recorded discussions with a treatment advisor.
In 2010 a trial to see if more out-of-treatment problem substance users (not just heroin or crack users) could be identified and referred for help was conducted at three job centres in deprived urban areas expected to have many such customers, but which had made relatively few successful referrals. It lasted eight weeks in two of the centres and four weeks at the third. Though the service was decided locally, in all three cases it involved treatment provider staff being in the job centre two to four times a week and being available to see job centre customers with substance use problems. Also the treatment agency staff provided job centre staff with training and/or awareness raising session on substance use and familiarised themselves with the workings of the centre. At one centre, job centre advisers operated outreach sessions at the treatment provider. The degree to which treatment staff at job centres could make themselves proactively known to the customers varied due to concerns over staff safety.
Views on the initiative were collected through focus groups and interviews with key stakeholders including:
• job centre district drug coordinators responsible for relationships with drug agencies and ensuring centre staff can identify, refer and work effectively with substance misusing customers;
• job centre 'drug champions' – local office front-line staff who have agreed to support drug strategy activities in their offices;
• job centre management and front-line staff;
• treatment provider staff; and
• representatives from local drug and alcohol action teams responsible for coordinating services in their areas, and from the National Treatment Agency for Substance Misuse which promotes and monitors drug treatment in England.
Also collected for each job centre were the numbers of treatment referrals, recorded disclosures of substance misuse (these are subject to the client agreeing to this being documented in their record) and resultant treatment starts for the period of the trial and before and after this period.
Stakeholders broadly felt that the trialled model of closer working between the job centres and their respective treatment providers was successful and the main cause of any increase in referrals. Central to this was the treatment provider presence in the job centre. It meant job centre staff felt more comfortable raising substance misuse with customers knowing that someone from the treatment service was on hand to take over any difficult discussions; in one centre this was formalised in to an agreement (if staff wished) exploring the nature of someone's substance use could be left to the treatment provider. Feedback on a customer's progress after referral to treatment would staff thought have helped motivate them to raise the issue with more of their customers.
Stakeholders from both sides reported improved understanding of the support offered by the other party and, as a result, were better placed to deliver more informed advice. At all three sites, job centre staff felt better able to 'sell' the services of a familiar and trusted treatment provider to customers. For their part, treatment providers at the two sites least affected by restrictions on their freedom of action saw their attendance at the centres as a success. Given that many of their potential clients were on benefits, job centres were an appropriate and productive outreach location offering an opportunity to engage such individuals in an immediate discussion about treatment, avoiding the risk that they would not attend a future appointment. At the one centre where from the start the provider was free to make their role known and proactively engage customers, the provider said they engaged with nearly 400 customers during the eight weeks of the trial. As a result of the trial, at one centre the treatment provider encouraged their clients to disclose their substance misuse to the job centre so they could access the additional support on offer.
Initial concerns that customers might react badly to the treatment provider's presence proved almost entirely unfounded and there were no serious incidents. At the centre where relations were closest between the job centre and the treatment service, job centre staff saw a marked improvement in the behaviour of some previously aggressive substance misusing customers.
At the one centre where this happened, outreach by job centre staff (in this case, the drug champion) on the treatment provider premises was felt to be a good way of engaging hard-to-reach customers in an environment in which they felt comfortable and unafraid of stigma and which afforded more privacy than the job centre. The sessions were in demand by clients and fully booked.
The initiative raised awareness in job centres of the importance of staff broaching the issue of substance misuse with customers, and supported them to do so. Particularly valuable were the roles of the district drug coordinators and treatment providers who organised and delivered training for job centre staff in (among other topics) identifying possible signs of substance misuse, how to ask customers about substance misuse, dealing with disclosure, making appropriate referrals, and the impact a particular treatment will have on ability to work. The training helped to break down job centre advisers' concerns about addressing substance misuse with customers and negative preconceptions about misusers, giving them the confidence and tools to broach the issue with customers when necessary, though in some cases this was still lacking and staff preferred to transfer substance misusers to specialist staff. Coordinators also invested considerable (and over the longer term, possibly unsustainable) time at the trial centres, organising the logistics and negotiating the terms of the presence of the treatment provider.
At one centre, transferring substance misusing customers to the caseload of the job centre's drug champion was seen as positive for customers, who benefited from greater continuity and more intensive support, and for those job centre staff who felt uncomfortable about discussing substance misuse. The champion had the motivation and people skills to work effectively with this group, as well as additional flexibility to see them for the longer and more regular appointments they often required, free from the standard productivity targets.
Trade union representatives who conducted safety assessments were concerned that the initiative would attract large numbers of substance misusers to the offices and that job centre staff might be at risk from drug dealers who felt they were helping to take away their business. As a result, at two offices the activities treatment providers could undertake while in the offices were significantly curtailed in ways stakeholders felt frustrated the trial. For example, providers were not allowed to approach customers or advertise their presence, and job centre front-line staff were not permitted to visit the treatment provider's premises.
Operational pressures too were a barrier. Job centre advisers were concerned that raising substance misuse with customers could end in a lengthy discussion which prevented them from dealing with other required issues or made them late for subsequent appointments. Knowledge that they would be able to make an instant referral to the treatment provider during their sessions helped allay these concerns. Work pressures also meant many advisers were not released for training. Drug champions responsible for conducting outreach sessions on treatment provider premises and caseloading substance misusing customers found it difficult to achieve their standard employment and training targets. There was also a strong suspicion that disclosure of substance use problems was not always recorded in the customer's record because advisers preferred to avoid the consequent time-consuming referral process.
Views about the overall success of the trial were mixed but on the whole stakeholders were positive, citing improvements in:
• the confidence, motivation and skills of job centre staff in working with substance misusing customers;
• the profile of the substance misuse agenda in the job centres;
• working relationships between the job centres and the treatment sector; and
• the standard of service provided to substance misusing customers.
The exceptions were some stakeholders in one of the offices who felt that the trial had failed largely due to restrictions imposed by the health and safety risk assessment.
Despite operational pressures and targets, it was thought that the job centre resource required to continue such work was realistic. After the trial, treatment providers reduced the time spent in the job centres due to resource constraints and a feeling that resulting referrals were too few to justify sustaining activity on that scale. However, all three providers intended to continue working more closely with job centres, and two intended to maintain one session a week in the centre.
Many stakeholders felt the brevity of the trials meant they did not reach their full potential, and were confident that if the work continued they would see a steady increase in the numbers of customers opening up about their substance misuse and accepting the offer of a referral to the treatment provider as the message about the support job centres can offer spread among local substance misusers.
Over the in total 20 weeks that the trial was operating (eight weeks in two offices and four in the third) 30 job centre customers were recorded as having been referred for treatment for their substance use problems, 16 were known to have initiated a discussion with the treatment provider, and 11 known to have started treatment. These compare to an estimated 348 heroin and/or crack cocaine users in the three areas in receipt of state funding for people fit to work but as yet unable to find employment, or unable to work because of illness or disability, but not in treatment for their drug use. More will have been using other substances and/or on other benefits.
Another comparator is the months before the trial started when no treatment staff At one centre, in the immediately preceding period treatment staff had conducted outreach in the office, so the figures cited here includes instead the time before that when no treatment staff were in the office. were located in the job centres, 20 months in total. During these periods 13 job centre customers were recorded as having been referred for treatment for their substance use problems, three were known to have initiated a discussion with the treatment provider, and two known to have started treatment.
A small survey of 46 treatment service users in one of the job centre areas explored the issue of barriers and facilitators to the disclosure of substance misuse. Barriers included never having been asked by job centre staff, being worried about stigma, worried about how their benefits would be affected, and a lack of privacy in the office. Conversely, disclosure would be promoted by greater privacy, assurances that the information will not be passed on to other agencies such as the police or social services, greater awareness of the support the job centre could provide, and greater flexibility in their benefit conditionality, for example, not having to sign on every fortnight if they are on Jobseekers' Allowance.
The impact of the trial on disclosures and referrals to treatment was variable, but increases were seen in all three job centres. However, even where this increase was greatest, referrals remained substantially fewer than hoped, suggesting expectations may need to be revised downwards. Given this, it is unlikely that many job centres will be able to justify intensive activity on this scale.
Lessons for centres which who do wish to adopt such a model include involving the treatment provider early on in its design and securing the support of job centre senior management. A visible show of commitment and encouragement from senior staff is crucial in helping to change attitudes to working with this customer group, and also in reinforcing the importance of substance misuse in what is a very crowded and process-driven agenda for front-line job centre staff. It is also important to develop guidance for conducting health and safety risk assessments in advance of the activity if successful models of working are to be implemented. The chances of success are likely to be greater if the treatment provider is proactive in familiarising themselves with job centre practice and processes, raising awareness of their presence and services, and forging good relationships with job centre staff and customers. Access to a private room is essential so customers can talk confidentially.
The evaluation also identified various lessons for job centres in general in working with substance misusing customers. These include having effective and dedicated drug champions to support and advise colleagues on how to ask customers about substance misuse, deal with disclosures and make referrals, and to work with the district drug coordinator to identify and develop solutions to any problems. These specialist staff can also successfully undertake outreach on treatment provider premises and caseload substance misusing customers. Whoever undertakes these roles, personal qualities are important such as empathy, compassion, a non-judgemental attitude, being a good listener, passion and enthusiasm for the task, as is the adjustment of productivity targets to take account of the intensity of this work.
The project trialled a particular model of closer working between job centres and local treatment providers, but less resource-intensive options also have promise. For example, having the treatment provider attend the centre for a familiarisation week during which they can attend team meetings, observe customer interviews and speak to staff about their roles. In return, key job centre staff could visit the treatment provider and make a presentation to the rest of the office on the services they provide, hopefully increasing the likelihood that staff would refer appropriate customers.
Awareness-raising in itself is however not enough. Job centre staff will benefit from concrete training on raising the issue of substance misuse and dealing with disclosures sensitively and effectively, as well as an understanding of the limitations that different forms of treatment (such as substitute prescribing) place on customers' capability for work.
commentary This in-house study is frank about the limitations of the initiative and how these came about. Unreliable and preliminary as they may be, the figures provided on referrals and treatment starts are the closest we have to a 'bottom line' set of outcomes for the initiative. It can be calculated that during the trial per month about six or seven customers were referred for treatment, three or four talked to a provider, and two or three started treatment. This compares to respectively about one, and virtually none and none in the preceding periods when no treatment provider was in the offices. So increases were seen in the rate of referral and treatment contact, but these fell far short of the possible. At the two centres where these figures were available, during the trial eight out-of-treatment heroin or crack users were referred to treatment from an estimated 205. It should be remembered, however, that people who have not already accessed relatively available treatment provision probably have their own reasons for avoiding treatment. The total out of treatment is not the same as the total who would be willing to own up to needing help or take up a referral if it were offered. There is no obvious reason why having rejected or avoided treatment in the past, it should be sought during a job centre interview, or why the mention of it by a job adviser should change one's mind in the absence of any coercive element or major incentive.
Arguably this was an experiment conducted in circumstances which made it hard to prove its worth. The work was done at a time when the chances of success were hampered by job cuts in the job centre service, when job centre staff were being held accountable to unrealistic targets, and there was severe pressure on resources generally. Also the offices were chosen to have high numbers of problem substance users locally but few treatment referrals, a choice which seems likely to have thrown up sites at best unenthusiastic and at worst hostile to this kind of work. To fully turn this round and work through the concerns and logistics was probably going to take longer than the few weeks allowed for the trial. Tellingly, the initiative was best implemented where similar work had already been going on for months and a close relationship had built up between the job centre and the treatment service.
There is also the question of the criterion for success. According to some calculations, getting just a handful of people in to treatment every few weeks would on average produce substantial social cost savings, largely due to reduced revenue-raising crime. In numbers the results may disappoint the staff concerned, but society may still experience a net benefit, which could be recognised in payment-by-results protocols in such a way as to incentivise the work and make it an income-generator rather than a drain on resources. However, such success as there was seems to have been greatly aided by the district drug coordinators, for whom funding has now been withdrawn. Their input could have been pivotal in adapting the featured schemes to local circumstances, drawing on the successes of the predecessor progess2work schemes, or creating new ways of working in response to incentives.
Thanks for their comments on this entry in draft to Mike Stewart of the Centre for Economic and Social Inclusion in London. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 23 September 2011