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Fitzpatrick R., Thorne L.
Advances in Dual Diagnosis: 2010, 3(4), p. 14–19.
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Based on exhaustive consultations in the south west of England, this report diagnoses the blockages to providing adequate alcohol-related services to offenders and makes recommendations to improve commissioning, coordination and practice.
Summary Complementing the featured article is a research report published by the Centre for Mental Health, which includes a review of the national policy and commissioning environment in Britain for services for alcohol-related offending and also more detailed recommendations arising from the research described in the article. Both documents have been drawn in this account.
The research was initiated by an alcohol subgroup of the multi-agency South West Reducing Reoffending Board which coordinates work in the south west region of England. Its initial aim was to develop guidance for the commissioning of alcohol treatment requirements, which can be imposed for up to three years as part of a community-based sentence or two years within a suspended sentence. However, the scope broadened to a broader range of alcohol interventions.
In total, over 100 professionals and 22 users of services were involved in interviews or focus groups for the project. It started by identifying key themes in relation to the commissioning and delivery of alcohol interventions for offenders across the south west region in interviews with commissioners, managers and frontline staff. Stakeholders from government and the voluntary sector with a nationwide interest in these issues were also interviewed. Then a comprehensive review was conducted of recent and current policy and research on offender alcohol interventions and generic community alcohol services. Stage three consisted of more detailed scoping of the commissioning and delivery of alcohol services in two areas of the south west, where focus groups and interviews were conducted with commissioners, managers and frontline staff. The groups were asked to comment on the draft themes and to offer their perspectives on how alcohol services for offenders could be developed. Focus groups were also set up in each area for members of multi-agency coordinating bodies. Contact with participants was maintained over several months to gain a detailed understanding of their work around alcohol. Feedback from service users was also sought through sustained contact and two focus groups with members of a user-led addiction support group. A focus group was also conducted with people serving prison sentences for alcohol-related offences. On these bases a revised set of draft themes was produced. In the final stage these revised themes were presented for testing and feedback to a focus group of senior stakeholders from key national and governmental agencies and reviewed at a focus group of business managers for local criminal justice boards in the south west region.
Universally respondents said alcohol-related provision was under-resourced both in generic and offender-specific settings. Demand for all types of intervention and treatment exceeded supply.
Considerable local variation was reported in the ways health and criminal justice agencies work together to plan and commission offender alcohol services. In some localities, this is conducted through joint commissioning panels; in others, it is led by probation; in others the process is contested between probation and health service primary care trusts. Significant variation in both levels and type of services was also evident.
Health and criminal justice agencies are expected to collaborate to commission and provide alcohol and other offender health services, but in practice there are significant challenges to this arising from the misalignment between their respective objectives and targets. Criminal justice agencies seek to commission and deliver targeted and timely interventions to specific offenders, while primary care trusts aim to provide freely available health care services to the general population and are accountable for achieving different targets, in particular the reduction of alcohol-related hospital admissions. Some NHS commissioners oppose commissioning offender-only alcohol services due to the perceived unfairness of offenders receiving services not generally available. Conversely, some criminal justice commissioners stress the unfairness of offenders on occasion being unable to receive targeted alcohol interventions, and cite the potential global cost implications for all sectors of not providing this group with appropriate interventions. At a strategic level, misalignment manifests itself in 'cost-shunting', whereby one sector shoulders the financial burden of meeting the objectives of another sector, leading to strained relationships. An example was a probation area which required its partner primary care trust to act as the lead commissioner for offender alcohol treatment services (as per national commissioning guidance), but the trust did not have the resources to meet this expectation. On occasions, these differences hindered local commissioning of alcohol treatment requirements.
Many commissioners observed that funding for general and offender-specific alcohol services is precarious. Concerns were expressed about the sustainability (and replicability) of much-valued projects, particularly in the context of current cuts to public services. Identified as a particular obstacle to securing sustainability was the lack of joint national commissioning guidance on alcohol interventions from the Department of Health and the National Offender Management Service.
There was a universally acknowledged lack of equivalence between alcohol and drug commissioning. Drug treatment has been prioritised and commissioned in a standardised manner for several years via the Drug Interventions Programme (DIP) in the community and in the criminal justice system the Integrated Drug Treatment System (IDTS), and the availability of services for offenders who misuse drugs was much greater than for those who misuse alcohol, yet commissioners and service users saw alcohol as a much larger problem. The requirement administered by the National Treatment Agency for Substance Misuse (NTA) that monies designated for drug misuse via the pooled treatment budget cannot be invested in alcohol interventions (where there is a primary alcohol need) was considered by many commissioners to present a significant obstacle to improved provision. There was also widespread recognition that, compared to drugs, the availability of alcohol services falls far short of needs. A reported perverse consequence is that in cases of desperate need, actual or invented cannabis use has been cited by staff or offenders to obtain support from drug services; starting treatment with a deception was not considered ideal.
As the process for commissioning alcohol interventions remains unclear and contested, commissioners from different sectors need to respond pragmatically and creatively to improve services using whatever tools or resources are available. Possible means include utilising political support and strategic leadership where this exists; building on existing service delivery frameworks such as: Models of care for alcohol misusers; place-based budgeting initiatives which pool budgets in local areas; integrated offender management programmes, which offer an opportunity for closer working between criminal justice, health, housing and social care agencies to address alcohol-related offending; the work of community safety partnerships; sharing human resources between agencies including commissioners from one sector being seconded to shadow or fulfil the role of their counterparts in another; and exploring innovative methods for funding interventions, for example through payment by results schemes, or by using part of the money offenders pay in fines to fund alcohol awareness sessions.
The evidence base for offender alcohol interventions needs to be developed. There is a strong body of evidence on the effectiveness of alcohol interventions in relation to health outcomes, but remains a considerable gap around the effective of offender-specific interventions on reoffending. Possible ways of addressing this gap were identified, including: mandatory collection of data about alcohol use and needs for all offenders entering the criminal justice system; working to strengthen the business case for joint commissioning for early alcohol interventions by assessing total alcohol-related costs to services and identifying the potential benefits and efficiencies of jointly commissioned interventions; and, in particular, strengthening the emerging evidence base around the effectiveness of alcohol arrest referral interventions.
Service users should be involved in the commissioning and review of interventions. The capacity of service users to strengthen the commissioning cycle for both health and criminal justice interventions was advocated and demonstrated in practice. Health and criminal justice commissioners saw the input of 'experts by experience' as providing a reality check that appropriate and effective services are delivered. For users of services, involvement in service planning was also described as being both empowering and a vital part of their recovery process.
Preventive interventions form a vital component of any local alcohol strategy. Commissioners expressed considerable enthusiasm for pre-criminal justice interventions, including: public education programmes; population-level controls on the supply, cost and promotion of alcohol; and support for local measures to regulate the night-time economy of bars, clubs and other licensed premises.
There was strong support for basic alcohol awareness training to be available to all frontline staff working in healthcare, criminal justice and other relevant settings such as housing offices. Additionally, training for GPs and court staff as the gatekeepers of services was recommended. Another need was training around managing drinkers with multiple needs, including how to develop multi-agency and multidisciplinary responses.
A very clear recommendation was that all front line agencies should be trained to provide brief interventions consisting of: opportunistic case identification; screening for risky drinking using the AUDIT questionnaire; brief advice; and referral when appropriate to specialist agencies.
Alcohol misuse should not be a label for exclusion. It was observed by both professionals and the users of services that problem drinking often acts as a barrier to accessing public services, resulting in wider exclusion. It was also very strongly argued that reliance on abstinence-only approaches in policy and commissioning could exclude many people for whom abstinence is not an appropriate or realisable goal. A number of ways were identified to address this, including: improved risk management and clinical governance processes within primary and emergency care services to address concerns that drinkers were a risk to staff; the commissioning of a range of abstinence-based and non-abstinence-based models of provision to ensure that differing needs can be met, including those of non-dependent 'binge' drinkers; improving partnership working between police and accident and emergency services in relation to admissions under the Mental Health Act; and joint work to address the causes of alcohol-related anti-social behaviour, including alcohol screening, brief intervention, signposting to services, and multi-agency interventions to reduce both anti-social behaviour and the escalation of offenders into the criminal justice system.
Appropriate alcohol interventions should be provided at all stages of the criminal justice pathway, from police neighbourhood teams identifying and referring problem drinkers who have not committed any known offence, through to prison. Several good practice initiatives were cited. Strongly noted were the limited continuity of care for offenders with complex needs or whose primary need is alcohol-related, and the common experience of a 'cliff edge' between prison and the community, especially after sentences of less than 12 months and for ex-prisoners unable to engage with abstinence-based services, leading to relapse and re-offending.
Services should be responsive to population groups with specific or local needs and requirements including perpetrators of domestic violence, women, younger adults, and black and minority ethnic individuals.
Charitable and voluntary sector agencies were seen as adding value and expertise when commissioned or supported to fulfil specialist roles. Their capacity to engage with both statutory agencies and service users in ways many mainstream services find difficult was widely noted. These included: providing flexible service responses that can operate outside standard working hours; peer-led support; facilitating involvement from the wider community through voluntary action; providing expertise by experience to inform the commissioning process; and providing developmental expertise to coordinate and improve alcohol interventions for offenders in local areas.
The professionals and service users consulted in the south west described a challenging environment in terms of the commissioning and delivery of offender alcohol interventions. Misalignment of the objectives and targets of health and criminal justice agencies was on occasion reflected in stalled relationships between commissioners. Without coherent policy guidance in relation to the provision of alcohol interventions, commissioners and managers can become forced to 'stand their ground' in relation to sectoral targets, to the detriment of effective multi-agency working. A consequence of this impasse at policy and strategic levels is the under-funding of alcohol services both for offenders and more widely, and widespread reported unmet need from the users of services. There are also major implications for the coherence of service provision for people with complex needs (including needs related to alcohol misuse) who require the most joined-up provision.
Nevertheless, the recommendations which emerged from the research show that, with a measure of facilitation, and in spite of a challenging environment, policymakers, commissioners, frontline services, and service users, can identify straightforward and workable themes for improving the commissioning and delivery of alcohol services for offenders. The effectiveness of the research method is demonstrated by the fact that these recommendations are practical, applicable and relevant to a wide range of parties and different areas.
Thanks for their comments on this entry in draft to Rob Fitzpatrick of Confluence in London. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
commentary For more on alcohol treatment requirements see this Findings bulletin. For examples of the ideas of using part of the money offenders pay in fines to fund alcohol awareness sessions, see Findings analyses of schemes in Hertfordshire and Derbyshire.
Last revised 19 September 2011
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DOCUMENT 2012 The government's alcohol strategy
STUDY 2010 Alcohol services in prisons: an unmet need