This article looks at current developments in substance misuse services in the context of prudent healthcare. It highlights the maturity of the existing user-led and collaborative approach in service delivery that has been developed over the past twenty years, while exploring how the prudent principles may be explored and developed to further improve outcomes, increase efficiency and build stronger partnerships with service professionals and service users. Examples of innovative services in Wales are given to highlight how prudent principles can bring additional value to services, partnerships and collaboration with people using the service, and wider communities. The article gives an overview of substance misuse services in Wales as a whole and offers insights from the experience of substance misuse services, on how a mature, prudent approach can deliver high value while continuing to improve efficiency.
Substance misuse services have certain characteristics in common with other service areas – most closely with mental health services –but they sit apart from other health and social care provision in many respects, particularly in the acute health sector. Substance misuse is one of only a few health and social care intervention groups that are regularly mandated by the courts – through drug rehabilitation requirements, alcohol rehabilitation requirements and alcohol treatment requirements, as these may be made by magistrates and judges.
The impacts of substance use continue to place extraordinarily large burdens on public services, despite the continuing, although diminishing, stigma that surrounds addiction and dependency. The over-consumption of alcohol, for example, results in lost working hours, issues of public safety and alcohol-related harm. It increases demands on emergency services, is associated with domestic violence and abuse and puts pressures on acute hospital services which respond to alcohol-related-health conditions. These are just a few of many examples of the wide ranging costs of substance use available.
Interestingly, the substance misuse field has been practising prudent principles for a long time. This is largely as a result of relatively low public sector funding levels prior to the beginning of the new millennium. It is also a sector in which service user motivation and commitment levels are critical to achieving a positive outcome from services. As a consequence, one of the difficulties in finding examples of prudent healthcare in practice for this article, has been distinguishing between genuinely novel and innovative practices that reflect the prudent healthcare principles, and the day-to-day delivery of good quality services. The best of day to day services for substance use, while reflecting many of the prudent principles, are simply doing what they have been commissioned to do and are doing it well.
Services in Wales
There are a range of unique and innovative practices to be found across Wales that demonstrate how this particular sector gains significant benefit from applying prudent healthcare approaches. In some cases, this has been led by the commissioners of services in response to a specific problem or issue and in others it has been a ground-up evolution of a service or intervention where service users, providers and community members have been determined to achieve better outcomes within available resources.
Prudent healthcare in substance misuse
The first example of prudent healthcare in substance misuse services has been largely led by commissioners and concerns the development of single points of entry into local substance misuse treatment and support services.
Single assessment services
Wales has seen a proliferation of single assessment services for substance misuse which promote the prudent healthcare principles of only carrying out interventions with proven clinical benefit, as well as carrying out the minimum appropriate intervention. Traditionally, individuals seeking support for their own, or someone else’s, substance misuse-related needs will most likely have gravitated towards a service that was either well known locally, recommended to them, or from which they previously had positive experiences. However, the emerging single assessment services are now able to undertake an objective identification of need and refer individuals on to the most appropriate organisations and interventions that have evidence to demonstrate they can effectively address that need.
Stopping onward referrals
This approach also addresses a concern previously found across the sector – onward referral of individuals. Before the single assessment approach, substance users would often present at services that may not have been best placed to meet their needs. The difficulty arises from a desire among frontline professionals to capitalise on what is often a fleeting motivation among service users to engage with treatment and support. In these circumstances the ethos of the provider will often be to do something with a service user at that point of motivation rather than sending them on to another service knowing there is a high likelihood of the individual losing motivation and not following through with that onward referral.
Single assessment services however are advertised and known from the outset to be environments where a person’s needs will be considered and they will be re-directed to the most appropriate form of support. In this way, service user expectations are met and access of the service is on that understanding. The impact of this approach results in improved retention rates across services with traditionally high rates of unplanned drop-out from treatment and support. This is evidenced through the performance data on the Welsh National Database for Substance Misuse (WNDSM) against the National Key Performance Indicator of case closures as a result of non-attendance. Performance has broadly improved against this KPI in areas that operate a single assessment approach. Knowing that substance users are being directed to the interventions most suited to their circumstances significantly increases the likelihood of retention within treatment and support, leading to better outcomes.
Alcohol Treatment Centres
Moving from assessment services but still supporting the principle of minimum appropriate intervention, as well as making best use of the workforce and the promotion of equity are the new Alcohol Treatment Centres (ATCs), which operate in Cardiff and Swansea. These have been designed, commissioned and implemented in response to the significant pressures that drunk people have traditionally placed on A&E departments, most notably on Friday and Saturday evenings. These centres operate as detached emergency units, with the same clinical governance procedures as the main hospital emergency departments, but with easier access as they are based in the centre of the night-time economy.
Individuals can either be brought to the centre by friends, the police, community volunteers or by ambulance services and paramedic staff. There are clear triage and escalation protocols for the transfer of patients to the main hospital units in cases where the presenting clinical need is beyond the competence or authority of the ATC staff or facilities, and in many cases this triage is performed by attending paramedic staff so that appropriate re-direction of patients takes place at the earliest opportunity.
The presence of the ATCs at weekends creates a separation of individuals needing care in relation to the consumption of alcohol or other substances and those in need of general hospital emergency treatment. This has markedly reduced the demand on hospital services and the level of disruptive behaviour within those services when the ATCs are operational. Additional sessions are carried out, and/or additional staff deployed at peak times, such as during international sports events, large concerts, over the Christmas and New Year period and other public holidays.
Joining up services with ATCs
There are a range of additional public service benefits that the ATCs have brought to the areas in which they operate. A significant amount of police time has been released with officers able to return to street level policing after quickly transferring patients to the care of the ATC staff rather than being held up for lengthy periods of time in a hospital emergency unit. The centres also provide a place of safety for people who are particularly vulnerable as a consequence of their alcohol consumption. The staff and volunteers supporting the ATCs are all trained to deliver alcohol-related harm reduction advice and brief interventions to individuals once they have achieved a sufficient level of sobriety. This uses the evidenced-based brief intervention methodology that is used across Wales to train a broad range of professionals to be able to undertake a structured conversation with someone regarding their alcohol use.
In terms of measurable cost savings, the evaluation carried out on the pilot phase of the ATC in Cardiff by Cardiff University demonstrated that the net cost of 10 individuals attending the ATC per session would equal the cost of mainstream provision – any more than 10 attendances per session generates a cost saving that increases with every additional individual treated. On busy nights, ATC sessions in Cardiff have seen more than 30 attendances .
Finally under this theme, it should be noted that the principle of only delivering the services needed, and only services supported by the evidence base is prevalent as an ethos across the sector. This is partly due to these principles being embedded in the National Core Standards for Substance Misuse . The Gwent Open Access and Liaison Service (GOALS) uses the community reinforcement approach, which takes a holistic view of a person’s needs which may influence the intervention used and the need or otherwise to refer on to other agencies. This ensures that they do not deliver any unnecessary interventions, nor do they refer on unnecessarily or hastily if they feel able to help an individual address multiple issues.
This moves the discussion onto the prudent healthcare principle that is most established and visible within the substance misuse sector – co-production. Co-production, and particularly mutual aid, has been central to the substance misuse service landscape for a long time. Most notably, the evolution of the Minnesota model and the 12-steps movement through organisations such as AA, NA and ADFAM (which uses the AA approach to support the family members of substance users) have been a feature of local addiction services for many year; AA has been active in the UK since 1947.
User led, user provided
The ethos of user-led, and user-provided services can be found across substance misuse services in Wales. DrugAid, a third sector agency, delivers the Choices programme which includes a comprehensive peer education programme, which up-skills young people to be a part of the Choices service and enhance the work that is carried out. Similarly, Recovery Cymru in Cardiff and the Vale of Glamorgan enables service users to develop into the role of recovery champions, who are trained to support and provide advocacy to other service users who are at an earlier stage in their recovery journey.
Peer led interventions
A recent large scale example of the peer-led approach to substance misuse service delivery in Wales has been the 2009-14 national peer mentoring project developed using European Social Funding with the primary aim of assisting ex-substance users across Wales to enter employment or further learning. Between October 2009 and September 2013, more than 9,600 clients were registered as participants in the project. More than a third had been dependent on substances (most commonly alcohol, followed by heroin) for most of their adult lives, and most of these had been unemployed for a similar period. The most common pattern was for them to take one or more short non-accredited courses (as an introduction to the service), followed by:
Allocation to a key worker and/or peer mentor to assess the case and make an action plan
Some would take more courses to enhance their social skills or confidence levels, some would start training for a qualification relevant to their planned area of employment, others would begin volunteering or work experience, and still others would start applying for jobs
A minority, too, would begin to train as a peer mentor.
Clients selected or choosing to become peer mentors underwent thorough training, mainly through a standard eight-week course supplemented by individual supervision. Once qualified, most began work in a voluntary capacity, but when vacancies became available could move into a paid post. The turnover of such posts varied, some providers aiming to move people on after a set period while others encouraged them to stay for as long as they wished. Larger provider organisations were also able to offer posts in other branches or with different client groups.
In terms of outcomes, and results, ten per cent entered employment, nine per cent entered further learning, 14 per cent had gained a qualification and 65 per cent had achieved at least one other positive outcome – most often, completing a course or volunteering .
CRAFT (Community Reinforcement Approach and Family Training)
Peer-led service delivery also extends to the carers and family members of service users within substance misuse. The CRAFT (Community Reinforcement Approach and Family Training) programme developed in the United States by Dr Bob Myers , is an exemplar of the principles of co-production, offering an approach that has potential benefits for many long-term chronic conditions. In CRAFT, the provision of service is directed towards the family members and loved ones of drug or alcohol users. The substance users themselves will often be resistant to engage with treatment and support services, with either no contact, limited or intermittent contact with treatment services.
Without the necessary skills and knowledge, family members can often unwittingly be a catalyst to someone’s use of substances, with their actions or responses negatively reinforcing the substance using behaviours. In the CRAFT model, practitioners develop and train family members and loved ones to enable them to adopt evidenced based approaches in their behaviour towards the substance user they are supporting. This is undertaken with the intention of maximising and reinforcing positive engagement and support within the home environment. The training enables the family member to react to tensions and situations in a manner that is most likely to secure a positive outcome; it teaches them how to engage in motivating discussions to encourage their loved one to either access support, or maintain their engagement with services, and it provides them with the confidence to walk away from difficult situations, and to make time for themselves.
Positive outcomes from CRAFT
There are multiple outcomes and results from this approach. Service users who live in an environment with a CRAFT-trained family member or loved one are more likely to access support and are more likely to maintain their engagement with those treatment and support services. The family members’ own levels of anxiety and stress decrease, reducing the potential need for them to access support services for themselves. The use of evidence-based approaches mean that family members take on a semi-professional role, ensuring the service user’s exposure to techniques such as motivational enhancement approaches is significantly increased above and beyond the limited contact that specialist services are able to provide. The CRAFT approach is currently being delivered in Wales in Cardiff and the Vale of Glamorgan and in Newcastle in England.
True co-production, however, goes further than simply the involvement and contribution of service users and carers to their services and starts to engage and involve whole communities. This can be seen working effectively in practice within the Communities Together Programme – a three-year project funded by the Big Lottery and delivered by Alcohol Concern with support from Hywel Dda University Health Board, Public Health Wales, Pembrokeshire Council and a wide range of other statutory, private and voluntary bodies. Since January 2014, it has been working in Fishguard and Goodwick, Pembrokeshire, engaging with local residents, businesses and community groups.
The project encourages local people to talk about the positive and negative aspects of alcohol use in their neighbourhoods and develop their own initiatives to address any identified problems. It does not aim to discourage alcohol use altogether but promotes a healthy relationship with alcohol for individuals and for the community as a whole. It draws on the asset-based community development model, which helps local communities to identify their own strengths and talents and their own capacity to effect positive change.
An Communities Together Programme action plan has been co-produced by local residents and the project manager, following extensive local consultation. It focuses on:
General alcohol awareness in all age groups
The role of adults in influencing children’s attitudes to alcohol
Reducing isolation, increasing community cohesion, and supporting people at crisis points in their lives.
Initiatives already arising from the project include a range of new diversionary activities as alternatives to drinking both for young people and older adults, with a strong intergenerational element.
The substance misuse sector offers a range of learning both for its own improvement and development and for other areas of service where the greatest need lies with hard to engage or hard-to-reach vulnerable members of society. The use of assessment systems demonstrates the impact and improved outcomes, which can be achieved when an objective process is used to determine the correct service or intervention required to meet a specific need. The alcohol treatment centre model, on the other hand, proves the undeniable benefits and gains that can be made across a broad range of public agencies when adopting a prudent approach within healthcare.
Lessons from CRAFT
There are valuable lessons to be learned from the CRAFT ethos and approach. Many long-term conditions will affect people with family members and loved ones who will be both willing and able to support their care and reduce the need for specialist services intervention and involvement. If training and development programmes are implemented for the family members and carers of individuals with chronic health conditions, to enable them to deliver or support the delivery of evidence based approaches in the home environment, then the reduced burden on specialist health and social care services could be substantial.
Finally, mutual aid movements and community involvement approaches are delivering valuable local support and networks for a group of service users whose needs are enduring and where substance use impacts on every aspect of their lives. These innovations help break down the social barriers between substance users and the communities in which they live. This in turn promotes the presence of drugs, alcohol, and their use as a challenge for the whole community to address rather than a set of problems that only specialist services are capable of resolving.
The field of substance misuse offers a range of examples and lessons to be learned across the spectrum of prudent healthcare. In particular, the themes of avoiding harm, meeting the needs and circumstances of citizens and, of course, co-production are most easily identified. However, despite all its successes, the principles of prudent healthcare need to be considered in context and then adapted to reflect the idiosyncrasies of the substance misuse field. These mitigations and refinements encompass the impact of working with a range of behavioural as well as medical conditions and the importance of individual service users’ motivation to the success of service outcomes. Substance misuse services are continuously seeking ways to overcome the challenges of supporting and engaging with service users who can often be ambivalent, disengaged or de-motivated
Prudent is working
However, prudent healthcare approaches are delivering results; the recovery movement, for example, which has a participatory, collaborative, mutual aid ethos at its centre, is rapidly gaining momentum across Wales and the UK more broadly. Innovative social enterprise solutions, such as the substance misuse service user-run and managed cafes in Port Talbot and Caerphilly offer substance users the chance to engage in structured activities and develop their confidence and skills through training, development and work experience while providing the potential for income generation and financial independence in a manner that is integrated into the communities within which these businesses function.
Services and activities that are conceived, developed and delivered at a community level are also diluting the entrenched stigma of addiction and substance dependency in society. The whole ethos of the field is shifting from one where services are provided for those in need, to one where service users and professionals are expected to collaborate in order to achieve outcomes as a joint responsibility.
- Moore S., Sivarajasingam V., and Heikkinen M., An Evaluation of the Cardiff Alcohol Treatment Centre Pilot, Cardiff University, 2013, pg.33-34
- Welsh Government, National Core Standards for Substance Misuse, 2010
- Maguire M., Holloway K., and Bennett T., Evaluation of European Social Fund peer mentoring Wales, Cardiff, Welsh Assembly Government, 2014.
- CRAFT Overview, https://www.robertjmeyersphd.com/craft.html, [accessed 10th December 2014]