Stemming the tide

Rising demand, increasing bureaucracy and a client group with complex needs are just some of the challenges facing alcohol services. Hazel Jordan offers a frontline perspective

As area manager for Islington Community Alcohol Service I’m aware that, despite the hard work of the team, we are struggling to meet the levels of demand. We feel ‘rushed off our feet’ and know that other alcohol services are in the same position. We realise we’re only scratching the surface of need in Islington and whenever we visit other health and social care agencies, or deliver training, we generate more referrals – while NICE estimates that only 6 per cent of harmful and dependent drinkers access services, the estimate for Islington is 10 per cent.

Following the introduction of the alcohol strategy and increased awareness of alcohol harm, alcohol services are expected to extend their range of activities. We now offer preventative work and brief interventions to hazardous and harmful drinkers, as well as partnership working with probation. While we wholeheartedly support this strategic direction we need increased capacity to put it into practice, and at a local level we receive many requests to extend our activities further, such as working to reduce anti-social behaviour among street drinkers. There’s so much more we could do, but we don’t have the capacity to respond.

We also expect demand to continue to rise. Between 2001 and 2009 there was an increase in consumption levels and a 25 per cent increase in liver disease (37 per cent of which was alcohol related). While consumption seems to have reached a plateau, we expect referrals to alcohol services to increase, as people often approach services at a late stage of problematic drinking. The increase in prevention and early intervention work will also generate increased referrals to specialist treatment services, and is already doing so locally.

It’s estimated that alcohol harm costs society £21bn per year. It’s the third biggest lifestyle risk factor for disease in the UK and 44 per cent of violent crimes involve alcohol, yet alcohol services have been chronically underfunded for many years. In order to reduce alcohol harm, in line with the alcohol strategy, investment is desperately needed. At this crucial point, we are extremely concerned that there is a serious risk to funding for alcohol services as a result of disinvestment from local NHS and local authority budgets and the transfer of funds to Public Health England, lifting the ring fence for drug and alcohol treatment funding. It’s essential that funding for alcohol services is protected.

A high proportion of our clients have complex and multiple needs including poor levels of physical and mental health, traumatic personal histories, homelessness or insecure housing, unemployment, poverty, domestic violence, involvement with the criminal justice system and child safeguarding issues. There are also particular groups who need specialised treatment, such as older people with dementia, parents whose children may be at risk of harm and groups who require additional support such as interpreting services.  

Our role as alcohol workers is to coordinate treatment plans to address the full range of needs our clients bring. Alcohol use cannot be tackled in isolation. Pathways and joint working between different sectors, for example between mental health and alcohol services, can be difficult to establish and maintain and clients with both mental health needs and alcohol problems can easily fall through the net. In a climate of public expenditure cuts, we are finding coordination increasingly difficult as partner services are reduced. This in turn puts further strain on our capacity and stress on staff. The most vulnerable clients with the highest needs are losing out.

Strategic planning is needed at senior levels within the different sectors to ensure that joint working is possible at service delivery level. The alcohol strategy and NICE guidelines include such principles as ‘one size does not fit all’ and ‘person-centred’ care, and NICE guidelines also recommend a 12-week limit for alcohol interventions. The guidelines refer to a ‘more intensive community intervention’ and this fits better for clients with complex needs. They can and do recover from addiction, but this often takes time. In the context of stretched resources, however, the 12-week limit is often taken as the guideline for commissioning services and this risks failing to meet the needs of some of the most vulnerable members of society.

We are very concerned that, in the current climate, these most vulnerable people may be at risk of losing their services if payment by results (PbR) is introduced without specific safeguards. If PbR only focuses on final results – ie full recovery – services may be tempted to cherry pick those clients who are more likely to make progress quickly. Furthermore, some of the work we do with these vulnerable clients who are not ready to stop drinking is about minimising harm. This work directly contributes to Department of Health priorities of reducing alcohol related deaths and hospital admissions but there would be no results demonstrating recovery. It is absolutely vital that services that mitigate harm to the most vulnerable people, and their families and communities, are preserved if PbR is introduced.

Both adult family members and children can be profoundly affected by the drinking of a family member, and we are fortunate in Islington to receive funding to run a service for adult family members. There is clear evidence that involvement of adult family members in treatment can improve outcomes for alcohol and drug users. We also receive funding towards our family service for children, young people and families affected by parental alcohol and drug use via the Safer Islington Partnership. Parental alcohol and drug misuse is one of the three major causes of children being accorded child protection status, and young people affected by parental alcohol use have higher levels of alcohol problems and other mental health problems themselves.
Despite the evidence that services for families lead to better outcomes, we are concerned that they may be seen as ‘extras’ and risk losing their funding. It is essential that a clear funding pathway is identified for services working with children and families affected by parental alcohol and drug as currently neither children’s services or adult substance misuse services see themselves as responsible for funding these crucial services. Investment to save the enormous human and financial cost of taking children into care makes sense.

Then there are issues of bureaucracy and paperwork. Over the years the amount involved with our work has increased dramatically. We fully support the use of thorough assessment and care planning, national frameworks and guidelines but the level of detail that is specified by our national framework, Models of care for alcohol misuse, and its local implementation has resulted in staff and clients being required to complete at least ten forms, some of them lengthy, before a client starts structured alcohol treatment. Six of these forms need to be signed by the client, and we also need to enter every contact with a client onto an electronic database.

This is extremely time consuming and we would prefer that the paperwork was streamlined so we could spend more time with the clients – the activity that is key to understanding their needs and supporting them to meet their goals. Often clients present in great distress and/or are very unsure about engaging in treatment, an completing and signing multiple forms can be counter-productive to engaging some people at this stage.

As experienced alcohol workers we feel that outcomes for clients would be improved if we were able to exercise our professional judgement and if paperwork were streamlined. At a broader level, the amount of bureaucracy involved in commissioning and procurement of services places a huge burden on the capacity of services, effectively excluding smaller local services from the process. During the tendering process, members of the commissioning and procurement teams and managers of services spend many days carrying out their respective roles and clients and staff experience long periods of uncertainty about the future of the service.

When services are restructured and/or change hands there is a great deal of change to manage and adjustment required from clients and staff. We are fortunate to have a three-year contract that can be extended for a further two years. Often this commissioning process is repeated every three years. We aim to provide stability and structure for our clients but this is difficult amidst constant upheaval.

Longer contracts would help to reduce this upheaval. We also think clients would benefit if the commissioning process was streamlined and some of the resources spent on the commissioning, procurement, monitoring and restructuring of services diverted to direct service provision which is so desperately needed.

Hazel Jordan is area manager for Islington Community Alcohol Service, Blenheim CDP