It\u2019s now almost six months since lockdown revolutionised the way services operate. But could this have actually led to an increase in service user choice? DDN reports. \u2018I don\u2019t like the phrase \u201cnew normal\u201d, but I think what that will be is a blended mix\u2019, Andrew Horne, executive director of We Are With You, Scotland, tells DDN. \u2018It\u2019s about giving people much more power over the choices they make. Rather than saying, \u201cHere\u2019s your worker, here\u2019s your one-to-one session, and you travelled 40 miles across the Scottish borders or Cornwall irrespective of what the transport system is like\u201d \u2013 now it\u2019s \u201cvideo me\u201d. COVID-19 has had a huge impact on service users\u2019 experience of treatment, not least the all-pervading sense of insecurity in the early days of the pandemic. But, as numerous DDN articles have illustrated over recent months, services were quick to adapt and ensure continuity of provision for their clients in exceptionally difficult circumstances. Initiatives adopted have ranged from preparing food for service users to providing them with smartphones, and one of the most significant changes \u2013 as with most other sectors \u2013 has been the large-scale shift from face-to-face to online activity. Scripts and pick-ups Inevitably, a key area to be affected has been provision of substitute medication, with many pharmacies \u2013 particularly in the early days of lockdown \u2013 either closing or operating significantly reduced hours. This meant service users being moved from daily to weekly or fortnightly pick-ups, often with little or no notice. \u2018There was a lot of uncertainty in the first couple of weeks, and real concern about continuation of scripts,\u2019 says national service user representative for Change Grow Live, Tony Lee. \u2018What my service was able to do was move everybody to a 14-day pick-up, and in the first couple of weeks that did create some anxiety. People were thinking, \u201cOh my God, will I manage?\u201d But by the time it came to the second pick-up two weeks later that seemed to have gone away.\u2019 Feedback has shown that the move away from daily pick-ups has actually improved some people\u2019s relationships with partners and children, he says, and has been particularly welcome for anyone looking after an elderly parent. \u2018Now they don\u2019t have to go to a chemist every day with the risk of bringing COVID back into the house. A lot of people have been really, really complimentary about the service taking that chance of giving them a 14-day prescription. It improves choice, it improves flexibility. We\u2019re not getting anything negative on that front at all. I\u2019m a national rep \u2013 I speak to people all over the UK \u2013 and it\u2019s the same feedback every time.\u2019 His service user council has now taken steps to ensure that no one is moved back to daily supervised consumption without good reason, he states. \u2018We demanded some safeguarding measures be put in place, so the person has to go through two processes to be put back on supervised consumption. That\u2019s really helpful because it reassures the client and brings them into that decision, so nothing\u2019s decided without their input. And we\u2019ve created an appeals system where we can respond rapidly to anyone complaining that they\u2019ve been put back on supervised consumption needlessly.\u2019 In control We Are With You has found much the same, adds Horne. \u2018We moved as many people as we could across to fortnightly pick-up, and the feedback has been very interesting. When we did our service user survey, 70 per cent said they didn\u2019t want to go back to daily pick-up. Two or three people said it was the biggest trigger point for relapse, because they were constantly in contact with people who were carrying illicit Valium or whatever. People also felt much more in control of their lives and how they dealt with dosage \u2013 instead of having to go to a chemist and drink 120ml of methadone they could spread that over the day.\u2019 His organisation changed all its prescribing options, with a lot more use of buprenorphine, for example. \u2018We just gave people options as to what they were more comfortable with. In Scotland we turned all our services into needle exchanges, because we knew people were going to struggle with chemists, we created click-and-collect for needle exchange, and did a lot of video prescribing as well.\u2019 Tailored to need Not every organisation made the shift to fortnightly pick-ups, however, and instead worked to make sure people were getting a service tailored to their needs. \u2018We never went to fortnightly,\u2019 says medical director at WDP, Dr Arun Dhandayudham. \u2018Even before the lockdown we were already risk-assessing each patient individually, looking at all their health risks and pick-up regimes. We were already well advanced in our planning, and the maximum anybody got was one week \u2013 we were also working very closely with the pharmacies to establish what kind of resilience they had in terms of cover. So we individualised each service user\u2019s pick-up \u2013 some went from daily supervised to daily unsupervised, or from once or twice a week to a maximum of weekly.\u2019 Closer working with pharmacies also provided a chance to stay informed about clients who weren\u2019t coming into services, says his colleague, operations manager Vanessa Duke. \u2018We\u2019ve been in pharmacies very regularly dropping off prescriptions and talking about clients that they might be seeing but maybe we haven\u2019t seen. We\u2019ve also taken in naloxone, safe storage boxes and leaflets around public health campaigns like World Hepatitis Day.\u2019 Online support One of the most significant changes across the sector has been the move to online support, which is not something that everyone thought would necessarily work. \u2018A really interesting stat among our service users is that 56 per cent were able to use online groups from a standing start, which is huge,\u2019 says Horne. \u2018Everybody said, \u201cIt\u2019ll never work \u2013 they just won\u2019t do it.\u201d But a huge amount of people have asked if we\u2019ll continue with the online groups after lockdown, because they like the blend of both.\u2019 \u2018My service has been a skeleton workforce, but it depends on what you want to put in \u2013 that\u2019s what you get out of it,\u2019 Barry, a service user based in Essex, tells DDN. \u2018You\u2019ll hear people complain, but it all depends on the individual and if you\u2019re determined to get help. My script\u2019s always there, I can always message my key worker to answer my questions or sort out any problems, and there\u2019s online support if you need it. It\u2019s down to your own determination.\u2019 The overwhelming majority of clients understand completely why these changes had to be made, stresses Duke. \u2018And many of them have enjoyed the opportunity to work in a different way. That\u2019s had some really positive outcomes, but some have struggled with the more limited one-to-one contact. And of course for some clients it\u2019s been a reduction in face-to-face contact across multiple services. Where that\u2019s been the case we\u2019ve worked with them and identified if it\u2019s ok to bring them in to service \u2013 where they\u2019ve got complex needs or are significantly socially isolated, or if there are particular risks in the home environment.\u2019 While many clients have enjoyed the opportunities offered by online support, it\u2019s been \u2018a mixed picture\u2019, agrees Tony Lee. \u2018We have a lot of clients who don\u2019t have access to the internet \u2013 one of the things we\u2019ve been trying is giving out phones so at least we can contact them and have a conversation. We can have a conference call and bring them into the meeting, and we\u2019ve taken it further than a therapeutic approach, with social evenings, quizzes and talent nights. So we\u2019ve definitely been able to broaden the scope of what\u2019s on offer \u2013 people are really happy with that extra choice of having a phone call or going on Zoom.\u2019 Improved engagement One of the recurrent themes of an ongoing Change Grow Live survey has been the choice aspect, he points out, and not just from service users. \u2018We\u2019re getting feedback from workers as well who are saying they\u2019ve never had so much contact with clients, especially the hard-to-reach people who would never come into a service. They\u2019ll pick up a phone, so the engagement side with these clients has been so much better.\u2019 In some cases, the new ways of working have sped up the implementation of initiatives that organisations were already thinking about. \u2018I think the big thing is that there\u2019s an appetite for change and a different way of working,\u2019 says Horne. \u2018For example, we\u2019re very conscious of the importance of the first four weeks in people\u2019s recovery journey. Traditionally you\u2019d call somebody in for an assessment and then try to get them into treatment. But an appointment in a week\u2019s time is very little use \u2013 people want an appointment tomorrow and the next day and the next. We really increased contact, so we\u2019ll still have physical meetings but interspersed with maybe three or four 15-minute chats \u2013 by phone or video or maybe just WhatsApp, \u201cHow are you doing, what\u2019s your plan for today, how did you get on yesterday?\u201d We lose a lot of people in the first four weeks across the sector, and we really need to engage \u2013 this has allowed us to do that. So a lot of what happened during lockdown has allowed us to unlock what we were thinking anyway.\u2019 The charity has also been able to reach out to people who wouldn\u2019t normally access services, he adds. \u2018Attending appointments online or via the phone can take away anxiety and logistical challenges, and we\u2019ve completely revamped our web pages to give much more clarity of advice. We would often have people come on a web chat to say, \u201cI think I need to do an alcohol detox but I\u2019m a primary school teacher \u2013 I\u2019m not going to a drug and alcohol service.\u201d We know there\u2019s this massive proportion of people out there who are struggling but never come near services, so we\u2019re really trying to open up.\u2019 Flexible approaches So with the new ways of working now bedded in, how are people feeling about the long-term options? \u2018At the beginning there was a lot of insecurity, a lot of uncertainty, but it\u2019s now a way of life,\u2019 says Dhandayudham. \u2018Early on we were very focused on the complex patients, the risky patients, the ones who had needs around safeguarding, but as time\u2019s gone on we\u2019re trying to bring back a lot of our normal interventions \u2013 the BBVs, the alcohol detoxes, and face-to-face work even for non-complex patients. But it\u2019s very much a flexible approach, so if local lockdowns come into place we\u2019re fully prepared \u2013 we can be very flexible in what we do.\u2019 \u2018I\u2019m fairly optimistic,\u2019 says Tony Lee. \u2018I\u2019m a client myself, I still access services, and I like my options now, I really do. Some days it\u2019s not always possible to go into a service so to be able to say, \u201cCan I have that by Zoom or a phone call?\u201d is tremendously helpful. It takes the pressure off me, and off the service.\u2019 \u2018I\u2019ve got COPD so I have to be careful,\u2019 says Barry. \u2018Where it used to be going to see your key worker fortnightly it\u2019s now monthly, and you\u2019re sitting two or three metres away. But I\u2019ve not found it to be a problem, and if there is any issue I call or text and things get sorted. If you go in daily you\u2019re drug tested and alcohol tested, whereas if you\u2019re having a conference call there\u2019s nothing to stop you drinking or using drugs after \u2013 but the only person you\u2019re lying to is yourself. I get all the help in the world, and it\u2019s because I want that help.\u2019 DDN This article has been produced with support from an educational grant provided by Camurus, which has not influenced the content in any way.