It’s 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. Read the full article in DDN Magazine ‘I don’t like the phrase “new normal”, but I think what that will be is a blended mix’, Andrew Horne, executive director of We Are With You, Scotland, tells DDN. ‘It’s about giving people much more power over the choices they make. Rather than saying, “Here’s your worker, here’s your one-to-one session, and you travelled 40 miles across the Scottish borders or Cornwall irrespective of what the transport system is like” – now it’s “video me”. ‘We’re getting feedback from workers as well who are saying they’ve never had so much contact with clients’ Andrew Horne COVID-19 has had a huge impact on service users’ 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 – as with most other sectors – 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 – particularly in the early days of lockdown – 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. ‘If local lockdowns come into place we’re fully prepared – we can be very flexible in what we do.’ Tony Lee ‘There was a lot of uncertainty in the first couple of weeks, and real concern about continuation of scripts,’ says national service user representative for Change Grow Live, Tony Lee. ‘What 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, “Oh my God, will I manage?” But by the time it came to the second pick-up two weeks later that seemed to have gone away.’ Feedback has shown that the move away from daily pick-ups has actually improved some people’s relationships with partners and children, he says, and has been particularly welcome for anyone looking after an elderly parent. ‘Now they don’t 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’re not getting anything negative on that front at all. I’m a national rep – I speak to people all over the UK – and it’s the same feedback every time.’ 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. ‘We 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’s really helpful because it reassures the client and brings them into that decision, so nothing’s decided without their input. And we’ve created an appeals system where we can respond rapidly to anyone complaining that they’ve been put back on supervised consumption needlessly.’ In control We Are With You has found much the same, adds Horne. ‘We 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’t 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 – instead of having to go to a chemist and drink 120ml of methadone they could spread that over the day.’ His organisation changed all its prescribing options, with a lot more use of buprenorphine, for example. ‘We 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.’ 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. ‘We never went to fortnightly,’ says medical director at WDP, Dr Arun Dhandayudham. ‘If local lockdowns come into place we’re fully prepared – we can be very flexible in what we do.’ Dr Arun Dhandayudham ‘Even 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 – 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’s pick-up – some went from daily supervised to daily unsupervised, or from once or twice a week to a maximum of weekly.’ Closer working with pharmacies also provided a chance to stay informed about clients who weren’t coming into services, says his colleague, operations manager Vanessa Duke. ‘We’ve been in pharmacies very regularly dropping off prescriptions and talking about clients that they might be seeing but maybe we haven’t seen. We’ve also taken in naloxone, safe storage boxes and leaflets around public health campaigns like World Hepatitis Day.’ 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. ‘A 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,’ says Horne. ‘Everybody said, “It’ll never work – they just won’t do it.” But a huge amount of people have asked if we’ll continue with the online groups after lockdown, because they like the blend of both.’ ‘My service has been a skeleton workforce, but it depends on what you want to put in – that’s what you get out of it,’ Barry, a service user based in Essex, tells DDN. ‘You’ll hear people complain, but it all depends on the individual and if you’re determined to get help. My script’s always there, I can always message my key worker to answer my questions or sort out any problems, and there’s online support if you need it. It’s down to your own determination.’ The overwhelming majority of clients understand completely why these changes had to be made, stresses Duke. ‘And many of them have enjoyed the opportunity to work in a different way. That’s had some really positive outcomes, but some have struggled with the more limited one-to-one contact. And of course for some clients it’s been a reduction in face-to-face contact across multiple services. Where that’s been the case we’ve worked with them and identified if it’s ok to bring them in to service – where they’ve got complex needs or are significantly socially isolated, or if there are particular risks in the home environment.’ While many clients have enjoyed the opportunities offered by online support, it’s been ‘a mixed picture’, agrees Tony Lee. ‘We have a lot of clients who don’t have access to the internet – one of the things we’ve 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’ve taken it further than a therapeutic approach, with social evenings, quizzes and talent nights. So we’ve definitely been able to broaden the scope of what’s on offer – people are really happy with that extra choice of having a phone call or going on Zoom.’ 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. ‘We’re getting feedback from workers as well who are saying they’ve never had so much contact with clients, especially the hard-to-reach people who would never come into a service. They’ll pick up a phone, so the engagement side with these clients has been so much better.’ In some cases, the new ways of working have sped up the implementation of initiatives that organisations were already thinking about. ‘I think the big thing is that there’s an appetite for change and a different way of working,’ says Horne. ‘For example, we’re very conscious of the importance of the first four weeks in people’s recovery journey. Traditionally you’d call somebody in for an assessment and then try to get them into treatment. But an appointment in a week’s time is very little use – people want an appointment tomorrow and the next day and the next. We really increased contact, so we’ll still have physical meetings but interspersed with maybe three or four 15-minute chats – by phone or video or maybe just WhatsApp, “How are you doing, what’s your plan for today, how did you get on yesterday?” We lose a lot of people in the first four weeks across the sector, and we really need to engage – 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.’ The charity has also been able to reach out to people who wouldn’t normally access services, he adds. ‘Attending appointments online or via the phone can take away anxiety and logistical challenges, and we’ve completely revamped our web pages to give much more clarity of advice. We would often have people come on a web chat to say, “I think I need to do an alcohol detox but I’m a primary school teacher – I’m not going to a drug and alcohol service.” We know there’s this massive proportion of people out there who are struggling but never come near services, so we’re really trying to open up.’ Flexible approaches So with the new ways of working now bedded in, how are people feeling about the long-term options? ‘At the beginning there was a lot of insecurity, a lot of uncertainty, but it’s now a way of life,’ says Dhandayudham. ‘Early on we were very focused on the complex patients, the risky patients, the ones who had needs around safeguarding, but as time’s gone on we’re trying to bring back a lot of our normal interventions – the BBVs, the alcohol detoxes, and face-to-face work even for non-complex patients. But it’s very much a flexible approach, so if local lockdowns come into place we’re fully prepared – we can be very flexible in what we do.’ ‘I’m fairly optimistic,’ says Tony Lee. ‘I’m a client myself, I still access services, and I like my options now, I really do. Some days it’s not always possible to go into a service so to be able to say, “Can I have that by Zoom or a phone call?” is tremendously helpful. It takes the pressure off me, and off the service.’ ‘I’ve got COPD so I have to be careful,’ says Barry. ‘Where it used to be going to see your key worker fortnightly it’s now monthly, and you’re sitting two or three metres away. But I’ve 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’re drug tested and alcohol tested, whereas if you’re having a conference call there’s nothing to stop you drinking or using drugs after – but the only person you’re lying to is yourself. I get all the help in the world, and it’s because I want that help.’ DDN This article has been produced with support from an educational grant provided by Camurus, which has not influenced the content in any way.