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CHAPTER SIX: LINKS WITH OTHER SERVICES
Awareness of the service
6.1 Initial interviews indicated that awareness of 218 and the aims and objectives of the service varied considerably among external agencies. At the outset of the evaluation in 2004, the researchers were regularly asked to provide information on 218, and on one occasion the researcher attended a team meeting to conduct interviews with staff only to discover the team expected her to conduct a presentation on 218 and its services. Interviews with key stakeholders and the referral rate to date suggests that some agencies are very knowledgeable about 218 and make regular contact to refer or accept referrals. 39 However, other agencies were less aware of what is on offer there and continue to be so.
6.2 218 staff have been very proactive in their attempt to inform services in Glasgow about their remit. 40 In addition to the production and distribution of leaflets and cards, agencies have been invited to visit 218, 41 and 218 staff have conducted a number of briefing meetings with relevant services. The initial 218 promotion leaflet was also redrafted into 3 different versions, with one each designed for courts, agencies, and clients, and 3 short DVDs have also been produced for these groups. The concern from staff was that lack of knowledge risked reducing the number of referrals from key criminal justice agencies such as courts: "I think a lot of [criminal justice agencies] don't really know what we're doing …" (day programme staff member).
6.3 Lack of clarity in the overall management of 218 arguably hindered its approach to other services. A senior official commented that 218 had to approach key agencies "through the back door" because of the uncertainty of its role in contacting them. Did alerting Sheriffs about 218, for example, fall to 218 or to the City Council for whom they were delivering the service? Managers at 218 eventually took the role upon themselves, though Criminal Justice Social Work at Glasgow City Council has since contacted a number of key agencies about the existence and purpose of 218.
6.4 Agencies who initially had limited contact with 218 were unsure about the criteria for referral to 218 and whether the project offered anything different to other services in Glasgow. All of those who had heard of 218 knew it was a project for women only, but beyond that their impressions were fairly diverse. Most information they had received was through leaflets about 218, though all had been invited to visit the project. The residential element of the service was only mentioned briefly in the initial printed information leaflet, which may have contributed to the fact that some agencies were unclear that supported accommodation was available as part of the service.
6.5 Those who were more familiar with the work of 218 were generally positive about it and believed it offered an important service for women in Glasgow. 218 was seen to provide a safe environment which could provide women with time out and a breathing space. The holistic approach that 218 offered through the provision of a wide range of services, was considered innovative, and it was acknowledged that 218 could be important in helping women to stabilise their drug use, and their lives, with ongoing support from project staff. Several respondents indicated that they would appreciate more information about the daily activities offered at 218 and the content of programmes and interventions ( i.e. what was available to address offending behaviour in particular).
Meeting Women's Needs
6.6 As awareness of what was on offer at 218 increased, external agencies were able to develop links with the service and in doing so, became more aware of what 218 had to offer women (see Chapter Five). The residential provision at 218, the overall atmosphere of the building and the range of services, including 'alternative' therapies, were viewed as 'very effective' in providing a resource for this group of women. These aspects of the service and its focus on a women-only approach were viewed by other agencies as clearly distinguishing 218 from other services in existence in Glasgow. It was also acknowledged that 218 could respond to women who had problems associated with alcohol use as well as drug use, something which some agencies (particularly those in the criminal justice system such as Drug Treatment and Testing Orders and the Drug Court) were not wholly equipped to deal with. Indeed, respondents who pointed out that the criminal justice system as a whole deals inadequately with women were appreciative of the services and support that was available through 218.
6.7 All respondents from other agencies were optimistic about the potential for 218 to provide an alternative to custody, although they acknowledged that this may operate in the longer term rather than directly 42 (this issue is discussed in Chapter Seven). One respondent noted that while it was unlikely that the population of Cornton Vale would be drastically reduced, 218 should identify the most vulnerable women to prevent them from serving a custodial sentence in the first instance. Important aspects of the service were the safety and stability it provided by being a 'woman only' environment.
Working with other agencies: practicalities
6.8 While respondents from other agencies appreciated the helpfulness of 218 staff when referring a woman to the service, the flexibility of the process 43 often meant that the criteria for referral could be unclear. At points, the referral list had been closed, although external agencies had not always been aware of this.
6.9 Respondents viewed the range of services available at 218 as excellent and considered the structured approach to after-care as significant. This consisted of a move to the day programme on leaving the residential service and ongoing contact with the project (for individual sessions and group work) after completion of the day programme. 218 provide this contact on an appointment or arranged basis, as opposed to the open drop-in provisions which characterise many other services when formal contact has been completed.
6.10 However the complexity of the service provision at 218 and a large staffing group had, on occasion, led to problems in communication with external agencies. Respondents indicated that there had been difficulties contacting specific workers when making or receiving a referral from/to 218. The lack of identified key workers (particularly in the residential unit where shift work had more of an impact) was viewed as making co-ordination and communication with external agencies more difficult, described by one referrer as constituting a "breakdown in communication"(addiction worker). "If there was an identified worker that was kind of co-ordinating and overseeing the whole case I think that might make things a bit easier you know, certainly in terms of communication". Where identified workers were in place, such as on the day programme, communication appeared to be more effective.
6.11 Problems had been experienced with information-sharing and communication both within and beyond 218. One worker commented that 218 was a key service for their client group and expressed a desire to set up clearer lines of communication with 218 in order to keep in contact with women attending/entering the residential unit, and to enable them to attend reviews, for example: "I'm not saying we have a fast track service, what I am saying is that that's part and parcel of an integrated service surely - to be able to share information" (community project manager).
6.12 The transfer of information between 218 and other agencies seemed generally unproblematic, although there had been 'teething problems' in this respect, particularly in the case of medical case notes (see Chapter Three). By 2005, difficulties in communication (between 218 and social work departments in particular) appeared to have improved, despite initial difficulties . Structural arrangements in some outside agencies had proved problematic, namely during the (lengthy) development of Community Addiction Teams, though this too was easing by the end of this evaluation.
6.13 It was noted that some operational systems still needed to be improved. A specific example of this was the difficulty experienced in changing a woman's bail address. A Day Programme staff member commented:
"We should technically change their bail address straight away. That took a worker two weeks to change that. So it's another system, whereby we could get a lot of work done a lot faster if we all sat down and said … right … maybe we just need a bit of paper … but we all really need to sit round the table and say … what's the easiest way of doing this. I don't know what the easiest way is … but I know from our point of view, it takes a long, long time."
6.14 Outside agencies, having developed links with 218 staff, were perceived to be more willing to share information. Notable exceptions were the Benefits Agency, which 218 staff said tended to be unhelpful, though this was not a consistent problem. Staff from government agencies who appeared to have undergone recent training in data protection could be very guarded about the information they were willing to discuss.
6.15 Social work teams were willing to send copies of Social Enquiry Reports to 218 on the understanding that this information would be returned or shredded once staff had seen it:
"Social work's policy is that clients don't read their SERs, so we can't have an SER in a woman's file because they could read it. So it can be quite sort of complicated so we, any SERs we need to read it and send it back or read it and shred it, because of the two different confidentiality policies." (day programme staff)
6.16 Access to data from the Scottish Criminal Records Office was also very difficult due to data protection issues and significant time delays, so staff at 218 were unable to follow a client's progress, especially after leaving 218, unless they came across the client at court or the client referred herself back to the project.
6.17 Although there was a recognition that different agencies often work to different agendas, overall communication between agencies appeared to be operating effectively. It was becoming an increasingly regular practice for 218 workers to attend reviews with other agencies and vice versa. If a woman had gone into 218 with an identified worker from an outside agency, the worker would generally be contacted and invited to attend the woman's case review.
6.18 The changing nature of the service provision, and the fluidity with which services developed along the lines of 'what works' and a 'trial and error' format, was not always made clear to external agencies. Other service providers did not always feel well-informed about changes in 218 policy/practice which could be problematic when working directly with women or when referring women to 218. For example, changes in the use of the residential unit from 12 weeks to 4 weeks (see Chapter Three) appeared to cause some confusion.
6.19 Similarly, as the service developed, non-criminal justice agencies said they had increasing difficulty getting women in to 218 and wondered if there had been any change in the assessment criteria, but did not know if this was the case. There was also a view that it may be best if 218 was not linked into the criminal justice service (voiced by agencies which were not themselves linked to criminal justice): "It's a shame it's linked to the criminal justice system, would be better if this weren't a requirement" (housing project worker).
6.20 A number of clients and staff at 218 expressed the same view. Evidence from the interviews supported the perspective that clients may be prepared to offend in order to benefit from the service:
"… I was just in total despair and self destruction before I came in here, so … I would have taken any help at all to get clean, you know, and I remember when I phoned up to see if I could come in here, I said, I'll go out and offend today if that's what it's got to take to get me in here and get help." (Exit 44)
6.21 Agencies had not experienced problems making referrals to 218, although the low level of referrals from 218 to other agencies was noted as a concern initially, but one which appeared to have improved by the final stages of the evaluation: "we have had difficulty receiving referrals from them, not sure the structure is fully in place for that yet, we need to close funding gaps and improve joint working in terms of the appointment of care managers etc" (addiction worker).
6.22 Staff at 218 did not perceive any major problems in working with other agencies to provide the services the women needed. Problems could arise in trying to place a woman with a GP who was willing to prescribe her with the medication they believed she needed, pharmacists who were willing to distribute medication, and to find appropriate housing at relatively short notice. They generally believed such problems were not insurmountable, however, and were often a feature of working with their particular client group.
6.23 The 218 environment, with the availability of ongoing support, meant that women appeared to manage well on relatively low doses (in comparison to external provider levels) of methadone. However, when women left, they were often unable to cope on the same amount, and it was suggested that doses of methadone should be increased for women moving back into the community. The use of Subutex as an option available in place of methadone was also considered a potential problem if a woman wished to continue this in the community:
"I think with Subutex it's a problem…, because GPs aren't used to prescribing Subutex, so as soon as they hear they are on Subutex then they maybe more wary about taking them on. They are not experienced with it, and they don't get paid to prescribe it. They get paid to prescribe methadone, but they don't get paid to prescribe Subutex, so there will be less incentive for a GP to take on a drug user and to have to see them as much as they will for methadone but they don't get a penny for it" (member of Health Team).
Partnership working: strategic level
6.24 Glasgow is comparatively well-served by services for women, and many of these are co-ordinated through the Social Inclusion Partnerships ( SIP), particularly Routes Out of Prostitution and Homelessness. Respondents who were involved with the Routes Out Social Inclusion Partnership ( SIP) 44 tended to be well informed about 218 and stressed the importance of services working together across Glasgow to provide the best service for women. This SIP consists of a Board, Working Groups, a support team which helps direct strategy and service the Board, an Intervention Team, crisis service and a 'network'. Key representatives from a range of statutory and voluntary agencies have been involved in the Partnership's Board and Working Groups (MacKay et al, 2004).
6.25 Respondents from the SIP believed that women accessing 218 were likely to be the same group of women for whom the SIP was working. While they were impressed with the range of services available through 218, concern was expressed that more dialogue in the early stages of the project's development would have been beneficial. Given the network of services available through the SIP in the broader community, it was viewed as important that 218 was aware of these provisions to help women move on from the service and to reintegrate them into the broader community. Members of the SIP were keen to see the establishment of some form of structure which would chart how 218 linked in with other services and vice versa and had developed an overview of this ( see Annex Two).
6.26 Developments had taken place through joint work and ongoing contact between workers in 218, the Routes Out Intervention Team and Base 75. However, there was a view that better communication should be established at more senior management levels. It had been anticipated that the SIP would have a representative on the 218 Monitoring Group, but this had not occurred to date. Given that some of the agencies involved had been part of the planning and commissioning stage, they had expected to be involved with the Monitoring/Steering group and were very disappointed when this did not happen.
6.27 One view expressed was that there was a distinct lack of joined-up planning at senior levels (particularly in relation to health). Similarly, a number of services providing support to women at the time that 218 was being developed perceived a lack of consultation in the planning stages. Indeed, a number of respondents were critical of the way in which 218 had been set up: "It was set up without taking the wider context into account and without putting any kind of requirement on the service to fit with that wider context"(member of SIP).
6.28 With the delay in establishing a Monitoring Group for 218, combined with a number of structural changes within Glasgow City Council, concerns were expressed that 218 wasn't linking into the strategic planning for the development of other services in Glasgow 45: "It's quite difficult to assess whether it has maximised the opportunities that exist in the city to link with a whole range of activities to support women and to help them to exit prostitution…" (member of SIP).
6.29 The delay in establishing the Monitoring Group was also cited as a reason agreed protocols may sometimes fail to be communicated or enforced. Equally, a small number of key agencies that had been invited to take part failed to attend when the group was eventually set up. This potentially limits the effectiveness such a group can have in practice. A prime example of this arose when police entered the residential unit at 218 to arrest a client - something 218 had agreed with senior officials would not take place. A similar problem arose when arrangements had been made for a client to enter the residential unit at 218 upon release from prison, "… and she walked out the gates and got arrested for an outstanding offence" (residential staff member). One member of staff commented:
"If they went up the road [received a custodial sentence], it would set them back like a whole year, not just a couple of months, it would be away back to the very beginning, and then when they come back out they would be back at the very start".
Helping Women to Move On
6.30 Despite the range of services that exist in Glasgow, agency respondents indicated that there continued to be areas where women were likely to experience difficulties in accessing services, particularly when they were due to move on from 218. Women were often viewed as not fitting the criteria for services while accommodation, for example, could be limited and was not always appropriate for individual women. Agencies indicated that more resources were needed to make a significant improvement for women. These included the availability of, and access to, single sex rehabilitation (for women with or without children) 46; access to counselling services; resources for those who have experienced child sexual abuse/incest/severe childhood neglect; better and more alcohol services; crèche facilities at court; greater number of Drug Treatment and Testing Orders and Drug Court referrals for women; and consistency of services, ensuring that follow-on support is available and appropriate to women's ongoing support needs. This required a co-ordinated approach between statutory and voluntary sector services.
6.31 In order to address the women's ongoing needs, inter-agency work was seen as crucial for many respondents. The 218 project was viewed as an opportunity to develop this work, particularly if agencies could be linked into the provision of longer term support for individual women. Twenty-one women interviewed indicated that they had been referred to services outside 218 (for counselling, training or other support). Given the multiple problems many women in contact with the criminal justice system faced (health, housing, childcare, legal, addiction, etc.) a multi-agency approach was viewed as a positive way forward. This was also considered a useful way of avoiding duplication of services and providing a 'package' of services for the client. Early liaison and assessment was viewed as providing a potential for effective joint working and consequently a larger range of options for individual women, and the courts.
6.32 Other respondents pointed out the importance of linking women into mainstream services and the need to monitor how effectively the 218 project is able to do this. It was noted that ensuring a smooth transition between services requires a significant degree of co-ordination and co-operation in addition to awareness of broader issues around social equality and inclusion. Linking women with mainstream services unaccustomed to dealing with a more chaotic client group was often a problem:
"Now the nature of the women that we work with, they are fairly chaotic, and just because they move in here doesn't mean that the chaos goes, some elements, the actual chaotic of their being is still there. So they cancel appointments at the last minute or they don't want to go because they feel bad or, you know, they are struggling with their medication so they don't want to do this, and the [service] was finding that quite difficult to deal with." (residential staff member)
6.33 The lack of coherent 'joined-up' provision was perceived as particularly problematic and limited the effectiveness of linking into other services when women were 'moving on' from 218. The lack of any overall co-ordination in this respect was commented upon. This includes the situation in which clients who were arrested and taken to prison were not always continued on the regime for medication arranged in her care plan: "There was no consideration taken of the work that she had done [while at 218] either" (residential staff member). The complexities of funding arrangements for accessing after-care resources was seen as very problematic, and respondents identified a need for strategic oversight in this area 47.
6.34 A number of agencies viewed developing services in the longer term as crucial. They noted that 'joined-up' services are required to address the complex problems a woman may face, but also that supports are needed within the community to ensure ongoing engagement with a woman when her statutory involvement with services may have ended.
6.35 218 staff had expressed some concerns regarding the resources available for women to move on to outside 218. These were mainly in terms of finding appropriate housing and, in turn, finding a GP willing to offer the prescribing services they needed in that area.
6.36 Housing was by far the most pressing issue 48; local authority flats were available, but not necessarily those that were safe for vulnerable clients recovering from addiction:
"Housing is a particular problem, you have to consider the quality and the surrounding environment. Housing may be available, but what good will it do to spend £5000 on treatment for a woman, then put her in a flat surrounded by 25 drug users?" (Addiction worker).
6.37 Equally, some housing services were perceived as having difficulty with clients referred to them:
"…the [housing service] can sometimes be - I don't know the word, how you would term it - but surprisingly for people who work with the homeless and with people who've got addictions and a whole load of mental health issues, they are not particularly tolerant. So if people get referred down to the [housing service] sometimes they don't get the treatment they deserve or they get treatment that they don't deserve." (Residential staff member)
6.38 Staff at 218 also noted problems with women who were 'intentionally homeless':
"Well some people say if they live in a certain area or that…maybe not violence that they have reported to the police, or grief, or harassment, or something, if they leave that place, they are then intentionally homeless. The council won't look at them for a year…" (Day programme staff member)
6.39 Considering the domestic circumstances of many of the clients at 218 in terms of domestic abuse and partners or family members who also use drugs, the 'intentional homelessness' of those who want to leave that situation is a very real concern.
6.40 Despite these difficulties, 16 of the women interviewed, noted that they had been able to access stable accommodation with the support of workers at 218, when previously their accommodation had been unstable
Summary
6.41 Awareness of 218 initially seemed limited amongst agencies that were expected to show a keen interest in the programmes there. This improved over time, and 218 made active attempts to inform key agencies and services of their work. The 218 Project was an ambitious attempt to link services across a number of areas. For the most part they had received full co-operation in doing so, though an important barrier thus far was the lack of an inter-agency monitoring group to assist 218 in its links with others. Such a group, though planned, only came into existence after a year and a half of operations at 218 and had yet to develop an active role. The delay in establishing the Monitoring Group was cited as a reason agreed protocols sometimes failed to be communicated or enforced. Equally, a small, number of key agencies that had been invited to take part failed to attend when the group was eventually set up, while representatives from other agencies felt excluded from this process. This potentially limits the effectiveness such a group can have in practice.
6.42 Evidence from the interviews suggests that the initial planning stages for 218 generally could have been handled more effectively. A number of services providing support to women when 218 was being developed perceived a lack of consultation in the planning stages, and a distinct lack of joined-up planning at senior levels (particularly in relation to health) was evident throughout the research. This meant that, while members of the staff teams worked well together at an individual level, staff structures and roles as well as lines of responsibility and accountability were often unclear.
6.43 Links with services such as social work, women's projects, community education, and supported accommodation to enable clients to move on from 218 were also generally good. More consistent problems existed in terms of finding suitable housing for clients and to some (often related) extent, finding community-based prescriptions and addiction workers. Problems were not due to lack of good will or lack of resources so much as ensuring appropriate provision was available where and when it was needed, often at fairly short notice. Such problems can have an impact on the outcome of services delivered at 218.
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