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CHAPTER SEVEN: OUTCOMES AND EFFECTIVENESS

7.1 Perhaps the greatest challenge for this evaluation is how to measure the effectiveness of a project like 218. The Centre aims to provide a realistic and workable alternative to imprisonment for female offenders aged 18 years of age or over who have involvement in the criminal justice system and who may have a substance misuse problem. However the nature of the service provided and the way resources are used goes well beyond most traditional service provision. Tackling the 'root causes' of women's offending behaviour involves addressing a wide range of issues with a complex array of consequences; 218 may be funded solely by the Justice Department, but its potential benefits - not least in terms of health, housing, preparation for employment, and longer-term benefits to children - are clearly much wider.

7.2 All respondents viewed 218 as being exceptionally good at engaging with women, and workers (within 218 and external service providers) gave anecdotal evidence of women they had encountered in other community settings who continually failed to engage with services, but who had come to 218, appeared to be making good progress, and who were attending regularly. The benefits of such engagement are likely to go well beyond the potential savings for the criminal justice system, and previous research has noted the importance of service retention in reducing reconviction rates (Hough et al, 2003; McIvor, 2004). This chapter addresses the outcomes that can be identified and highlights some of the difficulties in measuring these outcomes.

The impact of 218 on sentencing patterns

7.3 In order to assess the effectiveness of 218, particularly in relation to reducing the use of custody for women, we examined a range of statistical data. Baseline data obtained prior to the opening of 218 provided an indication of the outcomes of Social Enquiry Reports ( SERs) on women by Glasgow City Council Social Work Department and by local authorities across Scotland as a whole; figures on women appearing with charges in Glasgow courts; and prison receptions from Glasgow courts.

7.4 Given the time-scale of this evaluation it has not been possible to obtain data over a period of sufficient length to indicate any changes in sentencing practices or prison receptions for women in Glasgow that could be attributed directly to the operation of 218. It is also noteworthy that other services have developed or been consolidated during this period, notably the co-ordinated services of the Routes Out SIP. The operation of other services may have had an impact on women and their dealings with the criminal justice system in Glasgow (particularly in terms of SER outcomes, sentencing patterns and custodial rates). Similarly, developments such as the introduction of Mandatory Supervised Attendance Orders may have had some impact on female prison receptions for fine default, though practitioners in this area have suggested that this figure is likely to be low.

7.5 Data available from Glasgow courts was collated up to 2003 with limited provisional data available for 2004. Information on the outcomes of SERs was available up to 31 March 2004. As 218 only began to accept referrals in December 2003, this does not allow a sufficiently long period to show any effect on the figures or outcomes. SER data prior to this were problematic in that they included some degree of 'double-counting' where requests for reports rather than individuals were monitored, so breach reports, for example, could not be identified separately. According to council staff, the implementation of a new database by Glasgow City Council in 2004 has improved this situation. However, they appear to have ongoing difficulties in extracting the data, ranging from data quality (recording practice) to issues related to the operation of the databases. Researchers at Glasgow City Council are currently examining this situation, which appears to be both a result of data collection and software problems. Similarly, while information on prison receptions is available, the limited time-frame for the evaluation makes any statistical analysis partial and inconclusive. A follow-up study which enables accurate examination and analysis of sentencing practice, court disposals ( SER analysis) and prison receptions would therefore be appropriate.

7.6 Qualitative data from respondents do, however, provide some indication of the impact that 218 had on women who accessed the service and agencies which had some experience of referring women to the service.

Cost Analysis

7.7 This element of the research identifies the unit costs of 218 and compares these with alternative outcomes for women who offend. A distinction is made between start-up and recurrent costs, with the latter providing the basis for the calculation of unit costs.

7.8 218 provided the following information about expenditure. Since cost data were incomplete for the latest financial year (2005-6), and since the first year of project funding included non-recurrent start-up costs, we have concentrated on expenditure during the financial year 2004-5. Financial data provided by 218 and Glasgow City Council are summarised in Table 7.1.

Table 7.1: 218 costs

7.9 One of the problems in determining unit costs is that project workers did not consistently record the dates women went on and off programmes. Second, we do not know how active participation was: a client could be in every day for several months or may only show up once or twice in that time before being taken off the programme. Third, in the absence of accurate data about the amounts of time spent in the residential and non-residential parts of the programme, it is not possible to separate out residential and non-residential unit costs. The unit costs calculated, therefore, are average programme costs rather than costs for residential or non-residential engagement.

7.10 With these caveats in mind, across the period from April 2004 - March 2005, a total of 143 women engaged with the 218 project ⁵². Most of these clients (79) engaged only once while 35 engaged twice, 8 engaged 3 times and 2 engaged 4 and 6 times respectively. The women who were referred to 218 had an average of 1.4 engagements with the project. This results in a unit cost per engagement of £7,701. Data from project records on the length of time spent at the project was missing or incomplete in just over half of the 143 cases (often because women were still engaged with the project). In the 70 cases for which complete information was available, the average length of stay was 2.6 months, with a range from one day to 8.5 months (though information about programme duration was often missing in the case of longer-term clients) ⁵³. In FY 2004-5, therefore, 218 provided 372 programme months to the 143 women who engaged with 218 at a cost of £4,144 per programme month or £1,010 per week. The cost per referral to 218 (including those who did not take up the service) was £3,127 (based on 493 referrals involving 343 different women).

7.11 Clearly, day programme costs will be considerably lower than participation in the residential programme. Further cost data made available by Turning Point indicated that in 2004-5, the day service accounted for approximately 42% of the budget and the residential services (detox and supported accommodation) accounted for approximately 58%. This results in a total day service cost of £647,500 and a total residential cost of £894,167. Of the 143 women who engaged with 218, 30 participated only in the residential programme, 55 participated only in the day programme, and 58 participated in both. Thus the mean day service cost was £5,731 ⁵⁴ and the mean residential cost was £10,161 ⁵⁵. ⁵⁶

Costs of treatment and alternative disposals

7.12 While evidence indicates that good quality treatment can deliver long-term savings in a number of areas, initial costs are significant. For example, Godfrey et al. (2004) estimated that the total costs for a basic outpatient methadone-prescribing service were around £98 per person per week, rising to £1,112 per week for individuals in residential rehabilitation. At an average cost of £10,161 per stay, the costs of the residential component were equivalent to just over 9 weeks of residential rehabilitation.

7.13 The costs of the potential alternative outcomes for women had they not been referred to 218 can be derived from published data on the costs of the criminal justice system. In 2003-4 the average cost of a probation order was £1,173 and of a community service order was £1,499. Given the range of support made available to clients through access to 218 (in relation to health, welfare and 'coping' skills), it is important to acknowledge the considerable benefits associated with this intervention as opposed to other community disposals and, significantly, to custodial sentences. However, since the 218 project is intended to serve as an alternative to imprisonment (including a custodial remand), comparison with the costs of imprisonment are more relevant.

7.14 In 2003-4 the cost of 6 months in prison was £16,622 (Scottish Executive, 2005), and the average annual cost per prison place for 2005-6 is expected to be £35,000. This excludes capital charges, exceptional compensation claims and the cost of the Escort Contract (Scottish Prison Service, 2005). At £7,701, the average cost of an engagement at 218 would be similar to the cost of around 2.6 months in prison ⁵⁷ . The impacts of the resources available at 218 are likely to be much more significant in their longer-term benefits than those accessed during a short-term prison sentence. The average cost of a referral (at £3,127) would be equivalent to just over one month in prison ⁵⁸ . Note, however, that the per diem costs of short prison sentences are likely to be higher than the published cost of 6 months in prison because the costs associated with the processing of prison admissions are spread over a smaller number of days. It is also likely that the costs of imprisoning women are higher than the costs of imprisoning men because the latter will be associated with greater economies of scale.

7.15 While engaging women with services is likely to deliver a range of economic savings, particularly in terms of reduced drug use and offending behaviour, retaining individuals in treatment is likely to increase these benefits further (Hough et al, 2003; McIvor, 2004). One of the very noticeable issues in relation to 218 was the ability of the service to retain clients and to develop relationships that clearly encouraged women to maintain contact on an ongoing basis.

7.16 A study by Simoens et al (2002: 14) highlights the complexity of attempting to measure treatment and economic effectiveness in interventions with opiate dependent drug users. They point out, however: "Although there was no strong evidence to support the cost-effectiveness of any particular intervention, cost-benefit studies of treatment pointed towards positive net benefits from intervention."

Substance misuse

7.17 The majority of women entering services at 218 said they had been using heroin or heroin had been an issue for them in the past. This was the case for 84% (n=120) women of those who engaged with services in the study period. Other drug use included diazepam (100 women or 70%), alcohol (74 women or 52%), cannabis (85 women or 59%), and cocaine or crack cocaine (67 women or 47%). In addition 57% (82 women) had used other substances such as temazepam, illegal methadone, or solvents. For the 84 clients for whom we were able to record daily cost of substance use, based on their own estimates at their initial assessment, daily cost ranged from £5 - £400. Less expensive use was for people who used alcohol rather than costlier drugs. Average cost per day for clients was £61, with a lower median of £35 per day. ⁵⁹ A further 7 women said they were already stable when they engaged with support services at 218.

7.18 One can speculate to some degree about the reduction in more direct costs in terms of drug use. Chapter Four outlined the daily cost of drug use for clients before they entered 218. Each of these clients engaged with the programme at 218; if they reduced or stopped their use of drugs and alcohol in the time they were engaged in services and stabilised on methadone, even for a short period, the reductions in costs would be substantial. For example, the client who said she spent £400 per day on drugs said she funded this entirely through theft. If this client were able to stabilise even for a week, this is an immediate reduction of £2,800 in acquisitive crimes, not to mention costs involved in policing, arrest, prosecution, court costs, legal aid, and indirect costs to victims. Even reduction in the smaller average cost of substance misuse (£61 per day) would result in immediate cost savings of £427 per week. Reduction in the use of alcohol is also likely to have substantial cost benefits: although the cost of alcohol itself is low compared to other drugs, alcohol is more often linked to more serious offending such as violence (Scottish Executive, 2002c). Of the women interviewed, 52 (83%) said their drug use had decreased or stopped (usually the latter) since coming to 218.

7.19 Pagan (2004) found that 87% of the clients she canvassed committed theft to pay for their drug use, while 50% engaged in prostitution and 13% paid for their own use through drug dealing. With up to 74 clients engaged at 218 on a given day, one can surmise the cost benefits would be substantial, even if calculating exact figures is problematic.

Perceptions of an alternative to custody

7.20 Procurators Fiscal were clear that while 218 had the potential to stop women going to prison, they used it as a diversion from prosecution rather than as a diversion from custody: "If somebody is likely to be a custody, then they are going to custody". Procurators Fiscal may take the decision to divert people from prosecution, but ultimately only Sheriffs or Magistrates have the power to divert people from custody once the decision to prosecute has been taken. However, diverting women to 218 was viewed as a preventative measure that could avoid the use of custody in the longer term: "in that sense it is an alternative to custody, but not as an alternative to a custody court or short-term custody remand. It actually is a diversion to give them a chance to get away from the court system altogether. To actually break the link. That's the way I see it" (criminal justice professional).

7.21 In the initial stages of the development of 218, some workers noted that courts did not seem to be sending women to 218 instead of sending them to prison. There was a general view that initially, the service was taking women who were unlikely to have been facing custody at the point of admission to the service. The impression was that the service was used more in conjunction with penalties such as probation and community service. In saying this, the belief was that women who came to 218 were those who would otherwise have ended up in custody at some point, even if not immediately (see Hedderman, 2004).

7.22 Since 218 has become more embedded as a service, the expectation is that prosecutors and sentencers will have the confidence to start referring more serious offenders and using 218 as a direct alternative to custody. As 218 developed credibility with sentencers and court officials it appeared likely that the service would be used increasingly in this way:

"The availability of supported accommodation and specifically accommodation with in-built support is a valuable resource and is something I would look at carefully to divert someone away from the custodial route." (Criminal justice professional)

7.23 Staff at 218 believed it was an important resource to the courts in this sense:

" … I think it's a positive alternative to custody, because I think for the client group that we work with, giving them custodial sentences is not addressing the issue, so it's a waste of time, because the issue is drug use, and unless you take that out of the equation, then you're going to continue with the custodial sentences, because it's not a deterrent on the whole." (Residential staff member)

As a voluntary disposal, however, 218 was not designed as a secure facility:

"The doors are locked to keep people out, not to keep people in, and anyone who wants to leave has to say 'I want to leave', and the door will be unlocked, and they can go whenever they want." (Residential staff member)

7.24 A further concern from both staff and clients was whether 218 should be used as a direct alternative to custody (see also below):

"… I think a lot of the women who don't want to be here, or just see it as an easier option than maybe going up to Cornton Vale, don't do as well. I think their head is in the wrong place, and I think you still put in the same effort and the same work, and you are not maybe getting such a good end result, but that's not to say these women don't deserve that opportunity as well. It's just that maybe they are not ready to look at that." (Day programme staff member)

Since the Commissioning Group for 218 specified that eligible clients were those "assessed as particularly vulnerable to custody or re-offending" (see Chapter Four) rather than those at immediate risk of custody, emphasis on the use of 218 as a direct alternative should perhaps be less pronounced as a measure of effectiveness.

Perceptions of Cost-Effectiveness

7.25 Respondents were asked to comment on their views of the service in terms of cost-effectiveness. Very few staff members at 218 felt able to comment on this issue, though most seemed to agree that the service was likely to provide cost-savings in the long term if the support they offered successfully kept women out of the criminal justice system:

"I think if you're taking the long term view it does work, well, my impression is that it works better than sending them to prison, and I think from that point of view it must be cost effective, because even though it's probably ridiculously expensive when you look at it for how much you're spending on an individual and how many staff input you have, if it makes a difference for one or two, then that has to be beneficial, because you're not going to solve the problem en-masse, you're not going to be able to take away addiction, you know. You have to start somewhere, and I think it's worth the cost." (Residential staff member)

7.26 While acknowledging that the project was still new, staff respondents were optimistic that it would have a positive long-term impact on women who genuinely engaged with the project, both in terms of addiction and offending. In the short term, "if they're in here, they can't be out stealing or… you know, prostituting or breaking into people's houses…" (residential staff member). In the longer term, any reduction in offending was viewed as saving money that would otherwise be spent on processing people through the courts, Legal Aid, arrest and imprisonment, and the costs of crime and victimisation in general. The difficulty was that other costs and cost-savings were not always quantifiable:

"… regarding the cost effectiveness, … it's a 24/7 service, we've got health input … I know we need to again be accountable for the big aim of reducing the number of women going to Cornton Vale or remand and different things like that, but on a day to day basis we can see the impact on somebody's life, and that's what I think … we're actually doing more work than we actually are showing people …" (Day programme staff member)

7.27 Equally, stakeholders viewed 218 as being cost-effective in the longer term, particularly in terms of tackling the causal rather than secondary issues associated with women's drug use and offending behaviour. But it was also noted that government thinking tended to be short-term and this had to be counter-balanced for a project of this complexity.

7.28 Taken as a whole, however, there was a perception that costs had to be measured widely, and while the service may be perceived as operationally expensive, the alternative in terms of continued offending and drug use would also prove costly in the long-term. As one social worker noted:

"Well, anything good costs, doesn't it? But then bad things cost too, drug addiction costs, I reckon all the services - the police, health service, childcare services, costs lives. ...I mean I reckon if you tackle the difficulties that people have with addiction then it must be cost effective, if you get even so many people not using the other services then surely it must balance up… Addiction costs the community big style so 218, I would probably say we need more services like that".

7.29 Criminal justice professionals, in particular, were keen to indicate that reductions in offending ( e.g. for shoplifting) on a weekly basis soon multiplied into considerable savings on a yearly basis. Therefore some form of intervention was necessary and would inevitably be costly: "Give them a chance, take them away from bad influences and occupy their time, it will take a load of resources, it is expensive. I think, generally speaking, without looking at the figures, it's money well spent" (Criminal justice professional).

The benefits of 218

7.30 It should be borne in mind that while attention is often focused on the costs of interventions and their alternatives, the reported value of a service such as 218 by the individual women is considerable but practically impossible to quantify. This evaluation has, however, given some indications of the impact of 218 on women's lives and general well-being as referred to in interviews with 218 staff, workers from other agencies and service-users. Other studies have noted the omission of most cost analyses to measure the improvements in the lives of drug users (Godfrey et al., 2004; McIvor et al., forthcoming). Respondents in this evaluation of 218 commented frequently on the improvements they had witnessed and/or experienced in term of physical health, appearance and ability to 'cope'. These outcomes are crucial and worthy of recognition, although they cannot be measured in terms of monetary value.

Potential for reductions in offending

7.31 Findings from other research suggest that the programmes and services provided by 218 are likely to contribute to reductions in offending in the longer term. Godfrey et al. (2004) note in their study that clear economic benefits to treating drug misusers in England could be identified. These economic benefits were largely accounted for by reduced crime and victim costs of crime.

7.32 Drug-related crime in Scotland is likely to be significant. The Scottish Executive's Drugs Action Plan, Tackling Drugs in Scotland: Protecting our Future (Scottish Executive, 2000c) notes that 8,500 heroin injectors in Glasgow may be responsible for drug-related thefts estimated at a cost of £200 million.

7.33 The National Treatment Outcome Research Study ( NTORS 1996) analysed treatment outcomes for a number of clients who were either in residential or community settings. Although there were recognised difficulties with this data, the study concluded that for every pound spent on drug misuse treatment, there was a return of more than £3 in terms of costs savings associated with lower levels of victim costs of crime and reduced demands upon the criminal justice system. The study pointed out that the total costs savings to society could be even greater than this. This provides a clear example of marginal social benefit exceeding marginal social cost, and indicates that social welfare would be increased by an increasing in expenditure on drug misuse treatment.

7.34 Brand and Price (2000: 38) estimate the average cost per theft (under the category of 'other' which includes theft from the person but not from a shop) to be, on average, £340 per theft. Theft from a shop was estimated to cost around £100 for each incident ( ibid.: 46), while the average cost per incident of criminal damage offences were £510 for damage against individuals and households and £890 per incident of commercial and public sector criminal damage. No estimated costs were available for fraud and forgery or for drug possession and supply offences due to the complexity of the offence and lack of any reliable information with which to assess individual incidents.

Measuring Effectiveness

7.35 Statistical data were often a poor measure of the individual changes a woman made through her attendance at 218. While reconviction data, for example, is a useful measurement of changes in behaviour, the time-frame of this study meant that such data do not provide any conclusive results at this stage.

7.36 In 2008 complete data could be obtained for 2005 and 2006 and provisional for 2007 which would generate a full one year follow up period and a provisional 2 year follow up for all of the women. ⁶⁰ It would also be possible to look at patterns of offending behaviour before and after referral to 218 and to compare this among those who engaged with the service and those who did not, with caveats provided. Offending behaviour could be compared for the 1 or 2 years before 218 referral, with 1 or 2 years after 218 referral.

7.37 Identifying a comparison group would be useful, but there are likely to be challenges in identifying a sufficiently similar group of clients. 218 clients are not all referred by direct court order: many are referred by other agencies such as social work services, and procurators fiscal. In the majority of cases we therefore do not know the offence which led to their 218 referral. By determining what offence the 218 women had committed and narrowing down the comparison sentences we wanted to consider ( e.g. only those cases where custodial/community sentences are given), then results for a comparator group would be more useful. However, another difficulty might be that, with increasing use of 218, there must be some reason why women in Glasgow are not being referred there, and to compare these with the 218 women might not be sensible. It might be more useful to look at another urban area e.g. Dundee or Aberdeen and compare with women there who have no access to such a service.

7.38 While evidencing the impact of a service such as 218 is very difficult, respondents were clear that its impact was significant:

"I don't know how you would show it, but just seeing the graduations and knowing that there are people out there going to college, and they are clean and living a crime free life - if there is like 10 of them out there, then it's a success. If you think about the money and the misery that their lives…their previous lives were, and now they are not like that…. And because of this place, it's amazing." (Day programme staff member)

7.39 Staff respondents believed most of the measures were 'soft' measures such as the visible changes in the women who engaged with the services there, participation in 'normal' activities, and basic self-care. Some measures were more quantifiable, such as completions of the various programmes on offer, decreases in drug use and/or the levels of medication prescribed, cessation or reduction in offending, registration with a GP, and placements in stable accommodation. The fact that many of the outcomes for 218 were not immediate criminal justice outcomes were also of concern since funding for the project depends entirely upon criminal justice sources. The frustration was that limiting measures to quantifiable criminal justice outcomes missed the potential contribution 218 made to longer-term crime prevention:

"I think in some respects some people think, OK, criminal justice is fantastic, and it is, but if you don't look at a woman's problems or issues as a whole like the housing, like the medication, like the health stuff …you're never going to get her right out the criminal justice system, you know. That's really important. So for me it's … that she was in hostel accommodation and by the end of SAFE she's got her own tenancy. Fantastic. But we need to prove that we're doing that …." (Day programme staff member)

7.40 Staff noted that assessments at entry and exit now attempted to measure changes in the clients on measures such as psychological well-being. Recognising the chaos that existed for many of the services' clients in their daily lives resulted in broad definitions of what constituted an achievement. As one worker noted, in order to gauge success: "you have to measure it in different ways and I think a lot of it, it depends on the person and for one person it might be that they did have a safe place to be for a little while…" (Housing project worker).

7.41 A member of staff at 218 described it like this:

"Success I think in this field in general is very difficult to measure. I don't think you can have a set line and say that… anybody that jumps above that line is successful and anybody that doesn't, isn't. Success for any one person, a big success for one person might be the fact that they haven't actually stuck a needle in their arm for 24 hours. That might be an achievement; that might be a success for someone... Someone whose been on methadone for 10 years and comes in and detoxes off their methadone and goes home and gets a re-hab place and makes it through re-hab, that might be a success, but there's not a straight line to measure it by. It's very individual." (Residential staff member)

7.42 Progress for this client group was something that often had to be measured in small steps:

"… I have been on the day program before, but I have always been that pissed that I couldn't come in, so I am not now, so like this week I got told 'try and come in every single day at 11 o'clock', and I have done that. Whereas, I would never have done that, never, there would have been excuses flung everywhere…. And I have done it this week, every single day at 11 o'clock."

(interviewer): "That's a really big deal for you to be able to do that."

"Aye. And not coming in drunk, trying to just get myself sorted out…." (Exit 40)

Clients noted that evidence of the effectiveness of 218 largely constituted improvements in their physical appearance, health, and well-being. Of the women interviewed, 42 (67%) gave specific examples of direct improvements in their mental/physical health and general wellbeing as a result of attending 218. These improvements included improvements in physical well-being and self-care (ie they were now eating), improved mental health and a cessation in self-harm or suicide attempts). Such evidence of effectiveness was in abundance, although often anecdotal: "… 218 saved my life. It really saved my life, because I don't think I would be here anymore…" (Exit 24).

7.43 Staff reported that incidents of self-harm and attempted suicide were much lower than they had anticipated. However, 218 had no formal system of recording such incidents during this research other than recording them in individual case files. Unlike Prison Service establishments, 218 was not required to file official 'incident report' forms on such occasions, though staff are now looking at developing a more formal means of collation. Incidents of self-harm and attempted suicide were managed very differently at 218 than they were in establishments such as prisons: self-harm was recognised as a coping technique, and project workers and community psychiatric nurses worked with women on behavioural harm reduction techniques ⁶¹ rather than attempting to create an artificially risk-free environment.

7.44 As Zander et al. (2005) have indicated, individuals need to engage with services that recognise their personal and social circumstances in order to prevent drug-related deaths. This is something that 218 is perceived as doing exceptionally well:

"I feel like it has [worked]…. I couldn't have asked for more help, they have done everything I came in and asked them. I wanted to put more weight on, I have done it, I wanted my tenancy, I have got it, I wanted to be stable, I am." (Exit 20)

7.45 The examples continue. One woman said she had no memory of entering a shop with money in her pocket for conventional purchases such as magazines or sweets before (she had usually only entered shops to shoplift and used her money for drugs), and that this was a very good feeling. A previously chaotic user of heroin and cocaine had stabilised on methadone, reduced to 20ml at the time of interview. Others said they had purchased clothes for themselves for the first time, had left abusive relationships, or had stopped working the streets.

7.46 When asked whether 218 had addressed their needs, clients were universally positive:

"Everything as required… has been there." (Exit 47)

However, clients seemed realistic about their futures:

"… if you really think about it, people can be doing whatever they're doing for years and years in their life and it really doesn't take 3 months just to fix it all out." (Exit 7)

"218 has saved my life and I am grateful. I have got my wain back, but like I was saying I have still got a lot of issues when I get out of here. It's not going to be [easy]…it's a day at a time." (Exit 41)

Staff too tried to be fairly realistic about what they could achieve:

"At the moment I think that maybe we are trying to be all things to all women, and I don't think that we can be. Currently I think that's how we are operating, and I think that's just about the fact that the staff care, the staff want to try and do stuff, and sometimes you get caught up in that 'do' kind of philosophy, you know, 'I have to do something', when maybe the best thing is sometimes not to do something." (Residential staff member)

7.47 Like the clients and staff, representatives from external agencies emphasised that dealing with the root causes of offending and addiction is a long-term process and was much more effective than imprisoning someone:

"I think it does seem to be accepted that the first thing to go is your offending, and then we will try and work on your drug use" (health team).

"I think it [success] would be a reduction in offending, an improvement in their lives, improvement in their health and maybe going into the mainstream and living normal lives. (...) I don't think you can look at it in the short term and say, 'that's great, then turn around and ten minutes later it could all change again" (criminal justice professional).

7.48 218 was seen as particularly appropriate, given the opportunities it made available for women who were committing petty offences and who were likely to face custody as a result of accumulated, rather than serious, offending. Gelsthorpe and Morris (2002), for instance, have suggested that it was the increasing use of imprisonment for petty persistent female offenders that helped explain the major increases in the number of women sent to prison in England and Wales since the early 1990s (see also Tchaikovsky, 2000; Home Office, 2004b).

7.49 Interviewees acknowledged that a woman's receptiveness to 218 often depended on her current situation and her ability to utilise the services on offer. Nevertheless 218 was seen to offer something unique that women could potentially use to make significant changes in their lives:

"218 opens doors for people, but at the end of the day, they have to want to change. It gives stability to women whose lives are totally chaotic" (criminal justice respondent).

"If women aren't coming back into the criminal justice system, not going back to jail, the courts etc that is success. Many women are very damaged when they get to the stage of being on orders. I'm not sure you can fix that, or it is fixable, so it is about helping people develop coping skills, get a normal life, be as stable as they can be" (criminal justice respondent).

7.50 Towards the end of this research, Turning Point Scotland conducted an internal review of services at 218 using the standardised IMPAQT scale, developed in collaboration with Turning Point England and referenced to National Care Standards, the EFQM Excellence Model, and Investors in People. This review also found the biggest problem at 218 to be the lack of meaningful measurements of its activities and outcomes beyond anecdotal evidence and feedback. Like our research, however, a survey of service users revealed overwhelmingly positive responses of 100% agreement that staff listened to them and respected them; 100% belief from clients in the day programme that they were fully involved in their care plan and that 218 had helped them reach their goals; and 75% agreement from clients in the residential unit that they felt better since engaging in services at 218.

7.51 Respondents acknowledged that creative measurements were required to address the effectiveness of the unique impact of a service such as 218, and the gender dimensions were also acknowledged as crucial in examining successful outcomes: "the criminal justice system is so male, and so structured. If you impose these outcome measures on women, they don't fit" (criminal justice professional).

"I guess when you look at methadone or look at drug misuse treatment at all, it's very, very difficult to measure and you're looking at reduced morbidity and reduced mortality and retention rates and you know, surely it's effective if that girl was in complete chaos and she came in for two weeks and survived that and felt better, but you can't measure that". (health provider)

7.52 Measuring success can be done, to some extent, by looking at different aspects of a woman's life and charting any direct improvement, but this requires clear systems for monitoring change in terms of reductions in drug and alcohol use, offending behaviour and developing the ability to form healthy relationships:

"If nothing else the offending has minimised to a large degree as has their substance use. They are predominantly stable and other aspects of their life, which has an impact on the family, so from what they say, it's got an effect certainly for the individual and for the immediate family. From our point of view, yeah, we can show it as a definite sort of service that has been worthwhile and does work." (health team member)

7.53 Not all clients will persevere in a drug and crime-free life after leaving 218, nor will all even manage to do so before their contact ends. This does not however mean that a service such as 218 is not worthwhile:

"… we become complacent as workers, because we think we haven't achieved that much, but I think in respect of what these clients have been through, they have achieved a huge amount." (Day programme staff member)

Relapse

7.54 As in most areas of drug work, relapse is viewed as a regular occurrence and indeed forms a part of the recovery process for some individuals. Because of this, workers indicated relapse had to be considered when measuring success:

"There's some clients who I see who do all the right things, go through the motions then go right back out into their old ways, but the fact is, and for a few of them, I've noticed when they come back, they're not right back to square one...they have learned some skills even though they chose not to use them...every time they come back they are a bit stronger and a bit more knowledgeable and they are moving their lifestyle on. I know it's not to say 'yes, we are always here' so to speak, but I think if they fall off the track they can come back here if they want to re-engage with us." (Health team member)

7.55 As noted above in measuring effectiveness of a service like 218, staff were very clear that progress must often be made in small steps, and that relapse is likely to be part of this. Importantly, 'relapse' did not necessarily equate with 'failure' and could provide the opportunity for clients to develop coping mechanisms in the longer term. A number of clients in the 'intensive' sample we interviewed had been to 218 previously. This meant we were able to explore why people relapse. Each case was slightly different, but general themes were evident. Personal crises often triggered relapse:

"… I mean … everybody's got the best intentions, going to do this and going to do that, but all it takes is for one thing to knock you off, and you start taking a nosedive. [I managed to be stable on methadone for 2 and a half years, but]… after my brother died … things started going wrong. So all it takes is just one thing to knock you off balance." (Exit 45)

Others believed they had not been ready to stop their drug use, while others outlined problems they had experienced moving on to community-based services and supports:

"I stayed clean for 5 months, and then I got struck off my methadone. I was collecting my script, and they didn't give me it…. So I started using again…." (Exit 20)

7.56 Interestingly none of the women interviewed blamed 218 for their relapse, nor did they believe the staff at 218 could have done anything to prevent it or to support them more than they had. A number of clients commented that relapse was to some degree a learning experience - that perhaps they "needed to fall to get back up again" (Follow-Up 7) and that they were much more cautious afterwards, now recognising the danger of complacency after a long period of stability. Equally all the women appreciated the supportive and non-judgmental response from staff at 218 once they chose to return:

" I was quite nervous actually coming back in the second time…. But I think it's just the fact that you are kind of admitting that you have started slipping, do you know what I mean? Kind of denial to begin with so…but the second I came in the door, that was it, I was alright, so I was like 'god I have been nervous for nothing'." (Follow-Up 9)

As women engaged with the service, they were more likely to attend appointments and to access services that they may not have done previously ( e.g. reproductive health, nutrition), obviously with preventative costs in the longer term.

Longer-term impact

7.57 Many respondents acknowledged the need to consider the longer-term benefits that 218 could provide to the women who engaged with the service. One respondent, when asked to consider what the main impact of this service was likely to be, commented: "The potential really to improve the social implications and aspects of their life and their health issues, and it's got quite a kind of long-term, I mean it's not a kind of short fix..." (Health provider).

7.58 Staff at 218 mirrored this view, saying that longer-term impact depended on the extent to which they truly had the opportunity to address 'root causes'. Referrals to other agencies clients may not have used before and continuing support through 218 and through organisations such as Alcoholics and Narcotics Anonymous assisted them in this. Staff commented that for some clients, longer-term impact could be in the form of very basic stability, such as: "putting on weight and getting proper sleep, re-building their sleep pattern, things like that" (residential staff member). While such developments may appear minor, they were considered crucial in helping women get their lives back together.

7.59 Staff said they had already seen longer-term benefits in some of the clients who had been through 218, including cessation of offending and drug use and engagement in college courses or employment. For others, lasting change was likely to take longer, but staff believed this was to be expected:

"… it's like chipping away, it's just a wee tap, tap, chipping away and chipping away and hoping that somewhere along the line there's going to be enough to say 'right, maybe I do deserve something a wee bit better'." (Residential staff member)

7.60 Considering the overwhelmingly positive response from clients about the effectiveness of the service overall, we questioned whether they believed the impact of 218 would last beyond their time there and beyond the 'euphoria' of new-found stability. Clients were still fairly optimistic in this regard:

"I think it will [help in the longer term]. Obviously I could probably have a lapse, because everybody could go through a bad time in their life, because I used to think I wasn't good enough to lead a good life, and I didn't think I could do it…. I think this time it will [work]. You have got to want to do it and I do, I want to do it." (Exit 19)

Passing it on

7.61 Another qualitative measure of the effectiveness of 218 was whether clients were willing to recommend the services to others. Without exception clients said they would do so, and many had already done so: "… it's the best thing that ever happened to me" (Exit 15). We then asked whether they believed the programme was suitable for everyone. Here, the same dichotomy arose in that the service was appropriate for those who were motivated to take part in it, but less so for those who were 'there for the wrong reasons', namely those sent by court order:

"I think that should be something that they check out a bit more … that people are actually wanting to be here … if they're just here because of the [court] … because they're wasting a lot of money and resources on people that aren't interested in using them. And somebody else could have the place that is serious about coming off drugs like that." (Exit 46)

7.62 In saying this, a significant minority of clients believed everyone should at least be offered the opportunity to attend and that even people who originally attended the service reluctantly often benefited from it:

"You see the people that are here on court orders, you can see they are trying. They don't want to be here at first, but I mean, say after about 2 weeks, they want an extension, and they want to do well. They are really keen on seeing out the program…." (Exit 42)

Moving On

7.63 To judge from the comments of the staff themselves, the ability for women to move on from the services at 218 often 'makes or breaks' the impact it has had on them. This is where the 'other' services - those not directly related to criminal justice - come to the fore even more clearly:

"… it always seems to me women reach a certain point where they have looked at these things, they are doing what social work want, they do what the government wants, they are looking at the root causes, they get clean, they stop offending, but they are still in shabby accommodation, they still carry a Section 46 on their record, which prevents them going for a job." (Day programme staff member)

7.64 Respondents noted that new initiatives are constantly being developed and services created. However there can often be problems due to a lack of connection or interlinking between agencies. For women to be able to maintain the progress made at 218, there has to be consistency and continuity when women move on; going back to their communities requires that they be linked into mainstream services, which is problematic if there are insufficient resources. It was noted that there has been an emphasis on crisis intervention for services in Glasgow, but it was just as important that resources were available for preventative and follow-on services.

7.65 Respondents in strategic positions and from community-based agencies continually reinforced that preventative and follow-on services were necessary for longer term success. There was perceived to be an identifiable need for co-ordination to ensure a number of services weren't trying to do the same thing (overlapping resources), and a strategic overview was required to ensure there were no gaps in service provision. The absence of a Steering/Monitoring Group for much of the development of 218 has clearly been problematic. It was viewed as necessary for feeding into local partnerships and resources and into decision-making resources in other arenas.

7.66 As outlined in previous chapters, the importance of appropriate accommodation, and follow on support were considered extremely important:

"I am still waiting to be allocated a worker. It's been a nightmare trying to get one. I mean I saw them about 4 weeks ago, and they said I would get allocated somebody the following week. I am still waiting, I mean the staff have been phoning every day, and they keep saying they will phone back, and then they don't, because I really wanted to have that place before I went out." (Exit 16)

Clients were very positive about the difference a supportive doctor could make to their continued recovery. For the most part clients believed they were ready to move on from 218 when the time came, not least because appropriate supports had been put in place, and because of the reassurance that they could always return if they needed to:

"… I know that any time, day or night, I can phone here, or I can come down here, and I would be all right, you know, that way." (Focus group 2)

7.67 Staff worked hard to ensure that adequate supports were in place before clients left the service:

"We wouldn't put somebody back out into the community if they were struggling, you know. It's only if we believe they could actually do it. So it's just about reassuring them that it is positive, and that they are doing well and they can do it." (Day programme staff member)

Support workers assist clients in making links with supports outside 218 in terms of setting up appointments and accompanying clients to these. It was suggested that this type of 'outreach' could be developed further within 218 and that better use could be made of external project workers.

Developing 218 elsewhere

7.68 Ensuring links with outside services were available to clients upon leaving 218 was more difficult where clients came from outside Glasgow. 218 was designed to cater for clients in the Glasgow area specifically so they could be linked back into community-based services. However, referrals have included clients from Edinburgh, Stirling, Aberdeen, and the Shetland Islands.

7.69 Respondents, particularly those from other agencies, indicated that services such as 218 were needed throughout Scotland. They also stressed that difficulties faced by women are compounded by the lack of appropriate residential rehabilitation facilities capable of meeting the needs of women. It was acknowledged, however, that one difficulty in attempting to provide similar services elsewhere was due to the fact that other cities did not have the same services in place as Glasgow (particularly in comparison to the Routes Out SIP and the services developed through this Partnership). Similarly it was suggested that other areas did not tend to have the same volume or type of drug problems either. Nevertheless, the positive responses to the woman focussed service provided by 218 clearly illustrates the significance of developing gender-sensitive services elsewhere, within a multi-agency context where appropriate.

7.70 The individual skills of many of the workers at 218 and the expertise they had developed through previous resources was perceived to be something which would make the service difficult to replicate elsewhere. However, it was noted that other services in Glasgow had started to follow the lead of 218 in developing their services and making them more 'user-friendly' for women.

Summary

7.71 Effectiveness of a programme like 218 is often difficult to measure in quantifiable terms. Even where this may be possible, statistics on sentencing patterns and criminal justice outcomes were not available for this analysis and will not be available until the summer of 2006 at the earliest, since the standard follow-up period for reconviction is 2 years. Statistical evidence of any impact on sentencing patterns has thus far been inconclusive. Interviews with sentencers and prosecutors have, however, shown that they make use of 218 and value it as a resource. The interviews and statistics cannot say for certain whether the women referred to 218 would otherwise have ended up in custody in the short or long term; what they do say is that women who have engaged in services at 218 have been actively involved in offending and that they fit the profile of female offenders in prison.

7.72 Cost-effectiveness is impossible to assess at this stage in the absence of measurable outcomes. In terms of costs comparisons, however, we can determine that the average cost per engagement at 218 (£7,701), equals the cost of 2.6 months in prison. The average length of stay at 218 was 2.6 months, but this is based on those cases where complete information was available. Data from project records on the length of time spent at the project was missing or incomplete for just over half of the women, often because they were still engaged with the project. It is also clear from this evaluation and other previous research that there are numerous benefits associated with the range and level of services provided at 218 which are not offered over the course of short-term custodial sentences. However, limiting measurements to quantifiable and immediate criminal justice outcomes misses the contribution 218 is likely to make to make to longer-term crime prevention. As this evaluation has shown, women who used the services available at 218 identified significant decreases in drug and/or alcohol use (83%), improvements in their health and well-being (67%), access to stable accommodation and referrals to longer-term support services. Other research suggests that the programmes and services offered by 218 will contribute to reductions in offending over the longer-term. In terms of the current research, most support for the effectiveness of 218 comes from 'testimonies' of clients, staff, and stakeholders. Such feedback was almost universally positive.

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