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Chapter Six Conclusions and Recommendations
6.1 The Scottish Executive, Grampian NHS Board and Drugs Action Aberdeen worked together to design Incite, a pilot service for psychostimulant drug users. Incite is based in the Drugs Action premises in Aberdeen city centre and has been operating since September 2003.
6.2 Incite was set up to:
- provide outreach services to attract clients and market the service
- provide a flexible range of treatment, support and rehabilitative interventions
- increase and improve the range of pathways into other specialist treatment and generic support for clients
- provide multi-agency interventions to assist clients to capitalise on high motivation and secure good treatment outcomes
- provide easily accessible 'drop-in' and appointment-based services for referrals, as well as referrals from specialist and generic services
6.3 This evaluation was commissioned to examine Incite's effectiveness, particularly its ability to attract, engage and retain service users and work effectively with other services. It also investigated the service's delivery of interventions and where possible the impact that these interventions have had on clients' lives.
6.4 This chapter reports on each of these issues in turn and examines some of the underlying issues that affect delivery of the project's objectives. Key findings from the evaluation are summarised at the end of the chapter, selected to help inform the development of existing and future services.
Achieving the project aims
Attracting service users
6.5 Potential barriers to service takeup can be overcome by providing separate services and/or good publicity and referral routes. The original needs assessment conducted in Aberdeen prior to this pilot suggested that a separate service (as opposed to a psychostimulant service 'embedded' within a generic service) would be preferable, but due to the available budget this was not possible. The sharing of premises and overheads with Drugs Action proved to be a much more cost-effective solution. However Incite did employ publicity and outreach to ensure that the service had its own identity and make prospective service users aware of the range of interventions on offer.
- Publicity: COCA (2005) suggests that services to crack cocaine users should be publicised widely and be sensitive to the wording and imaging used to engage clients. Incite took COCA's comments on board when originally designing their promotional material. Promotion and advertisement activity, however, was one aspect of the service which was lower than expected by staff and described as poor by a number of service providers since the project launch.
- Outreach: The project has made some inroads into accessing some especially hard-to-reach groups of service users but the outreach component of the service is developing slowly. Recently the regular presence of Incite staff at a sex industry drop-in has enabled positive contact to be made with sex industry workers using psychostimulant drugs.
6.6 Developing outreach within Incite could be advantageous for a number of reasons. One reason is its geographical location: if Incite were to expand its service to meet the needs of drug users in Aberdeenshire, it would be advisable to conduct outreach from satellite premises in less accessible areas 4. Another reason is that outreach is a more proactive form of service delivery and would help the service access what is widely regarded to be a hard-to-reach population. Outreach sessions in other services undertaken across Aberdeen city could perform a number of different functions. As well as enabling the service to identify and target a wider range of clients, it could also facilitate transfer of knowledge and expertise from Incite staff to other service providers.
Engaging service users
6.7 Evidence suggests that conducting outreach work and provision of drop-in facilities are conducive to working with psychostimulant drug users (e.g. Turning Point 2005, COCA 2005, Home Office 2002). Outreach, discussed above, has been a small but important aspect of the project's work. Provision of drop-in, however, has not been possible for Incite because of limited staff resources. To a certain extent, this issue could be overcome by the outreach model described above, by using other services' premises for drop-in sessions. Development of these aspects of the service would be contingent on having more staff resources available.
Retaining service users
6.8 Active clients in contact with Incite have tended to attend erratically. This may be due to the fact that some clearly did not see themselves as clients of a service in a 'traditional' sense. Clients tended to report to the service at the relapse prevention stage, and therefore may not have regarded themselves as receiving regular interventions. As length of treatment and early abstinence are predictive factors of positive treatment outcomes (Turning Point 2005), this is an area which may require further investigation.
6.9 It has been suggested by other psychostimulant drug services that client retention figures can remain low throughout pilot stages of a project and that building up rapport with clients can take a considerable amount of time. Also, although Incite has a number of active clients who 'dip in and out' of the service, it has demonstrated an ability to provide appointments on demand, especially for referrals, and has not had to maintain a waiting list.
6.10 One difficulty for Incite in measuring how effectively it is retaining service users is that there has been a great deal of ambiguity in how 'open' and 'closed' cases are defined. This has impeded monitoring of the client's progress as well as examining the overall performance of the service.
6.11 One pattern seen throughout this evaluation was that clients attended a number of sessions and then failed to keep numerous appointments. When considering crack cocaine use in Greater Manchester, Bottomley et al (1997) observed marked differences in the patterns of use of cocaine and heroin. The different pharmacology of cocaine means that it can be used in varying quantities without noticeable withdrawal symptoms - unlike heroin.
6.12 Because drug use can fluctuate, individuals' perceptions of drug use as a problem also changes and this can affect motivation and the perceived need for help. Many service users believe that they can take drugs in the future without it becoming a problem and this came across in numerous interviews.
6.13 Creating a relationship which allows clients to re-contact the service after missing appointments is crucial, as services need to be 'accessible at those times when users themselves recognise that they have a problem' (Bottomley et al, 2004).
6.14 Incite have demonstrated the ability to provide appointments and support 'on demand', and have effectively used the medium of text messaging to provide an open avenue of communication to active clients. Evidence suggests that regular text messaging may help retain service users in treatment for longer ( COCA, 2005).
6.15 While one of the most influential factors in retaining opiate users in services may be the provision of substitute medication, this is not usually an option for psychostimulant users and such a provision has not been available through Incite. It is clear, however, that the provision of alternative therapies has been an extremely popular element of the project, and has been regarded as successful by both service users and providers. The provision of complementary therapies is also an effective way of attracting and retaining service users in psychostimulant services 5. Again, this is backed up by qualitative evidence from the staff and users of Incite.
Delivering interventions
6.16 Incite offers a wide range of interventions to active clients, and whilst there was no demonstrable pattern for use of specific interventions on the basis of quantitative data available, the cluster of clients with positive final outcomes received interventions directed more towards physical and mental health issues and social skills than financial or accommodation issues. Active clients with positive outcomes also received help in identifying and avoiding the triggers that lead to relapse through a range of crisis intervention, harm reduction, and relapse prevention techniques.
6.17 Mental health has also been an issue at the fore of reports such as The Crack Report (2005) and Tackling Crack: A National Plan (2002). The individual histories of active Incite clients and the interventions they have received also reflected a high level of mental health problems. Incite have been well-placed to deal with such clients because of the depth of experience and training the staff had in dealing with mental health issues.
Underlying factors
Co-location with other Drugs Action services
6.18 The housing of Incite under the Drugs Action umbrella has had an impact on the project in various ways which were mostly positive. There has been a lot of shared resource e.g. administrative, staffing support (secondment of Drugs Action workers to Incite), and it has allowed Incite all the advantages of being part of an established drugs service. This has been particularly beneficial in terms of covering case work during the project's staffing shortages.
6.19 Although it was within Incite's remit to provide a drop-in facility, this was not possible as there were not enough staff to meet this need. Separately-located and run premises might well be able to provide this useful facility, as well as provide more dedicated private space for treatment procedures and extend opening hours.
Staffing and structuring of the project
6.20 Incite staff have demonstrated a high level of knowledge and commitment to their work, demonstrated through the high opinions held by service users regarding the help and support they had received. Throughout the evaluation staff have been helpful and have shown great rapport with their clients. The staffing capacity and structure of Incite has, however, limited the development of the service.
6.21 If the service is to develop it is recommended that a manager/development worker should be employed full time to run the project. Research has shown that service providers talk more favourably and perceive themselves as having better communication and referral links when contact is regular and consistent ( HFAL, 2004). It is also recommended that the manager's caseload should be kept to an absolute minimum (if this post is to include casework at all) and the work focused on maintaining and developing the service.
6.22 The project had originally intended to recruit GP support as well as psychological input to its service users. GP support has largely been met in partnership with community GPs. Psychological service input has been provided to staff at different stages as a support and information point regarding service users. It was not offered to clients directly. Although a number of service users are in contact with other mental health services, some suggested that seeing a psychologist at Incite might be beneficial.
Efficient data collection and monitoring
6.23 Monitoring is an on-going process involving the continuous and regular collection of key information on the inputs, outputs and outcomes of a service, intervention or partnership. The main aim of monitoring and recording of activity is to establish if things are going to plan, and whether any change in activity is necessary.
6.24 Setting targets can aid this process and allow services to compare forecast and actual performance.
6.25 Case files should contain details of the " essential steps in the care of a drug and alcohol misuser and describe the drug and alcohol misuser's expected treatment and care course"' ( NTA, 2003). Standardising case file information is essential. This lets different cases be compared on a uniform basis, enables routine monitoring of clients and provides the information to create care plans. Care plans are an important method of providing a visible care pathway for individual service users.
6.26 Standardised case files also allow the transfer of information either from one service to another or between workers internally in the same service. This can be helpful should a member of staff leave the service or be on long- term sick leave. If standardised assessment tools have been used, completed forms should also be included in case files.
6.27 Important monitoring information should ideally be transferred on to a suitable database to allow a service to collate information on its referrals and active cases. It is from such databases that reports can be compiled to provide profiles of service users and service activity, examine whether targets have been reached and provide reports for funders.
Future development of psychostimulant drug services - key lessons
6.28 The Incite project has indicated ways in which future psychostimulant services might be developed:
- Flexibility
Incite has demonstrated that offering a prompt response to referral and a flexible, bespoke approach appears to increase a service's ability to attract and engage new service users.
- Friendly, fast response
Incite has shown that gaining client information unobtrusively (rather than by completing lengthy assessments) is favoured by psychostimulant drug users. This factor appears to have helped retain clients within the service. Incite has also demonstrated that when this client group requires intensive interventions, it is imperative they are offered quickly, again aiding retention rates.
- Effective, unobtrusive communications
Frequent text messaging between staff and clients has encouraged service-users to maintain contact with the service, another factor in successfully engaging and retaining clients.
- Extensive choice of interventions
A wide range of interventions, including the ability to carry out harm reduction and crisis intervention work, is crucial. Auricular acupuncture is beneficial because it helps clients relax and facilitates the engagement process.
- Professional, effective staff
The provision of well-informed and credible staff is essential and this has been one of Incite's key strengths. The ability to demonstrate in-depth knowledge of psychostimulant drug use and experience of mental health issues has helped to build up service user confidence. In turn, being perceived as a credible service has substantially helped Incite to engage with clients and enhanced rapport and trust. Effective staff training has played a vital part in this process. - Robust infrastructure and information management
When developing innovative services, it is advisable to have a strong management structure and robust systems in place for monitoring service developments. This helps services to detect what is and what is not working with their clients and to adapt service provision accordingly.
- Targeted outreach
It is widely accepted that psychostimulant drug users are a difficult group to reach. Ways of engaging with and retaining this group may include delivery of outreach to other services, promoting the service at nightclubs/dance events and providing drop-in facilities.
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