Introduction
The project included a survey of leads of young people’s drug and alcohol treatment services across England to identify ‘standard practice’ within and across agencies.
The aim of the survey was to collect data from each local authority area in England that had a service offer for a young person’s drug and alcohol service, in order to define usual care and identify potential research sites for a definitive trial. Of the 153 local authority areas, we obtained contact details for 150 commissioned or ‘in-house’ young people’s drug and alcohol services.
Methods
All of the services were contracted to deliver a service in a single local authority area, except one service which was contracted to deliver a service across two (adjoining) local authority areas. Therefore, at the time of conducting this survey there was 149 contactable young people’s services commissioned to deliver services across England.
Data collection took place over a 3-month period (December 2017–February 2018). The survey was carried out as a parallel activity to the formative research phase of the study. Each service was contacted by a researcher (HA, RB or DS) and a service manager or senior practitioner was identified. After introducing the study, researchers aimed to complete the survey (see Appendix 2) instantly over the telephone, or if participants preferred to complete the survey independently a qualtrics link was sent, enabling the survey to be completed online.
The survey explored whether or not the service offer available to children in care altered in any way (if so, how did it differ) compared with young people accessing the service who were not involved in the care system. It also assessed which screening tools services are used when young people accessed treatment and what a typical service offer would look like in terms of number, duration and frequency of sessions. In addition, it considered how managers monitored the content and quality of sessions provided to young people, the supervision and support arrangements that are in place for practitioners and the qualifications of practitioners within the agency. The survey aimed to capture the levels of standardisation or variability in practices across services.
Drug and alcohol survey results
Of the 149 services, 122 (82%) completed the survey, four (3%) declined to take part and 23 (15%) did not respond to multiple contact attempts. In total, 100% of participants provided answers to all questions when they agreed to take part in the survey; therefore, there were no missing data.
Organisations were commissioned and contracted to deliver a service for an individual local authority area; however, six third-sector organisations were providing 50% of the substance misuse services to children in care. They are organisations which have their foundations in adult recovery services and have diversified to offer substance misuse services to meet the needs of children and young people.
The remaining contracts were a combination of voluntary or third-sector agencies and in-house local authority services.
When exploring funding streams, most respondents reported that the drug and alcohol services were commissioned from local authority funding streams (n = 118), with only four services receiving money from alternative sources, such as Big Lottery funding.
Eighty (66%) services reported that children in care received exactly the same service offer as all young people accessing the service, whereas 42 services (34%) said that their service offer to children in care was different. Differences in the service offer included increased engagement work to identify children in care with problematic substance use; increased partnership working with children’s services once a young person accessed services (n = 32); the age at which a child in care is transferred into adult services was increased from 18 years to 21 years due to their vulnerability (n = 11); and children in care being prioritised on the waiting list (n = 6) to ensure they were seen as quickly as possible following a referral.
Screening tools used
Drug and alcohol treatment services were asked to provide information regarding the screening tools they used to assess the level of alcohol and/or drugs a child in care was consuming. The services reported using between one and three different screening tools. However, although some services reported solely on the screening tools used, other services completed the screening within the context of completing a more holistic initial assessment of need.
Ninety-four (84%) services reported using only one screening tool and for the most part, these were ad hoc, locally developed tools rather than validated tools. Twenty-nine (26%) services reported using two different tools and five (4%) services reported using three screening tools. Services reported using the different tools simultaneously during an initial meeting and over a prolonged period of time to establish levels of use and need. There was no standardisation regarding which tools were used and consistency varied even within agencies, as professionals reported using a tool that they felt best met the needs of the individual. Fifty-two (46%) services reported developing a tool ‘to meet their local need’, which, as identified above, could include an amalgamation of validated tools, such as the Alcohol Use Disorders Identification Test (AUDIT), Alcohol Use Disorders Identification Test for consumption (AUDIT-C) and Drug Use Screening Tool (DUST), and could also incorporate items from an assessment of need. The screening tools identified as being used can be seen in Figure 4.
FIGURE 4 Screening tools used. (Figure not reproduced here; see the original article.)
Interventions offered
Participants were asked to describe the delivery of the interventions offered to children in care, including the number of sessions, duration of sessions and frequency. When discussing the delivery of interventions, 67 (55%) services stated that they offered a completely ‘bespoke’ service, with each individual being offered a package of care tailored to their individual needs. This package of care was not restricted to a minimum or maximum number of sessions and could incorporate a mixture of tier 2 and 3 services to meet the child in care’s identified needs. Thirty-five (31%) services reported that they were commissioned specifically to conduct structured work delivered within 12 sessions. Twenty-one (19%) services identified that they offered a variety of structured work, such as harm minimisation and drug education. A maximum of 12 sessions was offered, although this could be flexible and could lead onto more bespoke work if necessary. Despite working in a structured way, services often reported having the flexibility to recommence work at a later time with a young person if a further referral was received or if the child in care’s circumstances had changed.
Delivery of services
A final area of interest was to explore the qualifications and/or professional training that drug and alcohol practitioners had achieved or participated in. The qualifications reported as present within services currently and/or regarding previous employees can be seen in Figure 5.
FIGURE 5 What qualifications/training do practitioners have? D and A, drugs and alcohol; H and S, health and social. (Figure not reproduced here; see the original article.)
The qualifications held by drug and alcohol workers were varied. Often workers had multiple different skill sets and expertise. Multiple responses were possible to these questions and multiple responses were present from each of the responding services. Youth work was the qualification reported most frequently (n = 93), with health and social care (n = 57), counselling (n = 48) and social work (n = 50) being other qualifications often transferable to the drug and alcohol work. There was no standardisation of training of drug and alcohol practitioners, and individuals utilised different skill sets when moving into this line of work.
Quality monitoring
Owing to the variable and adaptable service offers available to children in care, services were asked to describe what mechanisms were put in place to oversee the quality and content of sessions being delivered. Figure 6 shows the procedures in place to monitor the work being completed.
FIGURE 6 How is quality and content of sessions monitored? YPOR, young people’s outcome record. (Figure not reproduced here; see the original article.)
The quality of sessions was monitored using a number of different mechanisms, multiple responses were possible to these questions and multiple responses were present from the majority of the responding services. Line management was the most reported method and occurred at either monthly or 6-weekly intervals. Line management was used to incorporate both case management and professional development issues. Although 18 (15%) services reported that line management happens at ‘other’ frequencies and this spanned a range from managers having an open door policy within which practitioners accessed them as often as necessary, to formal line management only being scheduled every 8 weeks. Clinical supervision with an external supervisor or clinical psychologist was reported by 93 (76%) services, this provided an opportunity for practitioners to discuss individual ‘cases’, reflect on their practice and receive clinical guidance of how to work with children in care. Outcomes of care provision to young people were recorded within an individual’s case file.
Other mechanisms were audits completed by the local authority (n = 81, 66%); in-house case file management conducted by the service manager (n = 62, 51%); feedback received from the young people when they have completed a piece of work (n = 38, 31%); peer review, which often occurred in team meetings or within peer supervision (n = 24, 20%); and via the NDTMS or a young people’s outcome record (n = 14, 11%). Services referred to the young people’s outcome record more as a reporting process, rather than it reflecting the quality or contact of sessions.
When considering the number of methods used to measure quality and content of sessions, services reported using between one and six different mechanisms. Three services (2.5%) reported using one method, 17 (14%) reported using two methods, 32 (26%) reported using three methods, 49 (40%) reported using four methods, 20 (16%) reported using five methods and one service reported using six different methods to measure content and quality of the work delivered within their service.
Summary
The survey was designed to inform the definitive trial with regard to the specification of usual care. It was not designed to inform the pilot trial, it was conducted as a parallel activity to the formative phase of the study. The survey highlighted the high levels of variation in drug and alcohol service provision being delivered for children in care across the country. Although screening was carried out for drug and alcohol use by children in care, the tools used and the completeness in cover varied. The modalities of treatment differed across providers, the majority of services (n = 67, 55%) offered a bespoke service and 35 (29%) services reported only conducting structured work; however, even the latter could be delivered flexibly across sessions. The survey highlighted the lack of organisational readiness for protocol-driven research. None of the services reported delivering and adhering to a manualised evidence-based intervention. The survey also highlighted the range of qualifications that drug and alcohol practitioners have and a number of practitioners working within young people’s specialist agencies did not hold a formal drug and alcohol qualification. The levels of supervision and training were also variable. Owing to the high levels of variation regarding service provision, the lack of standardisation regarding screening tools used and the lack of adherence to manualised evidence-based interventions, future studies would be required to assess the organisational readiness of specific services to deliver interventions as part of a RCT or an evaluation study.