Describes our 2000-2002 national evaluation of projects supported by the Drug and Alcohol Treatment Fund (DATF) in Wales, detailing two particular projects, the North Wales Community Drug and Alcohol Liaison Midwife position and the Option 2 project in Cardiff. (3,498 words)
As indicated in an earlier article, I won the tender to evaluate all projects supported by the Drug and Alcohol Treatment Fund (DATF) in Wales early in the year 2000. The DATF was developed by the National Assembly for Wales (in effect the Welsh Government) in response to the recognised shortage of addiction treatment services, in particular for young people.
Although the funding £1.5 million per annum was initially conceived as being entirely for treatment, it was soon recognised that it must be used for a wider set of activities, including prevention and training. Organisations submitted bids for funding to their respective Drug and Alcohol Action Teams (DAATs)—Bro Taf, Dyfed Powys, Gwent, Morgannwg and North Wales.
The Gwent DAAT co-ordinator, David Jeremiah, was given the responsibility of initiating, developing and organising the DATF, which started on 1 April 2000. Each DAAT was given an annual sum for evaluating, monitoring and supporting projects, of which part was top-sliced to provide funding for a National Evaluation—funding was given to my employer, the University of Wales Swansea (as it was known then)—whilst the remainder was used for local evaluation.
Local evaluators monitored progress of the projects within their DAAT area, passed relevant information on to the National Evaluation Team, and facilitated meetings between project holders and the National Team. I directed the National Evaluation part-time and had a full-time assistant, one of my former Psychology undergraduate students, Becky Hancock.
Becky and I worked closely with David Jeremiah and we had a fruitful and enjoyable collaboration. We also collaborated with four of the other DAT Co-ordinators—the fifth decided that the DATF did not require an outside evaluator and refused to collaborate. She thought she knew best. David and I decided that we should leave her to her ‘own devices’, as she represented my local area and Becky and I could just work directly with the services and projects. They were all happy doing that.
Programme evaluation has been described as ‘the systematic collection of information about the activities, characteristics, and outcomes of programs to make judgements about the program, improve program effectiveness, and/or inform decisions about future program development’ [1].
The role that Becky and I were to play as the National Evaluation team was multi-faceted. I first invited all DAT Co-ordinators and their local evaluators to attend a one-day conference in Swansea where Professor Michael Williams, an evaluation expert, talked about the various facets of programme evaluations.
Over time, Becky and I, and the relevant local evaluator, visited all the projects in each area, some many times. We described the evaluation process to members of the project (the person hired and normally a senior representative of the organisation) and explained why such a process was necessary. It was important that the local project teams did not feel that they were being tested and did not feel threatened. We tried to encourage a healthy culture for evaluation in the organisation—the mission should be to continually question and gain information about the different elements of the project and the outcomes arising from the intervention.
I emphasised that we wanted to learn from what they were doing, write project profiles where relevant, and publish them to help other organisations learn from their experiences and be able to develop similar projects if required. We wrote a number of profiles which appeared on the early Wired In websites, substancemisuse.net and wiredinitiative.com.
During our visits, we had discussions with members of staff, heads of organisations and clients accessing the service. The latter often gave invaluable feedback. The range of projects varied greatly, so there was obviously no simple ‘one-fits-all’ measure of outcomes. It was also important to note that David Jeremiah and I considered it important that my team not only evaluate the DATF-funded projects, but also the system(s) within which these projects and services operated.
A number of clients and staff requested that I pass on their feedback about the wider system(s) to the National Evaluation Board and the National Assembly for Wales. This I did, although much of what I had to say was not appreciated by government. It was telling (and rather sad) that my National Evaluation final report, which included criticisms and suggestions to improve the system(s) to help people, was never published by the National Assembly for Wales.
The two years of working on the DATF evaluation gave Becky Hancock and I an initial understanding of what was happening in the addiction treatment field in Wales. I learnt more about the treatment field in the UK as a whole once I started visiting services in England and Scotland. I continued to read as much relevant material about addiction and addiction treatment as I could.
One of the most important things we learnt during the initial evaluation was the need for information and education about good practice to be circulated widely.
This was made all the more necessary given the UK Government’s 1998 drug strategy, which focused on an integrated approach to tackling drug problems involving health, criminal justice, and social service sectors. It was a tremendous challenge for the system to equip staff in all these areas with an understanding of the nature of addiction and how best to help people overcome substance use problems, ensure best practice, and develop approaches that facilitated communication between the sectors. High quality training was essential for the workforce.
It didn’t take us long to discover that this challenge was not being well met. Practitioners, clients and family members told us that they were not getting enough of the right information.
Leading addiction experts told us that whilst we knew a lot about how to help people overcome addiction, little of this information was actually used in practice.
Those practitioners working at the ‘coalface’ told us that the overall system was not working well. As we travelled around, we met many practitioners who knew little about how to help people overcome substance use problems. Training programmes were often inadequate and were one of the first things to be dropped if funding became tight.
The voices of recovering people were just whispers at the time.
2. North Wales Community Drug and Alcohol Liaison Midwife
The problem of poor information flow, and how this problem could be largely overcome—greatly benefitting the system—was well-illustrated in the report by North Wales DATF local evaluator Anni Stonebridge about the North Wales Community Drug and Alcohol Liaison Midwife position that was supported by the DATF.
Prior to this position being developed, expert guidance regarding how to manage pregnant women who had a substance use problem was not readily available in North Wales and many (probably most) other places. The personal prejudices of practitioners towards substance using mothers were more likely to fill in the gaps in their knowledge than the person trying to dig for the best advice.
Many pregnant women with a substance use problem who visited (or wanted to visit) services lived in fear of having their baby taken by the authorities. Child removals occurred in many cases, often for no reason. Some pregnant women were being forced into hasty abstinence by professionals with the best intentions, but little or no evidence-based guidance was available for them to design the best approach for the safety of both mother and child.
Frustrated by the above problems, nurse Jill Timmins, who had periodically worked with pregnant women with a substance use problem, became determined to find funding for a midwifery post that focused on pregnant women with drug and/or alcohol use problems. Jill had initially been inspired by a lecture given in the late 1990s by midwife Faye McCrory on the effects of using alcohol and other drugs in pregnancy. Her subsequent successful funding application to the DATF was the culmination of several years study, thought, and development.
After two-years funding was obtained, Christine Weaver was seconded from a community midwife team in North Wales to be the Community Drug and Alcohol Liaison midwife for the whole of North Wales for two years. Jill and Christine knew that the latter’s job would be challenging, given the geography of North Wales—smaller towns and rural communities—compared to Faye McCrory’s home town of Manchester. The post had five primary aims:
1. To develop and launch a treatment protocol for pregnant women who misuse drugs and alcohol.
2. To educate all professionals about substance misuse in pregnancy.
3. To meet all pregnant women who misused drugs and alcohol to offer advice and support.
4. To liaise with all professionals across North Wales.
5. To develop specialist knowledge ensuring recent research information is provided and used at all times.
Education and awareness-raising activities were used to promote and disseminate an evidence-based Protocol and Guidance document. A Midwifery Steering Group, led by Jill Timmins, had partially completed a draft of this document which Christine went on to complete. The document was informed by a wide-ranging research evidence and by the experience of existing Drug and Alcohol Liaison practitioners in other parts of the UK. The Protocol and Guidance document provided a quotation regarding the expected approach that professionals were to adopt when dealing with this group of pregnant women:
‘It is vital that health and welfare responses to pregnant drug users are both multidisciplinary and multi-agency, with effective collaboration between agencies which take into account the needs of both the mother and the new born. Similarly appropriate support for families and protection of children requires all agencies involved to co-operate and communicate with each other in terms of planning and providing services.’ Institute for the Study of Drug Dependence, 1999.
At the time of Annie’s formal evaluation of the project in the summer of 2001, the document had been made available to all professionals in the majority of primary care settings in North Wales. Direct education through regular lectures and updates had been delivered to approximately 85% of hospital and community midwives. Many health visitors, GPs, consultant obstetricians and paediatricians, social workers, and drug and alcohol workers had also received direct education. Christine also lectured to student midwives and nurses.
The second major element of the project concerned direct clinical support to pregnant women who were misusing drugs and/or alcohol, as well as their health care teams. The process of examining the care needs of clients generally involved a multi-disciplinary planning meeting or review. These could be a one-off meeting or, when complications arose, be more frequent.
The project adopted good practice guidelines detailed by the Standing Conference on Drug Abuse (SCODA) and the Local Government Drug Forum (LGDF), which emphasised collaborative case management and suggested the stages at which it might be important to hold multi-agency planning meetings.
The Planning Team generally consisted of Christine and relevant agency representatives: the community midwife, social worker, health visitor, a representative from the child protection team, a drug and alcohol worker, and consultant or community paediatrician. An opportunity was arranged for the client to meet all the professionals involved in her care at one time. Chris also met each new client at her home to discuss any concerns and inform them they could call her at any time. She provided support to the pregnant women and their community workers as and when needed.
Local evaluator Anni Stonebridge had been monitoring the different elements of the project since it had started. During this time, it was clear that there was strong support for the project from all agencies involved, and that the management and development of the post has been largely smooth and unhindered. Interest was being shown from other parts of Wales and the UK in establishing similar services. As indicated earlier, Anni conducted a formal evaluation of the project in 2001, which involved interviews with staff and clients, as well as Jill and Christine.
In brief, dramatic positive changes occurred for North Wales pregnant mothers who had a substance use problem. The knowledge base of different practitioner groups, and the communication between them, was greatly improved. A process was developed by which information could be shared by the relevant agencies, with the client’s full knowledge, and time spent developing an understanding of the work of other professional groups involved. There was a greater enthusiasm for multi-agency working.
Proper care plans were put in place. Babies of mothers with substance use problems were not routinely taken. Women on methadone were given the option of standard pain relief in labour. Pregnant mothers thought that with the new position there would be less chance of them being exposed to judgemental attitudes by workers. They knew that Christine would act as their advocate.
‘She has been a really good help, you know, making sure that I’ve been treated properly by other hospital people. Sometimes when you’re on heroin they think that you don’t care.’
Chris pointed out to Anni that in her first 18 months, only two of 82 pregnant women failed to turn up to their interview. That was a huge change. Anni emphasised that the midwifery post had been very effective in challenging existing practice when it was obvious that evidence for it is lacking, or previous directions have been superseded by more recent research findings. A couple of the people she spoke to explained how important it was Christine having authority both professionally and academically:
‘I think the fact that she’s been able to go and challenge practice that’s happened traditionally for years with no evidence base and that she’s been strong enough to do that in terms of consultants and senior midwives.’
‘[The] evidence-based stuff…sometimes we used to think, ‘Well that’s what we do, that’s why babies go into special care, because that’s what we do’ and Chris has come and said, ‘Why?’ She helped to sort of make people look at their practices.’
Finally, it should be pointed out that whilst here had been initial concern that the more remote areas such as South Gwynedd would not receive the same consistency of support as other areas geographically closer to Christine’s base in Wrexham, respondents from the former areas strongly stressed that it was to her credit that this fear had not materialised.
It was always a great pleasure to visit Chris and Jill and hear about their work. Their passion and commitment were so evident and it helped fuel our own passion. We could see how disseminating their story, and that of many of the other practitioners whose work was making a positive difference in their area, could help improve the practices of other people around the country and further afield. We therefore published reports on this project and others supported by the DATF on our websites. The dissemination of good practice became an important aim of Wired In over the years.
It was also a great pleasure to work with Anni Stonebridge; Becky and I loved our trips up to North Wales, and Anni always had our visits to various projects well-planned. It was clear that she was highly regarded by all the people we met who knew her. Anni eventually moved to Logie Coldstone in the north-east of Scotland, where she worked for a time for the Aberdeenshire Drug Action Team. She became part of Wired In for a while and I would visit her in Scotland to plot Wired In strategy and develop funding applications.
Another initiative which really impressed Becky and I was Option 2, a project developed in Cardiff by Rhoda Emlyn-Jones. Option 2 was a short-term crisis intervention service for families where there were serious Child Protection concerns and where substance use problems were an issue. It aimed at creating a positive change in the way that these families functioned.
Option 2 was based on a model of therapeutic intervention that had been developed over 20 years of evidence-based practice within the United States. Rhoda had been trying to develop the service in Cardiff for a number of years. With support from the DATF, she was able to set up the service and hire two Option 2 therapists, one being Mark Hamer with whom Becky and I spent a good deal of time.
Option 2 worked intensively with families over a four to six week intervention period where the therapist was available 24 hours a day, seven days a week. It focused on enabling people to learn and practice new skills so that children could remain safely in the family home without being placed on the Child Protection Register or being removed to alternative accommodation.
We were really impressed by this project and by Rhoda and Mark. Becky wrote an excellent report and we hoped that this would facilitate further funding for the Option 2 team, and an expansion of the initiative throughout Wales and further afield in the UK.
‘When you do your social work course you are taught, and it’s drummed into you, that people are the experts of their own situation. It’s like a buzz-word. People are the experts of their own situation. Then, you’ve got this in your head and you go out to do the work of removing the children, taking people to court and all the things that you do, and that gets lost. But, I’ve got that back, you know… You’ve just got to give people the time and the space and the environment to let you know what they know. And they will tell you what they know and they will help themselves.’
‘I think part of my role is about making people feel like a human being again. It’s about looking at the opportunities. I say, “There are real opportunities, you know. You’re not going to be a millionaire, you’re not going to have a great job and live in a wonderful house out in the country and have horses, you know. That isn’t going to happen. But what is going to happen is that you are going to be able to walk out your front door with your head up high, smiling. With happy children and doing the things that you need to do. And be pleased…and be pleased to be going out and be pleased to be coming back home again. You can do that you know, and that’s real.'” Mark Hamer, Option 2 therapist
‘Option 2 has made me become the person that I want to be, not the person I would have become, a druggie, hopeless, lost my kids and everything.’ L, a mother on an Option 2 evaluation form
‘… extremely helpful at putting back the perspective in my family life … helped me to deal positively with the past and get control for the future. It has helped me to view myself and my role as a parent in a much more positive light.’ E, a mother on an Option 2 evaluation form
All these years later, as I write this section, I find a 2009 presentation on Option 2 by Rhoda Emlyn-Jones OBE, on the Society for the Study of Addiction website.
‘The Option 2 experience: Delivering Services though families: Impact on policy and practise.
‘This presentation considers the key elements of effective family focussed interventions with families affected by serious parental substance misuse issues and child welfare concerns. What’s working and why?
It will explore the nature of service design in adult and children’s health and social care provision and the context within which family services are now emerging. How should we be planning for the development of core competencies, models and structures that support best practise in the wider workforce. How can the lessons of the last 10 years influence the growing policy agendas. Do family focussed interventions herald a new dawn providing a platform for shared professional skills and understanding and a new policy framework.’
You can see and download Rhoda’s presentation here.
Reference:
[1] U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. Office of the Director, Office of Strategy and Innovation. Introduction to program evaluation for public health programs: A self-study guide. Atlanta, GA: Centers for Disease Control and Prevention, 2005.
David Clark (Professor Emeritus of Psychology) spent nearly 20 years working as a neuroscientist, first training as a postdoctoral fellow with Nobel Laureate Arvid Carlsson and then running his own university research laboratory for 14 years. He closed down his laboratory at the beginning of the new millennium, since he did not feel that neuroscience was helping people overcome drug and alcohol addiction.
David developed the grassroots initiative Wired In and online community Wired In To Recovery in order to empower and connect people to facilitate addiction recovery. Wired In played a significant role in the development of an Addiction Recovery Advocacy Movement in the UK.
After moving to Perth, Western Australia, in 2008, David became increasingly interested in trauma—and the healing of transgenerational trauma amongst Indigenous people—resilience, and the healing of trauma. He currently runs the Recovery Stories and The Carrolup Story websites (the latter with John Stanton), and has published two related eBooks, the details of which can be found on these websites. ‘My Journey’ is a serialised account of his career and wide-ranging activities, and the people who have inspired him.
