Youth Justice Board

SUBSTANCE MISUSE SERVICESIN THE SECURE ESTATE

2009 © Youth Justice Board for England and WalesMaterial may not be reproduced for commercial purposes.

ISBN: 978-1-906139-64-3

Acknowledgements

The Youth Justice Board for England and Wales (YJB)would like to thank Galahad SMS Limited for theirwork in compiling and writing the full report on whichthis summary is based.

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05 Background

06 Aims

07 Methods

08 Substance misuse levels

09 Substance misuse services10 Implementing the national specification11 Substance misuse service integration

12 Meeting needs effectively12 Multiple needs12 Dual diagnosis12 Females13 Black and Minority Ethnic offenders13 Young people on long-term sentences14 Young people on remand

15 Identifying best practice

16 Aftercare

17 Data monitoring

CONTENTS

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05

In 2003, the Youth Justice Board forEngland and Wales (YJB) securedfunding for an initial three-year periodto develop integrated substancemisuse services for the secure estatefor children and young people. As partof this project, the YJB allocatedfunding to secure estateestablishments to aid the developmentand delivery of substance misuseservices. To support the roll-out ofthese new services and promote bestpractice in service delivery, the YJBdeveloped the National Specificationfor Substance Misuse for Juveniles inCustody (‘national specification’). Thiswas introduced across the secureestate in 2004. This nationalspecification framework was based onbest practice guidance and qualitystandards gathered from a number ofsources, covering five main elements:

1. identification and assessment

2. education and prevention

3. support and programmes

4. detoxification and clinicalmanagement

5. throughcare and resettlement.

In 2005, Galahad SMS Ltd wascontracted by the YJB to evaluate howwell the national specification had beenimplemented, and to highlight areas ofdifficulty with implementation. Theevaluation was conducted over twoyears, from 2005 to 2007, but drew oninformation and data, such as businessplans held by the YJB, which datedback to 2004. The evaluation exploredstaff’s experience of substance misuseservices and the extent to which theseservices met young people’s needs.

This summary is based on theevaluation findings.

BACKGROUND

The research evaluated:

• implementation of the nationalspecification

• substance misuse serviceintegration

• how well the secure estate meetsthe substance misuse needs ofyoung people in its care.

It also:

• looked at possible exceptionalneeds of certain groups includingfemales, Black and Minority Ethnic(BME) young people, those servinglong-term sentences and youngpeople on remand

• compared community and custodialsubstance misuse services

• reviewed promising practice

• examined data monitoringpractices.

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AIMS

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Seven case study sites were selectedfor in-depth reviews, and quantitativeand qualitative data was gathered fromstaff and young people in the secureestate. This included:

• 231 face-to-face interviews withyoung people

• 255 self-report questionnairescompleted by young people

• 96 follow-up interviews with youngpeople

• 69 in-depth interviews with staff.

Information on the range of substancemisuse services available in eachestablishment was collected via survey.Additional information was gatheredthrough analysis of the establishments’own audits, where provision ofsubstance misuse services wasmapped against the nationalspecification to identify areas of non-compliance.

METHODS

SUBSTANCE MISUSE LEVELS

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This research shows that young peopleconsume high levels of alcohol anddrugs prior to entering the secureestate. Before coming into custody,67% of the young people got drunk atleast once a week, and 16% weregetting drunk every day.

The proportion of young people incustody who drank on a weekly or dailybasis before they entered the secureestate has fallen from 74% in 2003 to64% in 2006. However, the proportionwho engaged in binge drinking at leastonce a week has increasedsignificantly, from 59% to 66%.

Up to 84% of the young people whowere interviewed could be consideredproblematic or potentially problematicsubstance misusers.

Use of the following drugs by youngpeople in the secure estate during theprevious year declined significantlybetween 2003 and 2006:

• cannabis – 83% to 75%

• ecstasy – 44% to 38%

• crack – 22% to 9%

• heroin – 13% to 1%.

The proportion of young people usingcocaine, however, remained largelyunchanged at 33% (from 32% in 2003).Of the 231 young people interviewed,53% said that members of their familyused drugs. Ninety of these youngpeople identified which familymembers used, of whom 39%described one or both of their parentsas drug users.

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Since coming into custody, 57% of theyoung people surveyed had beenoffered two or more substance misuseservices, but 20% said that they hadnot been offered any services at all.

More than 70% of those who wereoffered a service accepted it. All youngpeople who were offered a room on adrug-free wing and counselling forpersonal problems accepted.

Sixty-one percent of young people incustody wanted to make changes totheir substance-using behaviour, butonly 34% actively sought help while incustody.

The overwhelming majority of youngpeople coming into custody (84%) had,at the very least, Tier 2-level needs.1

Interviews with young people suggestthat few were offered the full range ofservices available within establishments.However, this may be because not allyoung people are eligible for certainservices, or because services may beoffered on the basis of young people’sassessment results.

The research also shows that:

• the percentage of establishmentsusing brief interventions rose from59% in 2003 to 96% in 2006

• the percentage of establishmentscarrying out harm reduction workrose from 3% in 2003 to 96% in2006

• between 2003 and 2006, theprovision of pharmacologicalmaintenance services increased byalmost 100%

• by 2006, 96% of establishmentsscreened all young people for druguse, and 92% screened all youngpeople for alcohol use.

Surveys completed by staff about theservices available in theirestablishments showed that in 2005,88% of establishments offered non-targeted (Tier 1) alcohol education, and100% of establishments offered non-targeted drug education. Targetedsubstance misuse education wasoffered by 96% of establishments.

SUBSTANCE MISUSE SERVICES

1Substance misuse services for young people are typically seen to fall into four tiers of servicedelivery. Tier 1 services are universal services foryoung people to promote health and prevent theonset of drug use. Tier 2 services are targetedservices for young people at increased risk ofsubstance misuse. Tier 3 services are specialistservices for those currently using substances.Tier 4 services are very specialised services foryoung people with intense problems associatedwith substance misuse.

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• young offender institutions (YOIs)achieved 32% compliance in 2004,rising to 63% in 2006, whichrepresents remarkable progress in ashort period of time.

The six most common reasons givenfor non-compliance were:

• targets were perceived as beingbeyond the authority or remit of thesubstance misuse manager

• units had resource or recruitmentdifficulties

• systems were under developmentwhen the business plan was beingcompleted

• the service requirement was notdeemed achievable

• staff disagreed with the relevance ofthe service requirement

• the target was met, but not in themanner described.

Although progress has been made withimplementation, gaps in provision doexist within the national specificationframework itself, particularly for:

• young people on remand

• highly mobile populations

• females

• BME young people

• those on long-term sentences.

Although most service requirementsand objectives in the nationalspecification were considered realistic

In 2006, some of these figures haddropped, with 76% of establishmentsoffering non-targeted alcohol educationand 76% offering non-targeted drugeducation. Targeted substance misuseeducation was again offered by 96% ofestablishments.

Overall service-user satisfaction withservices was consistently above 60%and usually over 70%. Since 2003,there had also been a noticeableincrease in the number ofestablishments offering services inmost tiers.

Although this study found that fewerestablishments were offering Tier 1substance misuse services in 2006than in 2005, an increased number ofestablishments were offering Tier 2, 3and 4 services.

None of the establishments had theireducation programmes evaluated byindependent organisations.

Implementing the nationalspecificationProgress has been made in all areas ofcompliance with the NationalSpecification for Substance Misuse:

• secure training centres (STCs)achieved the greatest level ofcompliance, rising from 71% in2004 to 89% in 2006

• secure children’s homes attained81% overall compliance

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Factors that were found to undermineeffective integration included:

• lack of consistency andstandardisation in assessmentpractices

• lack of coherence in practicebetween the YJB and the HerMajesty’s Prison Service, and anunnecessary divide betweenpractice, systems and tools used insecure children’s homes, STCs andYOIs

• lack of clear guidance andstructures for integration, such asprotocols and enhanced servicelevel agreements

• lack of money for training and forimproving the integration ofcustodial and community servicesto facilitate a young person’stransition to and from custody

• lack of communication andintegration of working practicesbetween the secure estate andcommunity services

• the physical distance of thesubstance misuse team from otherunits; where there was closeproximity between the substancemisuse team and other units, thiswas found to positively influencethe ability of the substance misuseteam to integrate with other multi-disciplinary team members.

and relevant by secure estate staff,some were not. Most staff membersfelt that a detailed review of theframework, objectives and servicerequirements would be helpful.

Substance misuse serviceintegrationAt the time of the study, noestablishment was classified as havinganything less than ‘good integration’. In all seven case study sites, multi-disciplinary working was seen to haveincreased substantially since 2003.

Data suggested that the integration ofsubstance misuse services in thesecure estate is progressing well, andthe national specification has had apositive influence.

The extent to which the five elementsof the substance misuse service wereintegrated far exceeded expectations.It would appear that a major culturalchange in working practice is takingplace.

In most sites, substance misuseservice provision had become firmlyintegrated into decision-making bysenior management. It was generallyagreed that the national specificationfacilitated integrated policy, strategyand practice. There is still a great need,however, for senior management totake responsibility for cross-departmental compliance.

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Multiple needsThe needs of young people in custodystretch beyond substance misuse.Young people entering custody oftenhave a number of problems that co-exist with their substance misuse,and need realistic remedies for a hostof common problems, such as:

• lack of secondary school education

• the influence of close familymembers who use drugs

• uncertainty about accommodationupon release from custody

• drug dealing by young people

• mental health issues.

Dual diagnosis2

Evidence from staff interviews andsurvey responses suggested thatmental health screening waswidespread, with most establishmentsassessing for such problems. In 2005,72% of establishments screened allyoung people for mental health issues;in 2006, this had increased to 92%.

Overall, 62% of the young people saidthat they had used substances forreasons that might indicate mentalhealth or anger management issues.

Of the young people surveyed, 14%had overdosed at some point in theirlife, and in 34% of those cases, the

overdose was deliberate. This alsosuggests that, for young people,mental health concerns were oftenlinked with substance misuse issues.

FemalesYoung females in the sample weresignificantly more likely to have beenheroin and crack users than youngmales. Females were also significantlymore likely to be offered detoxificationmedication in custody than males(females 20%; males 4%),demonstrating perhaps that theirgreater need is being addressed in thesecure estate.

More young females than young malesreported potentially problematicalcohol use (females 73%; males 61%)and binge drinking (females 86%;males 78%).

Significantly more females reportedthat they had overdosed at some stagein their life (females 34%; males 12%).More worrying figures showed that, ofthose who had overdosed, over half ofthe females reported that they haddone it deliberately (females 58%;males 19%). There was little evidencethat the majority of staff members wereaware of this key difference in riskbetween male and female offenders.

MEETING NEEDS EFFECTIVELY

2Dual diagnosis is a term used to describe thecondition of people who have co-existingsubstance misuse and mental health problems.

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Many young females interviewedexpressed frustration at the non-participatory, overly structured andnon-interactive nature of theinterventions offered.

Black and Minority EthnicoffendersMost units were aware of the differentcultural, religious and language needsof BME groups, and took steps toensure that those needs were met. Thisusually took the form of practicalinitiatives, such as making informationavailable in different languages, rightthrough to consideration aboutreligious practices. These efforts weregenerally well-appreciated by theyoung people.

However, compared with services inthe community, there was lessevidence of systematic consultationwith BME young people aboutservices, and less evidence ofavailability of BME-specificprogrammes.

Compared to White offenders,significantly fewer young BMEoffenders reported using drugs in thepast year (BME 71%; White 83%),potentially problematic drinking (BME40%; White 74%) and binge drinking(BME 59%; White 86%).

BME offenders appeared reluctant toaccurately self-report specificsubstance misuse, possibly due to thewell-documented stigma attached tosubstance misuse. Staff were aware ofthe stigma and denial of substance

misuse in certain cultures, and tookaccount of this in the provision ofsubstance misuse services to BMEoffenders.

BME offenders were significantly morelikely than their White counterparts towant more help than they had beengiven, either in custody or on release(BME 29%; White 18%).

Young people on long-termsentencesIn contrast to findings from otherpublished studies, young people onlong-term sentences involved in thisstudy reported slightly lower (pre-custody) drug use than other offenderswho were not on long-term sentences.The three drugs used most prevalentlywere:

• cannabis

• ecstasy

• cocaine.

Young people on long-term sentenceswere significantly less likely to havebeen either permanently or temporarilyexcluded from school than those onshorter sentences (offenders on long-term sentences 47%; other offenders65%). They were also significantly lesslikely to be offered:

• advice from a substance misuseworker

• an assessment of their drug andalcohol use

• complementary therapies

• detoxification medication.

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This is disappointing, as 73% reportedthat they had considered makingchanges to their substance misusewhile in custody.

There were many comments praisingthe attitudes of staff who took the timeto build a rapport with seriousoffenders on long-term sentences, andto see their potential. There wasevidence that such positive attitudescontributed to offenders’ academic andcareer ambitions, and their hopes for abetter future on release. Staff inspecialist units set a positive examplefor the rehabilitation of society’s mostserious young offenders.

Young people on remandYoung people on remand appeared tohave more difficulty coping withoutalcohol or drugs than young peoplewho had been sentenced, perhaps dueto the uncertainty of their situation.

Compared to previous studies,significantly fewer appeared to be atrisk of deliberate self-harm, deliberateoverdose, or suicide. YOI staffappeared to have a greater awarenessof the risk.

Young people on remand were morelikely to receive drug testing than thosewho had been sentenced (remand58%; sentenced 45%) and advice froma secure establishment-based drug/alcohol worker (remand 70%;sentenced 50%), though they were lesslikely to receive drug and alcoholcounselling (remand 28%; sentenced40%).

These figures suggest that youngpeople on remand may only receivebrief assistance with their substancemisuse due to their transitory paththrough custodial care, and that theymay miss out on the more intensivetreatment services.

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Within the secure estate, the conceptof ‘best practice’ is poorly understoodand requires clarification. With oneexception, no substance misuseprogrammes met best practice criteria,and there has been no overarchingquality control or evaluation system forthe programmes on offer.

Some examples of promising practice3

were:

• a solution to ensure continuity oftreatment for hepatitis Binoculations

• the development of a qualityassurance tool and system

• systems to help young peopleparticipate more actively in thedevelopment of services

• a multi-disciplinary model ofmanaging detoxification andprescribing activities

• a training system for managingconflict with young people.

3Defined as work that may not have beenevaluated, but which presents useful solutions tobarriers commonly faced in delivering substancemisuse services.

IDENTIFYING BEST PRACTICE

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Secure establishments play a vital rolein helping young people to learn usefulvocational skills, and in supportingresettlement arrangements.

Aftercare needs identified include:

• post-custody accommodation

• help to find employment or supportwith returning to education

• diversionary activities to providedistance from drug-using lifestyles

• preparation to reduce the likelihoodof relapse into a previoussubstance-misusing lifestyle.

Many of the young people were veryhappy with the skills that they hadlearned while in the secure estate,particularly the trades they hadacquired. Others said that YOTworkers had helped them to findvocational training and educationcourses while in the community.

YOI staff reported that new paperworkand protocols had improvedcommunication during transfers, and anew programme introduced in YOIscalled ‘Better Choices’ had enabledwork with young people to continueafter transfers.

However, the variation in substancemisuse service provision throughoutthe secure estate meant that careplans devised in one unit could notalways be continued after transfer. Thislack of continuity was noted both bystaff and some young people; it meantthat care plans were being shaped byavailable resources rather thanindividual need.

It was found that most establishmentsneed to improve co-ordination foryoung people who are released into thecommunity.

AFTERCARE

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Substance misuse managersrecognised the benefits of gatheringdata from the entire secure estate. Inparticular, they believed that it couldhelp improve the delivery anddevelopment of substance misuseservices.

But they felt there was an absence ofappropriate measures on the data-monitoring forms that they completefor the YJB. They thought themeasures should be reformulated and:

• made appropriate to substancemisuse services

• be capable of informing programmedevelopment

• provide evidence of inputs andoutputs.

Staff submitting the information saidthey would benefit from clearerguidance, feedback on theirsubmissions and greater balancebetween information requestedbecause it is essential and informationrequested because it is useful.

DATA MONITORING

Stock code: B445

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