Monitoreo, Acompañamiento y Evaluación

The Prison Drug Treatment Strategy Review Group are asked to determine and agree the key outcomes needed for prisoners and offenders, both in prison and on release into the community.

2. BACKGROUND CONTEXT

2.1 In considering the above, the Review Group must take into account and have an understanding of the national context and the key factors that are currently shaping the drug treatment sector and which may have an impact in determining outcomes for drug- using prisoners and offenders. These are briefly summarised below:

The 2008 Drug Strategy

The National Drug Strategy, Drugs: protecting families and communities (2008), provides the policy context within which the work of the Review Group, including work on

outcomes, must be considered. The Drugs Strategy features an undertaking to get drug- misusing offenders into effective treatment and to improve prison treatment

programmes. The strategy also concentrates more on families, addressing the needs of parents and children, and working with whole families to prevent drug use, reduce risk, and get people into treatment (see Sections 6 and 7 of this paper).

Treatment Effectiveness

2.3 National and international evidence shows that good quality drug treatment can be effective in reducing illegal drug use, improving the health of drug users, reducing drug-related offending, reducing the risk of death due to overdose, reducing the risk of death due to infections (such as blood borne viruses) and improving social functioning. 2.4 With the development of the National Treatment Agency’s (NTA) Models of Care for the treatment of adult drug users: Update 2006, there has been a greater focus on improving drug users’ experience across the treatment system. It is recognised that drug treatment is not so much a singular event as a process, usually involving engagement with different drug treatment services, perhaps over many years. Every drug user’s treatment needs are different and depend on a range of factors that often vary across time, including health status, relationships, accommodation, nature of the drug problem and the quality of the drug treatment or treatments they receive.

2.5 Drug treatment use is also often episodic, with drug users dipping in and out of treatment over time. Evidence indicates that entry into treatment often has an

The ‘Recovery’ Debate

2.6 There is an ongoing debate in the UK that has misleadingly portrayed abstinence and maintenance approaches to drug treatment as an antagonistic ‘either/or’ issue, with little reference to the evidence on treatment effectiveness, which indicates a treatment system should be composed of a range of different services to meet different needs. 2.7 This debate appears to be diverting attention away from key issues such as whether drug users in need of treatment have enough choice, the variability in quality of services, and the focus on outputs such as numbers in treatment, rather than outcomes. 2.8 The UK Drug Policy Commission established a consensus group to agree a

definition and published a vision statement in their document The UK Drug Policy Commission Recovery Consensus Group. A vision of recovery (July 2008):

‘The process of recovery from problematic substance use is characterised by voluntarily-sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society.’ Effective Drug Treatment in Prisons

2.9 There is no doubt that prison presents a great opportunity to help those who want to be drug free. There are now increasing opportunities for drug-using offenders in prison who are assessed as requiring drug-replacement for a period of time. Effective drug treatment raises considerably the quality of prison life, for example, reduced illicit drug use by an offender can result in better health outcomes for that individual. 2.10 Prison treatment goals have a key influence on the treatment modalities available in prison and on defining prison treatment outcomes. Treatment goals will depend very much on individual need at the time. The effectiveness of prison

treatment, when judged against most potential outcomes, is influenced by Prison Service treatment policy, which is to provide appropriate treatment and support for those who have the goal to be drug free (this may be a less realistic goal for those in prison for only a short length of time).

Reintegration/Continuity of care

2.11 The effectiveness of prison treatment is influenced as much by the interventions and support received in the community and the extent to which reintegration needs are met. If accommodation needs, benefits support, education and training, family linkage and ultimately, employment needs are met, most drug treatment modalities, wherever delivered, are far more likely to be effective. If these needs are not met this will reduce considerably the likelihood of successful reintegration.

2.12 This effect is much more pronounced for those staying in prison for short periods of time (the majority of prisoners).

2.13 The above issues are discussed in more detail in the attached Annex A. 3. ESTABLISHING OUTCOMES IN PRISON

3.1 The range of existing outputs data, outcomes, surveys, etc. presents potentially a very complex picture that creates difficulties in establishing and measuring prison treatment outcomes. Whilst some treatment outcomes may be common to all prisoners, outcomes may vary considerably and in a way that is not always readily quantifiable. Factors that will have an impact include:

• Gender, age, ethnicity;

• Nature/severity of drug dependency; • Treatment goals;

• Type and quality of treatment provided; • Extent of co-morbidity;

• Levels of accommodation and support post release • Length of time in prison; and

• Discharge distance from home.

3.2 Thought clearly needs to be given to establishing an outcome based model or framework, which should be considered appropriate for use.

3.3 Arguably, the key outcome measure of interest to the public will be of sustained stability post-release (however, this is measured e.g. reduction in illicit drug use, sustained abstinence, reduction in crime, etc.). However, other measures, such as health outcomes should also be considered, including prevention of the spread of blood borne viruses.

3.4 Another key question to consider is whether it is best to focus on developing a few high-level outcomes that apply universally to all prisoners or develop a more complex matrix of outcomes, which more closely reflects prisoner segmentation. Thought also needs to be given to how all potential outcomes are measured. 3.5 The Review Group will need to make decisions as to what can be used as ‘evidence’ i.e. there is a risk that if the Review Group is too restrictive as to what is evidence they may miss the opportunity to develop key outcomes but if the Review Group is too flexible they may lead to straying from effective, evidence-based practice. 3.6 Therefore, the Review Group need to consider a programme of work that determines:

• What are the key outcomes for offenders in prison and for offenders on release into the community (i.e. continuity of care);

• What are the existing initiatives and strategies that would have an impact on this work, such as the Reducing Re-offending National Action Plan, the Drug System Change Pilots, The NHS Operating Framework, Treatment Outcomes Profile (TOP), etc.; and

• Users and carers views on what constitute desirable outcomes.

3.7 There is a wide range of literature on outcomes, so to assist the Review Group the attached paper in Annex 1 is intended to provide a summary of the issues to help inform discussions, but it is important to note that the information provided is in no way definitive. The attached summary paper includes:

• Background information on outcomes measures; • Factors that affect outcomes in prisons;

• An outline of Government targets; and

• An outline of existing relevant output data/information, outcome measures and surveys, etc.

3.8 The attached paper (Annex 1) needs to be read in conjunction with the paper on the evidence-base.

Annex 1

REVIEW GROUP SUMMARY PAPER ON OUTCOMES

1. INTRODUCTION

1.1 The last ten years have seen significant improvements in the provision of drug services. There are now far more people in treatment than ten years ago, waiting times have fallen sharply and there is a range of good practice in multi- agency working.

1.2 _{The Drug Strategy acknowledges that while there have been successes}

particularly in fast-tracking people into treatment, there is a need to focus more upon the outcomes of treatment, including its impact on crime, health, and harms caused to families.

1.3 _{Treatment to address drug use can take many forms. The evidence base informs}

national policy and the regional and local decisions that are made to provide the best outcomes for those using drugs, both in prisons and in the community. There is evidence that interventions, which aim to reduce offending by addressing the drug use of dependent users who offend, do work to reduce offending. Research shows that drug treatment can achieve reductions in offending behaviour.

1.4 _{The Drug Strategy also states that aftercare and wraparound provision are}

associated with better outcomes for prisoners. Treatment is often most effective when combined with additional support to tackle the underlying contributory issues such as homelessness, long-term unemployment or mental health problems. Evidence cited by the Drug Strategy, for example, demonstrates that mental health problems suffered by drug users, left unaddressed, can impact negatively on drug treatment outcomes.

1.5 _{The Price Waterhouse Cooper (PwC) report, Review of Prison-Based Drug}

Treatment Funding (2007) was conducted within the policy context of the Drug Strategy. The PwC report considered what realistic, achievable and measurable outcomes could be set for the provision of drug treatment in prisons. The report’s recommendations on outcomes are to:

• Articulate and agree the key outcomes for prisoners and offenders in prison and in the community;

• Demonstrate how the partner organisations will work together to successfully deliver those outcomes;