Is the NHS just too important to be controlled by politicians?

The latest policy disaster currently affecting the NHS has put it into sharp focus - not only as institution but as saver of life and national treasure. It has also made me consider more deeply the unique position it occupies in our collective consciousness.

I can tell you a tale of its life saving accomplishments, of selfless nurses and committed doctors. Tales of compassion and hope, of the role it plays in the start of life and the dignity it provides at the end.

But, I can also tell you of the nurses with no time or emotion to spare, of dirty sheets and terrible food. Tales of despair and horror, of mistakes made and the loss of dignity at the end.

This is not unique, and I would imagine most of us have seen the NHS at something approaching its best and its worst. But if your anything like me that doesn’t stop you loving it, for all it can be and all it is, limitations and all. Don’t get me wrong I’m not a fundamentalist, I would like to see reform in some areas but I’m becoming increasingly convinced that politicians are not the correct people to drive that change.

As someone who has worked within the NHS I was always impressed that it worked at all, that it didn’t just all collapse under its own weight, like a patient on the gastric band waiting list.

So whilst the criticism of the NHS by the coalition and the plans to reform it didn’t come as a total shock, it certainly took me by surprise given that they didn’t give any warning like, I don’t know, actually putting it in a manifesto maybe?  No, that would be too easy they must have said, people might not like that, you know what let’s just get elected then just change it all anyway.  

Not long ago Andrew Lansley was lauded as a leader, someone who could drive change and modernise the NHS. The NHS was failing, unsustainable and stifled competition. It was too beauracratic, wasteful and led by the wrong people. GP’s are the people to lead the NHS given that they work on the frontline, let’s give them the money and let them spend it. Get rid of the PCT’s and save the nation a fortune.

What a difference a day makes (or several months) fast forward to the present and Lansley is political death and his reforms lie in tatters. Why? Because it doesn’t appear he did the thing that people usually do when they want to change something.

Ask the people who know about it, will be affected by it and care about it.

On that basis that’s everyone.  

The NHS for me is not like other elements of government, its not transport or highways or overseas aid, it’s not trade and industry or even the military it occupies a different space altogether and one which people are far less likely to go quietly into the night when changes are proposed. We are all heavily invested in its past, present and future and we cannot allow it to be destroyed by those who believe it to be just another public service which can be 'modernised', reformed and used for political capital.

When politicians can prove they have its best interests at heart then I will agree they are the correct people to be custodians of it. What their latest proposed reforms have shown is their inability to understand it, both as service and institution and a lack of respect for those who care about its future direction.

The real irony is that the coalition believe front-line medical practitioners are the correct people to decide how the resources of the NHS are distributed but they can’t help decide or be consulted on the future direction of it as an organisation.

Let’s just hope the coalition listening exercise moves beyond just that and they actually hear what the people of this country are saying.

Mark Bowles

The Training Effect

Young People and Drugs – Defining levels of use

Drug use amongst people of any age can be categorised into three main categories: Experimental, Recreational and Problematic.

For specialist and non-specialist practitioners alike an ability to indentify levels of use and thus act accordingly and in the clients best interests is key to effective intervention. Levels of use can go up and down and what may be recreational use for one young person may well be problematic for another.

The following articles aims to provide a brief outline of the levels of use to provide practitioners with an initial picture of the issues that may be present for clients who find themselves at each stage.

Experimental

It stands to reason but everyone’s initial use of a substance is, by definition experimental. Reasons for use at this stage may include availability, curiosity, peer influence, initiation and anticipation of positive effects.

Experimental drug use amongst adolescents should not be viewed in isolation as it represents a wider desire amongst this group to attempt and try a range of new experiences. Not all experimental drug and alcohol users move on to use substances recreationally.

For adolescents they may remain experimental drug and alcohol users for some time, it should not be viewed as a time limited stage of use. Some adolescents may only choose to use substances when they are available, which may be infrequent. The lack of seeking the drug out, or those using it, can be a further sign of experimental drug or alcohol use.

It is also not true that all experimental drug and alcohol users are adolescents, many adults may also experiment with drugs and our alcohol at any stage of their lives.

Recreational

Those that have experimented with drugs and or alcohol may choose to remain at the experimental stage. They may however move on to become recreational users of a particular substance or substances.

Recreational drug and or alcohol use can be thought about in terms many of us find familiar, given that we may be recreational users of alcohol. Recreational use can be identified by having set patterns to use (evenings and weekends possibly), a motivation to use to relax, pleasure is obtained from the experience and use often does not occur on consecutive days.

The user will also continue to function and complete everyday tasks that are expected (attending school, college, work etc). Often the user has found a drug of choice and has discovered how to enjoy and maximise its positive effects.

Problematic

As the name suggests problematic users of substances have progressed beyond the recreational stage and are now dependent on a particular substance or are now poly drug users.

Their behaviour and use has become problematic and the rules and boundaries which governed their recreational use have rapidly diminished.

Psychical and/or psychological are now present which furthers distinguishes the user from experimental and recreational users of substances. The reasons for use in the recreational stage have significantly altered, the process of obtaining the drug rather than the pleasure and relaxation provided by it has become the key driver. Any pattern of use (evenings and weekends) has vanished and the young person’s use has become more regular and less controlled.

Problematic users who are injecting are commonly exposed to further health implications if injecting equipment is shared. All domains start to be affected in this group: psychical, social, emotional and psychological. This group of young people will often have legal problems, be involved in the criminal justice system and experience worklessness.

Friends, family and former social and recreational activities become less important and the user often becomes isolated from former family and friends.

The information above is intended to provide a brief introduction, the most effective way to further educate yourself or your staff is through outcome focused workforce development programmes which can effectively support staff and equip them with the skills to effectively support young people with substance misuse issues when they first arise.

With better education on substance misuse we can reduce the harm they cause.

Mark Bowles

The Training Effect

Families With Complex Needs – An introduction to Intervention.

Families that have one or more parents with vulnerabilities or problems such as alcohol misuse, drug misuse, mental health problems, domestic abuse or criminal involvement are shown to have poor outcomes for the children as well as the adults. These problems are often overlapping creating complex families that present a challenge for services to deal with effectively. These complex families can cost public services between £250,000 and £350,000 a year to deal with.

Government policy and evidence of effective programmes support a move towards giving greater priority to vulnerable families, and adopting an approach to build their resilience through whole family assessments, whole family care plans and intensive whole family interventions.

If we can see these families coming (by identifying them through services or data) and know that they are not likely to do well in our normal service responses (by acknowledging the evidence of poor outcomes, difficulties in intervening effectively and the resultant high costs to public services), then we have a duty to do something different with them in future. We can intervene early rather than wait for a crisis to happen.

Adults who are parents and have more than one vulnerability is the norm for adult and children’s social care rather than the exception. The prevalence estimates we have generated show that these issues should not be considered to be a “hidden harm” or a specialist issue – these families form the bulk of those who regularly attend key agencies and should be considered a core issue and be afforded greater priority.

A more tailored response is needed from adult services for parents with multiple vulnerabilities as evidence shows that these parents are likely to drop out of standard support services or be hard to engage.

Strategically we should concentrate our resources where it will have the biggest impact, especially during a time of public sector spending cuts.

This means identifying and targeting high cost families with programmes that have been shown to work and save money.

The current set up of services encourages the fragmentation of families into individual members (adults and children) with numbers of individual problems dealt with separately, in spite of research demonstrating how linked these problems are and that parent’s affect the whole family’s outcomes not just those of the individual.

Intergenerational transmission, where many of these parental vulnerabilities mean that their children are significantly more likely to experience similar problems, typified by local case studies we were told about showing 2nd and 3rd generation drug misuser's and children in care, demonstrates the need to adopt a “never too late to intervene” principle to ensure that services do not give up on families or pre-judge their ability to improve.

The evidence shows that you can have success and change the lives of vulnerable families by pro-actively engaging them, building their resilience, reducing their risk factors and strengthening the family to cope by themselves in the long term.

There appears to be an opportunity for a “Win-Win” situation. By developing and building capacity for whole family interventions with families with complex needs, the evidence suggests that it can be better for the outcomes of the children and the adults in that family, whilst also serving to reduce the cost burden on social and health care, and even improving staff recruitment and retention.

In short, now is the right time to look again at families with complex needs and use the evidence and policy direction to change our approach for the better.

The above information was produced by our partner organisation Tonic as part of their work with local authorities and other providers to better support families with complex needs.

Alongside The Training Effect they offer a range of services that can help local authorities and other providers to better support these families, saving money, improving efficiency and improving outcomes for children and families.

For further information please take a look at our websites.

Mark Bowles

Families with Complex Needs – What should Local Authorities do?

The Issue A number of factors for parents impact on their ability to parent well and impact negatively  on their children in terms of both immediate safety and longer-term outcomes, including if a  child is taken into care. Most prominent amongst these vulnerabilities for parents are drug  misuse, alcohol misuse, mental health problems, domestic abuse and offending. These vulnerabilities are often linked, overlapping and mutually reinforcing.  Families with multiple vulnerabilities present challenges for services, cost the local authority  and health services significant amounts of money to respond to, and are difficult for staff to  work with effectively across social care and partner agencies. Policy Context The new Government has committed to helping families with multiple problems.  Nationally, there has been a raft of policies over the last decade placing greater emphasis on  the importance of the family, including Think Family, the Drug Strategy, the Youth Alcohol Action  Plan and Working Together to Safeguard Children guidance. What Works There is a growing evidence base to support the efficacy of whole family interventions that  demonstrate improved outcomes for vulnerable and complex families and provide evidence of  cost savings or cost avoidance for public services. These have been shown to be effective for  families with parental substance misuse, domestic abuse and mental health problems.  These programmes include Westminster Family Recovery Project, Family Intervention Projects,  Strengthening Families Programme, Option 2, M-PACT and Family Drug and Alcohol Courts. Delivery Options Using the evidence of what works and the local needs analysis, we have developed a set of  principles and characteristics of effective programmes that should underpin any future service  development, joint working protocols and training. We have also outlined three delivery models  to take this work forward: 1. A multi-agency joint working protocol 2. A programme of training, support and co-location 3. Adopting an evidence-based programme Identify Conduct an exercise to identify the top 400-600 complex families that cost local authorities the most money to deal with. Pool training resources by bringing together budgets, expertise, venues and  overlapping issues (e.g. parental drugs, alcohol, mental health, domestic violence)  into a single set of training programmes to: (i) help identifying agencies to spot signs  and engage complex families; and (ii) develop whole family working practices across  key agencies. Pool communications resources to ensure that key messages about working  with complex families go to all staff across agencies in a joined up way, spreading  evidence of what works. Commissioning priority should be given for parents with vulnerabilities and complex families,  with commissioners actively ensuring an appropriate response from service providers. Intervene Improve inter-agency working through developing and implementing a specific  protocol to drive improved joint working for complex families. Key agencies need to  sign up, setting out expectations and commitments from each agency in line with  evidence of what works. Consider adopting evidence based programmes to deal with complex families more effectively. Bridge the gap between adult and children’s services by joining up the safeguarding  functions and championing a multi-agency approach to complex families, in line with  evidence based programmes. Consider whether the current use of money for drug testing and substance misuse experts  in child care proceedings could be more effectively used to fund specialist drugs worker  input co-located with children’s social care to joint work these cases. Prevent Address the current gap in support after a child goes into care when parents have  vulnerabilities, by ensuring appropriate family strengthening support and parenting  skills for the parents and specific support for the children who may experience long term problems. Establish self support groups for parents (esp. mothers) going through these issues. The above information was produced by our partner organisation Tonic as part of their  work with local authorities and other providers to better support families with complex needs. Alongside The Training Effect they offer a range of services that can help local authorities  and other providers to better support these families, saving money, improving efficiency  and improving outcomes for children and families. For further information please take a look at our websites. Mark Bowles

Drug and Alcohol Testing – Pro's and Con's

This article is intended as a companion piece to our other article on drug and alcohol testing programmes. It aims to give a brief introduction to some of the common positives and negatives, pros and cons that can be encountered when organisations decide to implement testing programmes in their workplaces.

Pros of Drug and Alcohol Testing.

Increased Safety:

Drug testing in the workplace can make the workplace a safer place to be for employees and customers alike. In safety critical industries this increase in safety is magnified and the positives benefits of drug and alcohol testing programmes massively increased. Testing programmes can also offer piece of mind to employees and customers alike.

Reduces Accidents: 

Evidence exists which suggests that drug and alcohol use increases the risk of accidents in the workplace. Those under the influence of drug and alcohol whilst at work clearly increase the risk of workplace accidents. In industries where travel is an essential part of the role this risk of accidents increases greatly, given the well known increased risk of road traffic accidents by those impaired by drug and alcohol use. For employers with staff in this position it is their responsibility to ensure their staff are fit to travel on company business.

Good Practice:

For employers, the implementation of effective drug and alcohol policy is not just about drug and alcohol testing programmes. Employers will find themselves open to possible litigation if they do not have effective policies and procedures in place when problems arise. Employers have a responsibility under the misuse of drugs act 1971 to ensure that drugs are not used or possessed on their premises and have responsibilities under the road traffic act 1988 and the transport and works act 1992 if employees drive company vehicles. Employers also have legal responsibilities under the Health and Safety at Work Act 1974 and Management of Health and Safety at Work Regulations 1999. With this complicated policy and legal framework in mind, it is essential that organisations obtain professional advice to ensure that they are meeting their legal obligations.

Supportive for Staff with Substance Misuse Problems:

Companies with effective drug and alcohol policy in place are in a strong position to pro-actively support staff who may be experiencing difficulties with substance misuse. This support is not necessarily about detection through testing programmes, it is also about effective procedures that offer support and guidance to staff with substance misuse problems.

Cons of Drug Testing in the Workplace

Privacy:

Drug testing in the workplace can give an employer the option for staff to submit tests as a requirement of their employment. Some staff may consider this an invasion of personal rights, privacy and be discriminatory practice against employees, especially when there is no perceived cause to conduct a test.

Cost:

There is an inevitable cost attached to the implementation of drug and alcohol testing programmes. The different tests available (which are highlighted in another of our articles) all carry differing costs, timescales and accuracy. Whilst testing in safety critical workplace environments can pay for itself (as the cost implication if procedures are not in place can be extremely high) for other businesses the cost can be considerable, especially for large organisations with many staff to test.  

Issues of Trust:

If not properly managed drug and alcohol testing programmes can result in negative perceptions from staff to managers and vice-versa. A ‘them and us’ culture can develop in organisations with drug and alcohol testing programmes becoming an example of ‘managers not trusting us’ or ‘thinking we are all using drugs’. These issues are a clear example of the need for organisations to employ and consult with experts in the implementation of drug and alcohol testing programmes.

As we have seen organisations need to be aware of the positives and negatives of implementing drug and alcohol testing programmes to ensure that the desired and positive outcomes are felt within their organisations.

Without professional support and advice from specialist organisations it can be easy for programmes such as drug and alcohol testing to have negative implications and consequences unforeseen when first envisaged. Like many issues it is vital that professional advice is sought and heeded to ensure that organisations observe more ‘pros’ than ‘cons’ after implementation.

Mark Bowles

The Training Effect

Drug and Alcohol Testing – What are the options?

This article aims to provide information on the most common types of drug and alcohol tests currently available. For those wishing further information on the pros and cons of drug and alcohol testing programmes please take a look at my other articles.

Below are 4 of the most commonly used drug and alcohol testing methods. They vary widely In sensitivity, accuracy and accurate testing period. Like all medical tests accuracy can be affected widely by multiple factors.

   

1.     Urine Drug Screen

Urine drug tests are probably the most widely used option, certainly in the workplace. The test consists of a sample of urine being obtained from the employee; often this can take place at a off-site collection facility, the sample is then sent to a laboratory for testing.

On-site drug and alcohol testing is becoming more common, this allows results to be obtained at the workplace/collection site. This can represent a more cost effective option and can be very useful when ongoing testing is required, in a residential rehabilitation programme for instance.

2.      

            Hair testing 

    

    Hair testing represents a far more accurate and long term testing option than urine testing.  Hair testing represents a non-invasive testing option, one which can test for a large number of drugs and is relatively low cost. It has advantages over urine and saliva testing as it can detect substances in the system over a longer time period.

3.     Blood Testing

Blood testing is an invasive and rarely used testing option and is primarily used in medical settings in the context of a full toxicology screen. The accuracy of blood testing in the context of illegal drug and alcohol use is also of questionable value as any use would have to be relatively recent to be detected.

4.      Saliva / Oral Fluid based Screen

A very common example of drug and alcohol screening, often conducted with a swab inserted into the side of the mouth. This test is accurate only for relatively recent use, and as such can be of more use in transport situations and safety critical situations. These tests can give instant results and can be very useful in the workplace and in residential programmes where abstinence is required.

There is a responsibility on all employers to have an effective drug and alcohol policy in place, regardless if they implement an employee drug testing programme or not. Unfortunately many organisations still do not have robust policy in place, leaving themselves open to possible litigation.

Specialist and experienced organisations do exist however who can support organisations to develop effective approaches to workplace drug and alcohol concerns. This support ranges from training for managers and senior staff to policy development and consultation on the implementation of testing programmes.

What we can be sure of is the need for organisations in the public and private sector to ensure they have robust policy and procedures in place to manage drug and alcohol concerns as they arise, effective policy cannot prevent drug and alcohol issues but it can ensure that your business is prepared if and when they do occur.

Mark Bowles

The Training Effect

Families with Complex Needs – An Introduction

In the UK public services are facing unprecedented demand in a period of financial and political upheaval. A growing realisation across public services is the need to engage with families with complex needs, those presenting with profound and enduring health and social needs, the often named ‘high cost’ families.

For the past few years successive government initiatives have attempted to address this issue with varying degrees of success, the latest incarnation is the coalition’s flagship Community Budgets.

All of these governmental approaches have tried to reduce the costs associated with families with complex needs whilst at the same time improving outcomes for them.  This cost reduction and outcome improvement is achieved through a ‘joining up’ of services locally, mapping of resource to reduce duplication, increased efficiencies and where possible, the pooling of budgets and resources.

The current experience of social care services is that families with more than one vulnerability are the norm rather than the exception. These vulnerabilities or problems may include but are not exclusive to:  drug and alcohol misuse, mental health, involvement with the criminal justice system and domestic abuse. These vulnerabilities lead to not only poor outcomes for the adults in the family but also for their children. Where more than one vulnerability exists it does not butt up neatly against the other, it is the overlapping nature of these vulnerabilities and the co-dependency between them that causes the complex social problems that successive governments and successive interventions have tried to address.

These attempts have all been in reaction to the realisation that these so called high cost families can cost the taxpayer anywhere from £250,000 to £350,000 a year to manage, in real terms however the true cost is much higher. If we were to include educational costs and general services, or the reduction in taxation and NI from worklessness the quoted figure would increase exponentially.  Also, this figure doesn’t take into consideration the fact that often no perceptible improvement in outcomes for these families can be measured over the long term, effectively £250,000 to £350,000 of investment for no measurable return.

With the renewed focus on initiatives to support these high cost families local authorities are tasked to have full roll out of community budgets by 2013. This presents major challenges to commissioners, providers and local authorities in a time of cuts to public spending at every level.

The challenge for local authorities and commissioners cannot be underestimated, tasked as they are with finding ways to improve outcomes for these families, interpret and deliver effective interventions as part of community budgets, effectively evaluate these programmes, reduce cost and pool budgets across localities.  The need for effective support from specialist providers with experience of these approaches at a local and central governmental level will be vital to ensure successful delivery.

What we can be sure of is the need for co-ordinated approaches to ensure that community budgets can achieve its fundamental aim, the reduction in reliance on the state by complex families.

Mark Bowles

The Training Effect