CGL Women’s Hub: A new Treatment Pathway?

Ideas about who uses drug and alcohol services and how they use them need to be challenged. In Hastings, the CGL Women’s Hub has been quietly doing this. However, in the run up to the publication of a report on its work, the noises coming out of the Women’s Hub are getting louder.


In a way it’s a simple idea. Create a place where service users want to go, that meets their needs… and meet them there.

CGL (or Change Grow Live to give it it’s full name), is the main provider of drug and alcohol support services across Sussex. In August 2021, a new initiative with Fulfilling Lives saw the appointment of Rachel Payne, a practice development worker who identified a need for better treatment pathways for women. Nationally, treatment services have seen considerably more men access their services than women (69% to 31%, PHE 2020). For many this has reinforced the idea that men are more likely to need the service. However, there are a few working in these services who have been questioning whether the way a service is offered can be a barrier to more women accessing effective treatment. The CGL Women’s Hub seems to suggest this is the case.

Katie Lowe went to the weekly Women’s Hub to see first-hand what is happening at a service which is seeing a 78% increase in engagement compared with keyworker meetings and a nearly 300% increase in their participation compared to groups run out of their high street offices. As a psychology student on placement with Fulfilling Lives, Katie had no previous experience with drug and alcohol services and really didn’t know what to expect:

When I got there, I was given a warm welcome and encouraged to get involved in the craft session that had already started. I later found out this is run every week by one of CGL’s volunteers. What struck me early on was how much everyone seemed to want to be there. Not just the women but the staff too. Rachel filled me in on the details: The Hub meets every Tuesday at a local community venue. This allows the service to provide an inclusive women-only space. This neutral venue is not associated with medical treatment, men who may or may not pose a risk or the stigma of being seen walking in from a busy high street. Deciding to run it on a Tuesday was not an accident. Rachel mapped out the other services women might want to attend and found a space that didn’t clash. Staff at the Hub have encouraged women to try out these different services, with small groups arranging by themselves to go together. In some cases, their participation has gone from just turning up for a required medical appointment to attending multiple support groups across the week.

Women can come and go as they please, take part in any of the available activities or just sit and chat. It’s their choice. With an average of 2.6 hours spent at the Hub when they do go, it suggests they get involved in a lot. Local charity Dom’s Food Mission provides supplies for breakfast and lunch. There’s the 2-hour creative group which I dropped in to, often running alongside a beautician offering hair and nail treatments and once a month a hairdresser. After lunch there is an accommodation specialist on hand for drop-in advice, a space to generally chat and get support and regular visits from an NHS sexual health nurse (who reports being able to see as many clients in an hour at the Hub as a whole day trying to meet them in the community). Then there’s acupuncture with a guided meditation followed by a yoga session before everything ends at 3pm. Coming together in this way has allowed women to meet with friends and make new ones in a place that feels safe. It seems to restore social and relational experiences in a way that feels normal in a sector where treatment can be retraumatising for many women.

Friendships, community, meals and clothes are all things we can take for granted if we are not dealing with multiple complex needs. However, Rachel will tell you this busy schedule wasn’t always the plan. Local services have been as much drawn to the Hub as the women themselves, offering support and staff time, all focused on a shared desire for women to get the service they need. Outreach workers, care coordinators and keyworkers from CGL, Seaview and Project Adder have all been involved in running and planning activities. Others have provided quality clothes donations and the combination of a local branch of Tesco and the Hygiene Bank provided items to give to women for free.

Taking this approach has the potential to make a huge impact on the way substance misuse services are structured, and how clients access treatment. There are spaces at the Hub for care coordinators and outreach workers to meet confidentially with women. The Women’s Hub has also been used by occupational therapists, domestic violence workers from Respite Rooms, HomeWorks and the Rough Sleepers Initiative, to meet clients and connect them to CGL’s treatment pathway. So far there’s been cases of women accessing CGL treatment by coming along to the Hub, assessments being carried out at the Hub, and this has even led to women going to detox and rehab. In a way it’s a simple idea. Create a place where service users want to go, that meets their needs… and meet them there. The statistics back this up as a place women with multiple and complex needs want to go. Since it began in November 2021, the Hub has seen 47 different women with an average attendance of 63% – no mean feat for a weekly programme with a service user group often considered ‘difficult to engage.

With Rachel’s own interest and the years-long investment of Fulfilling Lives in specialist women’s services, this approach made sense. However, there is already talk of how this approach might better meet the needs of other marginalised and minority service user groups who are not accessing treatment at CGL’s main offices. With 65% of service users accessing treatment by self-referral or through family and friends (PHE 2020), creating spaces that feel safe for marginalised people will be vital to genuinely inclusive treatment pathways.

Providing the service is inexpensive, with activities and groups being offered free of charge by the different services involved. Many of the staff can use the space to do work that they would have been doing anyway and reach several clients at the same time. There is a small cost for venue hire and arts and crafts projects but that is easily justified by the reach of the service. Creating and chatting with other women is what makes the Hub what it is. Rachel and the team are using these activities to engage with some of the most marginalised and excluded women, reaching out and connecting in a meaningful way.

It’s early days but all the indications are that the Women’s Hub is demonstrating a model of drug and alcohol treatment that is meaningful. There are many positives to this approach; building a safe, inclusive environment for women to access services which otherwise might have felt unsafe. Of course, moving from centralised office spaces would be unfamiliar to most in substance misuse services. There are also some logistical challenges to booking suitable community venues (made easier in the wake of the pandemic as bookings dried up leaving space for new initiatives like this). However, the early signs present an exciting challenge to drug and alcohol services that will be hard to ignore.



Authors:

Katie Lowe, Psychology student on placement with Fulfilling Lives

David Garret, Practice Development Coordinator

For further information about Fulfilling Lives work in this area, please contact:

david.garret@bht.org.uk

For more information sign up to our newsletter:

https://bht.us6.list-manage.com/subscribe?u=b43e61c311da27ad5194daffe&id=148d2193de

Review on Drugs – will change happen for people with Multiple Complex Needs?

In August 2020, Fulfilling Lives South East (FLSE) responded to a call for evidence to support Dame Carol Black’s Part 2 report that focuses on the treatment, recovery and prevention of substance misuse. FLSE’s Service User Involvement team also contributed directly to Dame Carol’s consultation through the National Expert Citizens Group. The report, which contains 32 recommendations for change across various government departments and other organisations, was published in July 2021 and the Fulfilling Lives’ team now reflects on how far the measures go in meeting the needs of those with multiple complex needs.


Time to reflect and review

The Review is momentous on several counts and relevant to the work FLSE undertakes. When reflecting on the recommendations we made in 2020, altogether, we found 14 recommendations out of the total 32 that speak to our asks related to multi-agency working and integrated services; trained workforces providing trauma-informed support; the criminal justice system/repeat offending; housing and employment support; treatment and access needs for co-existing conditions; healthcare inequalities; assertive outreach; peer mentoring and recovery communities. The Review contains findings that are compelling and serve as a reminder that organisations working to improve systems for people with multiple complex needs are not lone voices.

For example, our research found that substance misuse problems always exist in a wider context so it can’t be addressed in isolation. Overlapping complex issues need to be considered when providing support in a trauma-informed manner because addiction is often a response to deep trauma. We were pleased to see that the Review acknowledges that mental health problems and trauma (physical, sexual and psychological) often lies at the heart of drug and alcohol dependence and views them as “co-morbidities rather than separate problems for ‘dual diagnosis’”.

An overwhelming majority of our research respondents strongly felt that peer support and mentoring had been essential to their recovery and peer mentors should be assigned to those finding it difficult to engage with services. In response, the Review recommends that services recruit or include people with lived experience of drug dependence working as recovery champions, recovery coaches and peer mentors, which speaks to our work with the DWP. It further states that they should also provide networks of peer-based recovery support and establish communities of recovery and mutual aid groups. We’re thankful that the Review also calls for increased funding to aid the expansion of local areas’ support for peer-led grass-roots recovery communities and peer mentoring in order to complement professionally led services.

Our Concerns

Whilst we welcome the Review’s recommendations on peer-based recovery support, we are disappointed in the lack of advocacy for more specific women-only recovery and refuge spaces in early recovery and intervention. Our Lived Experience Perspectives Report, which was drawn from a series of conversations with women that have experienced drug and alcohol misuse, highlights the need for women to feel safe while sharing a number of gender-specific intersecting needs and issues including (but not limited to) the experience of coercive and abusive relationships, removal of children by social services and sexual exploitation. Many women we spoke to felt that mixed settings in hostels and temporary accommodation pose a risk to women who may have experienced complex trauma and valued ongoing participation in women’s groups:

“We share and see emotions in a different way to men, so it is essential to be in a safe space where women have similar ways to understand and to communicate emotions.”

Fulfilling Lives South East submission on ‘Lived Experience Perspectives’ for the Independent Review of Drugs by Professor Dame Carol Black

Despite the acknowledgement of overlapping and complex issues, we still feel there needs to be an explicit definition of multiple and complex needs within Dame Carol Black’s part 2 report. We believe that the complexities of overlapping and multiple disadvantage should be named and adequately defined in order to provide more targeted support that is free from judgement, stigmatization or unfair treatment and exclusion.

How will these measures impact those experiencing drug/alcohol misuse and complex needs?

The recommendations – if enacted – have the potential to radically change the way someone with multiple complex needs experiences the support system while on their path to recovery. Agencies working together would reduce the likelihood of service users being left out in the cold or reaching an impasse where no service assumes responsibility. The suggestion of consideration (unfortunately not a requirement) that the NHS target those with substance dependencies, and that commissioned substance misuse services incorporate select mental health treatment, would finally allow those suffering mental ill-health and substance dependency to engage in treatment that is designed to target both at the same time, rather than neither, as is the case for many. This is the official stamp for what many in the sector have been championing for a long time.

Increasing the number of well-trained mental health professionals is a necessary complement to combined mental health and substance misuse treatment, and a trauma-educated workforce would help to build trust with those they support, the importance of which should not be understated. With many mental health professionals and psychotherapists holding the view that early relationships are a significant contributor to mental health problems and addiction, it follows that they are also an important part of someone’s recovery.

The review recognises that the criminal justice system isn’t the most appropriate place for someone with substance dependency, and rightfully suggests that treatment is the most suitable outcome. It goes on to recommend that upon release, everyone has identification and a bank account, with access to benefits services and community drug treatment as soon as possible after release from prison.  If these recommendations are enacted, those already stigmatised could avoid further stigmatisation and damage to their sense of self, the additional barriers that result from incarceration, and the effects of being institutionalised by the prison system.

Although the review didn’t go on to recommend any direct action to improve housing for those with substance dependency, it was a step in the right direction to suggest the relevant government departments work together to gain a better understanding of the needs of this cohort. Similarly, regarding health inequalities, there was no proposed solution, more of a stern word to the government to get a plan together by the end of 2021 to integrate specific health service provisions for this group into the local integrated care system.

Final reflections

The recommendations vary in their assertions and don’t always provide direct solutions. Regardless, the Dame Carol Black review has laid bare the barriers faced by people with multiple complex needs who suffer from addiction. The proposals are a clear message to the government to take responsibility for the systemic shortcomings that, at best, hinder recovery and at worst, add to the physical and psychological decline of the most vulnerable in society. The announcement of a 10-year drug strategy provides the government with the opportunity to implement the recommendations put forth in this report, ensuring that the road to stability for people experiencing addiction and associated problems would be smoother and easier to navigate than ever before.

“The government’s 10-year strategy looks great on the surface, with commitment to delivering on all recommendations laid out in Part 2 of the report being a highlight. There is some cause for concern though. It doesn’t reflect the lack of control faced by people with substance addiction, as judges will still be able to issue custodial sentences for non-compliance of community sentences. The ‘tougher consequences’ line is also baffling. Tough consequences don’t deter people from using drugs and the idea of taking away someone’s passport/driving license is bizarre. They haven’t alluded to what other ‘tough consequences’ are being considered, so that is a bit of a worry. It also would have been nice for the government to legitimise the role of peer supporters by referring to the post as a paid role’’

– Engagement and Co-Production Worker

Authors: Ian Harrison, Emily Page, Aditi Bhonagiri

Resources:

Lived Experience Perspectives Report: Fulfilling-Lives-Lived-experience-Dame-Carol-Black-Independent-Review-of-Drugs.pdf (bht.org.uk)

Dame Carol Black’s Part 2 report that focuses on the treatment, recovery and prevention on substance misuse: Review of drugs: phase two report – GOV.UK (www.gov.uk)

For further information about Fulfilling Lives work in this area, please contact Rebecca, Systems Change Lead: rebecca.rieley@sefulfillinglives.org.uk

For more information sign up to our newsletter:

https://bht.us6.list-manage.com/subscribe?u=b43e61c311da27ad5194daffe&id=148d2193de

Hospital discharge – a road to recovery?

Reflections on the experiences of patients with complex needs and thoughts on how discharge approaches can be developed


At Fulfilling Lives South East, we’ve seen how hospital discharges can be a challenging time for patients with multiple and complex needs (‘MCN’). Our client casework has shown us how clients are often discharged to unsuitable accommodation, or to the street in the very worst of cases.  The NHS is a complex system, and in the area of discharge this complexity is compounded by the fact that there is a shared responsibility with Adult Social Care for discharge planning in complex cases.

Hospital discharge – Case example:

S is a female homeless client who had been in hospital for five weeks. She was diagnosed as suffering from endocarditis, with damage to the mitral valve, two thalamic infarcts and two cysts on the brain. At the beginning of week six, despite her being homeless, it was recommended that she be discharged and that she “go home and gain further weight and return after a month to review her health ahead of a referral for heart surgery”.

In April 2021, FLSE and the Brighton Healthwatch Hospital Discharge Project invited organisations from the Voluntary and Community Sector as well as the NHS to discuss how hospital discharge for people experiencing MCN can be improved.  The overarching themes identified were that community mental health support services are stretched and can be difficult for patients to access after hospital discharges but also that hospital discharge means different things to different organisations. We understand that the health, social and third sector are funded and set up quite differently and this runs the risk of services being fragmented which in turn contributes to the difficulties when supporting patients and clients. These difficulties include challenges around information sharing and communication between services and lack of knowledge on where to find the right support depending on referral criteria and thresholds.

At Fulfilling Lives, we have dug deeper into the processes and procedures of hospital discharge and challenged ourselves to articulate what a better hospital discharge system could look like. This involved a focus group of specialist workers who support people with multiple and complex needs, systems change staff and those with lived experiences of hospital inpatient and discharge procedures.  Our key thoughts are outlined below.  

Key Thoughts

Underpinning PrinciplesWe feel that all processes should be informed by the following principles

  • Support starts early when planning for hospital discharge with the first paramedic / GP / professional contact. These people help inform the patient’s needs and contexts that should be considered in discharge plans.
  • Treatment will be delivered in a Psychologically Informed Environment (‘PIE’) which respects privacy (i.e. no interviews in glass interview rooms) and client ‘agency’ i.e. respects the fact that the client is in the room and isn’t ‘spoken about’ as though they are not.
  • Being human   We want the best medical outcomes for clients and understand that this is best supported by recognising the humanity of the client and taking a trauma informed approach to their care and recovery.
  • Ensure that the client’s voice is heard early in the process and consistently throughout.
  • Hospital discharges for people with multiple complex needs will have clear accountability and oversight within the healthcare system.
  • Discharge planning takes patient’s outside circumstances into account and reflects their impact on health – this will require consistent consideration for health determinants not just the presenting clinical healthcare needs.
  • Recognition that in-patient treatment, including the impact of medication, can impact on a patient’s ability to make decisions.

Underpinning Behaviourswe believe that certain professionals’ behaviours enable successful hospital discharges.  

  • Demonstrating kindness and flexibility is key to providing reassurance to people with MCN who have had multiple negative experiences of support services.
  • Creating opportunities for friendly conversation is important to minimize the perception of care being perceived as ‘business like’ or the patient feeling unwanted in the hospital and helps to build trust.  The client will be alert to any signs that they are being judged in a negative way and will be at high risk of self-discharging.
  • Be mindful of one’s own stigmatising views and unconscious bias. Be aware that factors such as workplace stress and our own health and wellbeing will have an impact on our work.  Take active steps to maintain your equilibrium and expect the workplace to support your performance through supervision, reflective practice and other means.

Toolsenabling factors that will support positive hospital discharges

  • The hospital will keep details of the client’s support network.  This will include details of community-based professionals trusted by the patient to help them communicate with the hospital and likely provide care post-discharge.
  • Published policy regarding MCN patients including standards relating to discharge planning.
  • Explicit monitoring, and management of hospital discharges for patients with MCN.
  • Training in trauma informed care for staff at all levels of the hospital to support effective engagement, communication and support for patients with MCN.
  • Mechanisms for feedback that enable feedback from the voices people with lived experiences to be easily captured and learnt from with minimum bureaucracy.
  • A strategy to tackle ‘self discharges’ and unplanned exits from hospitals.

Ideas

Ideas for hospital discharge protocols – tangible practices that we feel can inform hospital discharge protocols for patients with MCN

Admission

  • Patients with Multiple and Complex Needs (MCN) should have a risk assessment and support plan to improve the prospects of the patient engaging with the full course of treatment and reduce risks of unscheduled discharge.
  • The client’s admission paperwork will include the contact details of support staff who can help the patient communicate with the hospital and articulate their views. For patients with MCN, this may include social workers, mental health nurses, GPs, probation workers and members of the voluntary sector. The ward staff are encouraged to help the patient liaise with that support network to ensure that they are included in the whole process.
  • The admission will take an overview of their housing situation, pets, family and medication. The client may need help to pack a bag or provide themselves with the things they need for a stay in hospital. 
  • In an unplanned admission the multiple and complex needs of the patient will be recorded by the Accident and Emergency team (or earlier where the patient has received an initial assessment by a paramedic) and communicated to ward staff when that patient is admitted to a ward. 
  • At admission, or preferably before, there will be an assessment of the patient’s safety and needs.  This assessment will include drug and alcohol use, issues concerning visitors and issues of domestic abuse.            
  • We would also recommend informing the patient’s GP of the hospital admission.

As mentioned in the Mental Health Act Review 2021 (Chapter 4), we support the idea of strengthening the patient’s right to refuse and choose treatment.

We would like patients to have:

  • greater influence over decisions about their care and treatment,
  • their wishes and preferences respected and followed
  • the opportunity to challenge their care and treatment if their wishes are not followed. 

FLSE would like to see an ‘advanced choice document’ across all healthcare sectors, physical and mental. With a system in place that communicates between services, information sharing is increased which in turn helps patients to feel more confident and less stigmatised.

We would strongly encourage for the healthcare system to introduce this trauma informed approach.

To read more about how we contributed to the Mental Health Act Review please see our blog post here.

Discharge

  • We would strongly suggest that prior to discharge of a person experiencing MCN, Adult Social Care is required to assess the patient’s needs. This would include closer collaboration between discharge coordinators, social workers in hospital and Adult Social Care.
  • Ideally, a multi-agency health and complex needs forum is created to discuss more vulnerable patients. This is to make sure that a support system is in place prior to discharge. This includes informing GPs and other non medical support networks of the discharge and we are aware that in Brighton & Hove there is such a forum to discuss patients with complex needs to support their care in the community – this is an approach we support.
  • In our experience, patients with MCN being discharged on a Friday is difficult. This is because there is sometimes not enough time to organize and set up support for the weekend and the accommodation they may need, especially when at risk of homelessness.
  • The patient’s GP would be notified of the discharge and given the community care/discharge plan.

Monitoring

  • There will be a specific record kept of the steps taken to include the patients voice including specific details of what they have done differently to capture innovation.
  • Patients with MCN will be recognized throughout the patient record data systems and accountability will sit with an accountable person within the hospital staff team for hospital admission and discharge of those patients with MCN.
  • There will be a loop for patients to be able to provide feedback and suggestions to improve interactions.

Hopes for the future hospital discharge system

During the Connectivity Meeting, it was clear that communication between different services (NHS, social care and the Voluntary and Community Sector) is difficult.

We discovered that hospital-based social workers don’t automatically collaborate with community based social workers and information isn’t being shared with other non-medical support networks. We also learnt that the Voluntary and Community Sector services, as well as mental health services, have long waiting lists and that their services are stretched.

The group has also identified that the different systems feel silo-ed and there are few opportunities for collaboration and smooth discharge transitions into the community.

The below was an attempt to map the different services involved in hospital discharge and how these relate to each other. It prompted us to reflect on the commissioning of services to support hospital discharges and how there is an opportunity for commissioners to improve linkages between services and help the support system organise in more joined up and efficient way.

Image showing connectivity in the system

However, the group also suggested that it would be useful to improve communication between hospital, social care and community teams by introducing joined access meetings. These meetings would focus on all aspects (medical and non-medical) of the patient’s support system and that the patient would be able to join this meeting.

Our conclusion is that the hospitals need to review their discharge protocols and develop revised ways to support patients with MCN through the system. This needs to include mechanisms for joint planning with the patient and their closest support networks.


Author: Michaela Rossmann & Rebecca Rieley

Independent Review on Drugs: Perspectives of women and creative recovery groups

In 2020, the Service User Involvement team at Fulfilling Lives South East fed into the public consultations towards the Independent Review of Drugs by Dame Carol Black, commissioned by the Home Secretary. This blogpost outlines the process of gathering the unique lived experience perspectives of women who had used the substance misuse services as well as creative recovery groups. The findings from our submission have now been published into a report which provides the local context of accessing drug treatment and recovery in East Sussex.


Context

In February 2019, the Home Secretary appointed Professor Dame Carol Black to undertake an independent review of drugs to inform the government’s thinking on what more can be done to tackle the harm that drugs cause. The study took place in two phases; the first phase was published in February 2020 and included a rigorous and ground-breaking analysis to understand the complex and overlapping markets for illegal drugs, which can be read here: https://www.gov.uk/government/publications/review-of-drugsphase-one-report/review-of-drugs-summary.

In July 2020, public consultations began for the second part of the review and focussed on understanding the challenges involved in drug treatment, prevention and recovery and opportunities for improvement. Fulfilling Lives South East Partnership (FLSE) fed into the public consultations though the National Expert Citizens Group (NECG), who were approached to gather the views of people with experience of substance misuse as well as other intersecting complex needs such as mental ill health, homelessness, domestic abuse, and removal of children.

The NECG is a partnership of people connected to all of the 12 Fulfilling Lives projects across the country, who also have direct experience of multiple disadvantages. Their aim is to raise the bar on co-production and to demonstrate how lived experience leadership and insight can change systems and services.

Collecting Insights

As part of our contributions, team members from FLSE’s Service User Engagement team conducted a series of 1-2-1 and group discussions to collect unique perspectives from women who have experienced drug and alcohol misuse as well as with mixed gendered peer-led creative recovery groups. The conversations centred around four questions:

1. How can we make it easier for people to access drug treatment and recovery services, and stay in contact with those services?

2. How can we ensure the mental health needs of people in treatment are met?

3. What is the best way to meet the employment and housing needs of those in treatment and recovery?

4. What else stops people recovering and why might they relapse? What would help?

Summary of Findings

Throughout these conversations there were common threads; regardless whether the individuals were currently using services, had used them in the past, or were themselves providing support at present. These consistent messages highlighted the following:

1. Trauma needs to be addressed as part of any treatment.

2. The need for a holistic approach to treatment and support; mental and emotional health, access to employment and housing, community support, etc.

3. The importance of personal development; rebuilding one’s identity, develop self-esteem, focus on assets, learn healthy interactions and relationships.

4. The power of peers; they act as role models, inspiration and aspiration.

5. The impact of the Recovery Community; that it’s not necessarily focussed on addiction, develops creativity, sense of community, enjoyment and fun.


Author: Aditi Bhonagiri and Nelida Señoran-Martin

The full report on FLSE’s submission with in-depth findings on the lived experience perspectives from our target group for the Independent Review of Drugs by Professor Dame Carol Black can be found here: Fulfilling-Lives-Lived-experience-Dame-Carol-Black-Independent-Review-of-Drugs.pdf (bht.org.uk)

Dame Carol Black’s recommendations on the second phase of the Review can be found here: https://www.gov.uk/government/publications/review-of-drugs-phase-two-report