Evaluation of Advocacy for Service Users

withSubstance Misuse Issues

Final Report July 2017

..... SERVICES FOR YOU, INFLUENCED BY YOU......

Evelyn Cook

Project Worker

The Mental Health Advocacy Project (West Lothian) (MHAP) offers independent professional Individual and Collective Advocacy services. MHAP is constituted to provide advocacy for young people, adults, and older people who experience or have experienced mental health and/or addiction problems and live or are receiving a service in West Lothian.

The Project is based in the Mental Health Resource Centre, Strathbrock Partnership Centre in Broxburn. Our service is independent and not connected with providers of healthservices or carers. We act on behalf of service users in a way which is completely free from conflict with any other agency or service.

The Mental Health Advocacy Project (West Lothian) SCIO:

  • Is a fully independent advocacy provider.
  • Is a full member of the Scottish Independent Advocacy Alliance (SIAA).
  • Is registered as a Charity in Scotland.
  • Is governed by a Management Committee of 10 members the majority of whom experience mental health problems.
  • Is an “employer of excellence with Peninsulas Employment Law and Personnel Consultancy Support”
  • Is guided by the SIAA Code of Practice and Principles and Standards for Independent Advocacy
  • Is an equal opportunity employer
  • Is a Scottish Charitable Incorporated Organisation

Our Aims

To empower service users to become involved in decisions about their care and treatment and protect their rights.To offer a friendly and accessible service that values and respect service users.

Our Mission Statement

“We endeavour to provide service users with the opportunity to take control of their own lives, help them to exercise choice based on their needs and wishes, and to have their views heard”.

Executive Summary

  1. MHAP continue to receive referrals for individuals with substance misuse issues, accounting for 14% and 17% of all referrals made in 15/16 and 16/17, respectively
  2. Self-referrals to MHAP are common and the evidence raises a tentative suggestion that individuals who make contact with the service directly initially may engage better when the referral is followed up
  3. Service users most commonly needed support from advocacy for issues related to benefits, housing or care and treatment
  4. The case record analysis revealed that initiating and sustaining contact with service users was one of the challenging aspects of providing advocacy for individuals with substance misuse issues
  5. Advocacy was most commonly used by service users to raise concerns about a service or treatment they were receiving; access additional services/resourcesappropriate for the issues they were experiencing; or to communicate more effectively with services or professionals
  6. Service users reflected positively on their experience of using advocacy services. There is an ongoing challenge for both the evaluation, and for routine monitoring purposes with gathering feedback from service users, particularly those who disengage from the service
  7. Feedback from service providers suggested that advocacy was valued as a service that could improve outcomes for service users
  8. Continued efforts to promote awareness and understanding about the role of advocacy would help ensure advocacy is available to those it would benefit
  9. Finally, the evaluation has helped to inform the development of a new outcome recording and monitoring system which will help MHAP to further evidence the impact of their work

1.Overview of report

This is the final report for an evaluation of advocacy for individuals with substance misuse issues. It outlines the findings from evaluation activities conducted between August 2016 and July 2017.

The evaluation has two aims (a)to outline the role and effectiveness of advocacy for individuals with substance misuse issues and (b) to consider the role of advocacy in understanding service user’s experiences and views of drug and alcohol services.

An interim report was provided in January 2017 and this final report incorporates the findings from that report with the results from additional evaluation activities.

The first section considers data on referrals made to the service in both 15/16 and 16/17. In addition to offering a comparison of referrals made across both years, this section includes findings from an extensive case record analysis conducted on all referrals from individuals with substance misuse issues. Section two provides information from individual interviews with service users and additionally reflects on the difficulty of obtaining feedback from this client group. Section three details findings about how service providers view the role and impact of advocacy for individuals with substance misuse issues. Sections two and three were largely reported in the interim report but are included here for completeness.

The final section of this report addresses advocacy’s role in supporting individuals with substance misuse issues. This section brings together findings from all aspects of the evaluation to consider some of the advantages and challenges associated with providing advocacy for this group of individuals.

2.Advocacy work: Referrals & Activities

This section focuses on data gathered to address the question, What is the level and nature of advocacy provided to service users with substance misuse issues?In January 2017, the interim report detailed referrals made to the service in 15/16 and we can now compare this data to referrals made in 16/17.

As shown in Table 1, there was an increase in the number of referrals for those with substance misuse issues from 15/16 to 16/17. Overall, the number of referrals made to MHAP increased but there was also a slight increase in the proportion of these associated with addictions issues. In 15/16, 14% of all referrals were from individuals with substance misuse issues and in 16/17 this rose to 17%. This represents a change from 62 people in 15/16 to 76 people in 16/17.

Table 1: Referrals by month

Month / Total 15/16 / Total 16/17
April - June / 14 (21%) / 29 (35%)
July - September / 19 (29%) / 24 (29%)
October - December / 17 (26%) / 13 (16%)
January - March / 16 (24% / 17 (20%)
Total / 66 / 83

There were slightly more referrals from males in 16/17; 64% of referrals compared to 53% in 15/16. Similar to 15/16, the majority of referrals were for those aged 25-65 (93% in 16/17 and 88% in 15/16).

The above figures refer to the number of referrals received in 15/16 and 16/17. Since there are likely to be referrals that have been carried forward from previous years, the number of people that MHAP worked with is likely to be higher. Indeed, overall, MHAP actually supported a total of 118 cases associated with substance misuse issues in 16/17.

In both 15/16 and 16/17, the majority of referrals for individuals with substance misuse issues were self-referrals. Table 2 shows that in 16/17, there was an increase in referrals from social work accompanied by a decrease in the number of referrals from other services. Whilst in 15/16, only 48% of referrals came either directly from service users or from social work, in 16/17 this rose to 70%. MHAP continued to receive referrals from addiction specific services. A total of 19% of all referrals were identified to come from social work addictions team, NHS addictions, WLDAS or Cyrenians.

Table 2: Source of Referrals to MHAP

Source of Referral / Total 15/16 / Total 16/17
Self / 23 (35%) / 34 (41%)
Social Work / 9 (14%) / 24 (29%)
NHS Addictions Service / 5 (8%) / 3 (4%)
Mental Health Officer / 3 (5%) / 1 (1%)
Family/Friends / 4 (6%) / 7 (8%)
HMP Addiewell / 3 (5%) / 0
Other / 19 (29%) / 14 (17%)

Table 3 shows the geographical spread of the referrals and suggests that in both 15/16 and 16/17, MHAP was able to engage with service users from across West Lothian.

Table 3: Referrals by Location

Location / Total 15/16 / Total 16/17
Armadale/Blackridge / 4 (6%) / 12 (15%)
Bathgate/Blackburn / 7 (11%) / 12 (15%)
Broxburn/Dechmont/Winchburgh / 11 (17%) / 10 (12%)
Bridgend/Linlithgow / 5 (8%) / 3 (4%)
East Calder/Livingston / 19 (29%) / 15 (19%)
East Whitburn/Fauldhouse/ Whitburn/Longridge/Stoneyburn / 6 (9%) / 14 (17%)
West Calder/Mid Calder/Polbeth / 4 (6%) / 7 (9%)
Unknown / 7 (11%) / 5 (6%)

Table 4shows the length of time from referral to discharge. A total of 10 service users who were referred in 16/17 were still receiving ongoing support and therefore are not included in this analysis. In both 15/16 and 16/17, the majority of service users were supported for under 5 months (77% in 15/16 and 75% in 16/17).

Table 4: Time from referral to discharge

No. of months / ≤ 2 months / 3 to 5 months / 6 to 9 months / 10 to 12 months / < 12 months
15/16 / 34 (51%) / 17 (26%) / 6 (9%) / 2 (3%) / 7 (11%)
16/17 / 41 (49%) / 21 (25%) / 11 (13%) / NA / NA

Referrals were made to MHAP for a variety of reasons. In 15/16, 30% of referrals had more than one issue and 24% of referrals were supported with more than one issue in 16/17.

In both years, the most common issues service users needed support with were Care & Treatment, Housing and Benefits/Finance (see Table 5). There seemed to be a slight trend towards fewer care and treatment issues in 16/17, together with a rise in benefits and housing issues. More people were supported with criminal issues in 15/16 than in 16/17. This perhaps reflects an overall reduction in referrals from HMP Addiewell; in 15/16 there were 51 referrals overall and in 16/17 there were only 18 referrals.

Table 5: Nature of issues supported

Issue / No. of referrals 15/16 (%) / No. of referrals 16/17 (%)
Mental Health Act / 3 (5%) / 6 (7%)
Benefits & Finance / 17 (27%) / 27 (33%)
Housing / 20 (32%) / 28 (34%)
Self-Directed Support / 1 (2%) / 1 (1%)
Care and Treatment / 26 (42%) / 25 (30%)
Employment / 1 (2%) / 3 (4%)
Criminal / 10 (16%) / 2 (2%)
Family / 9 (15%) / 9 (11%)

Case Record Analysis

To gain a better understanding of the referrals made to advocacy for individuals with substance misuse issues, all case files for referrals made in 15/16 and 16/17 were analysed. Information was extracted to address the following questions:

  1. How did advocacy establish contact with service users?
  2. What did the issues described above look like in practice?
  3. What specific activities did advocacy do in supporting the individual?
  4. What services/professionals did advocacy work with to resolve these issues?
  5. What outcomes emerged as a result of advocacy’s involvement?

Engaging service users

Attempts to establish contact with service users included reaching out via telephone and letter, sending a proposed appointment time and contacting initial referrers. Perseverance by advocacy did sometimes result in a positive engagement. A few phone calls, a letter and some patience could be effective and positively, in over 80% of referrals, contact with the service user was established. Nevertheless, some individuals did not engage. In 16/17, advocacy workers were unable to establish contact with 10 referrals. Interestingly, only 2 of these referrals were made initially by the individual directly. The majority of referrals to advocacy are self-referrals and it may be that those who seek out advocacy on their own are more likely to engage when the referral is followed up.

In a few cases, contact was able to be established but service users decided after an initial meeting that they no longer needed or wanted advocacy’s support. For example, in one case the service user contacted advocacy due to feeling that he had been mistreated by his pharmacist. Advocacy offered to take forward a complaint but in the end the service user decided to take no further action. Arguably, the service user was still able to voice their concern and understand how to communicate these to others, despite choosing not to do so.

Sustaining contact with service users could be quite difficult and in at least 17% of referrals, clients disengaged during the process of addressing their concerns. This is likely to be due to a multitude of issues but it nevertheless highlights the difficulty in obtaining information from service users about their experiences of engaging with advocacy.

Issues

In both 15/16 and 16/17, the most common issues advocacy supported individuals with were care and treatment, housing and benefits/finance. At times, the issues services users needed support with were different to what was initially recorded at the time of the referral. Case record analysis has provided the opportunity to look beyond these coded categories to understand in more detail the difficulties facing service users.

Across both years, care and treatment included support to:[1]

  • communicate with GP or psychiatrist, most typically about changing medication or treatment (47% of referrals);
  • request a change in allocated professional, including CPN, psychiatrist or other consultant (11% of referrals)
  • access support for mental health or addictions issues, resulting in a referral or information about relevant services; (30% of referrals)
  • liaise with addictions worker due to feeling confused or unhappy about treatment plan (16%)
  • raise concerns about medication issues whilst in prison, for both mental health and addictions issues (9%)

Analysis of the case records revealed that the number of care and treatment issues involving eithersubstance misuse or mental health issues were relatively similar. With regard to addictions issues specifically, advocacy was used by service users who were yet to engage with addictions services and needed referrals or signposting to drop-in clinics. Some service users requested support from advocacy to communicate with their addictions worker, either because they were unhappy about their treatment plan or because they were finding the process confusing.

For referrals associated with housing issues, service users needed to support to:

  • Accessor communicate with services that could help with housing issues e.g. Moving Into Health; Safer Neighbourhood Team (23%)
  • Request repairs or other work to property (19%)
  • Access housing benefit/other grants (4%)
  • Make a new housing application or secure accommodation (40%)
  • Understand housing options (31%)
  • Organise a new housing payment plan (4%)
  • Raise concerns about treatment about treatment from housing services (4%)

Service users most often needed support to communicate with housing services to find out about what options were available to them or gather supporting letters and other relevant documentation to submit a new housing application. In these cases, the majority of advocacy’s work involved liaising with housing officers.

Service users who got in touch with advocacy for benefits and finance issues most often needed support to:

  • Access grant or other public entitlement, including crisis grant, food bank, bus pass (19%)
  • Request home visit for medical assessment (10%)
  • Investigate concerns about benefits allocation, involving backdated monies (29%)
  • Access or communicate with services that can help with benefits issues e.g. Corporate advice team, advice shop (62%)
  • Submit a new benefits application (34%)

In 62% of referrals involving benefits issues, advocacy workers made a referral to services such as Corporate advice team or the advice shop. In these cases, advocacy workers most often continued to support the service user in accessing the service, for example in gathering support letters or following up on progress and communicating this back to service users.

Specific activities

The interim report listed the different kinds of activities that MHAP do in order to resolve issues for service users. A much more detailed analysis reveals that the most common tasks undertaken by advocacy workers are:

  • Making referrals to services
  • Raising concerns about treatment from services
  • Requesting and providing supporting letters for benefits and housing applications
  • Providing information about available services
  • Contacting services/professionals to find out information on service users behalf
  • Arranging appointments with professionals and services (e.g. GPs, lawyers, psychiatrists)
  • Supporting service users at appointments
  • Supporting client at Mental Health tribunals
  • Completing applications for benefits and housing

Depending on the nature of the issue, these activities can involve a number of letters and phonecalls. As discussed below, it remains important for MHAP to record this information more robustly and systematically link such activities to the service objectives.

Services/Professionals

In order to carry out the various activities mentioned above, advocacy worked with a wide range of services. The most common services during both 15/16 and 16/17 were social work, housing, Corporate Advice Team, lawyers, GP and Psychiatry.

Other services that MHAP often engaged with during both years included the advice shop, NHS addictions, Department for Work and Pensions, WLDAS, CPN Services, HMP Addiewell healthcare team, local councillors and Mental Health Officers.

In total, advocacy workers had contact with just over 60 different services over the course of the two years. In addition to those mentioned above this included:

Moving into health; ATOS; Police; Client’s Employer; Victim support; Ward staff; LAMH; Cyrenians; Debt collector; Safer Neighbourhoods Team; LEAPS; HM Court and tribunal service; Pain clinic; OPD 5; Bank; Procurator fiscal; COT team; Carer; Primary school; Step out group; CAB; Bathgate benefits centre; Health in Mind; DASAT; Royal Edinburgh Hospital; Scottish public services ombudsman; Cyrenians; Buddy Project; Patient Transport Service; Advocard; Criminal injuries compensation authority; Scottish welfare fund; Food bank; Homeless prevention; Ethnic minorities law centre; Sherriff court; Civil legal assistance office; Ritson clinic; Transport Scotland; HM Revenue and customs; Library; A4E; Penumbra; ACAST

Outcomes

The evaluation activities havehelped to inform the development of new outcome monitoring system for MHAP. Moving forward, it should therefore be easier for MHAP to evidence the impact of the service. Over the past year, MHAP have been piloting a new outcome recording sheet. The information gathered has been collated with data extracted from the case record analysis. Across 15/16 and 16/17, advocacy workers have supported service users with substance misuse issues to:

  • Secure a requested change to their medication
  • Securean alternative member of staff
  • Have full custody of children granted
  • Overturn a benefits decision and have payments reinstated and backdated
  • Access appropriate support, including GP, support for addictions issues, support for homelessness
  • Secure access to entitlements, including buss pass, food parcels and employment pay
  • Obtain requested property repairs
  • Communicate concerns to services or professionals

The current outcome recording system means it remains difficult to report on the frequency of the above achievements. The evaluation has helped to highlight some particular difficulties with evidencing outcomes which MHAP will need to address when implementing a new system for recording and monitoring outcomes.

Firstly, as highlighted earlier, often service users disengage from advocacy before any outcomes can be recorded. For example, advocacy workers may submit a benefits application but have no further communication from the client and therefore remain unaware of the outcome. It may be helpful for advocacy workers to make further attempts to follow up on what changed for the service users as a result of advocacy’s efforts. This will no doubt add to the administration time needed by advocacy workers.