In this section:
- qualities of a service delivering an effective intervention.
From observing the five Comic Relief projects over three years, it quickly became apparent that there is no one ‘right’ intervention in working with families affected by alcohol hidden harm. In Section 10 we describe some of the characteristics of the interventions most likely to bring about changes in the lives of children and young people. However, it is also important to note that however high quality the intervention, change will be limited or unsustainable unless services enable children and families to benefit from social structures that than can assist in the development of resilience .
These structures could include:
- Well resourced universal services able to address the needs of young people affected by alcohol hidden harm: We learnt of the critical importance of schools and teachers. One of the projects being evaluated was located in a local authority where learning mentors and other schools based services had their funding cut. Therapeutic staff delivering high quality interventions questioned how sustainable the changes would be for young people without support in schools. This was particularly relevant given that the agency delivering this intervention has not been commissioned to deliver an on going service and as of March 2012 there is no dedicated alcohol hidden harm service in this local authority Outcomes.
- Strong partnerships: We saw two projects struggle to enable families to achieve change because of cuts in other local services, poor or non-existent hidden harm networks or because other agencies lacked the resources or leadership to engage with the interventions Partnership.
- Resilient communities: One project was based in a deprived local authority area with little resilience to the economic recession. While parents struggled to make changes to their alcohol use and parenting styles, the lack of employment, training and leisure opportunities restricted the potential for any change to be sustained. Individuals can learn skills which help to develop their resilience but acquiring resilience is a dynamic process and families and communities need to be part of service delivery. Location can be a hugely significant barrier to improving family life. See also Needs assessment.
Services for children whose parents misuse alcohol come in different shapes and sizes. In earlier sections of this toolkit you have had the opportunity to think about what your clients needs are and what kind of practitioners you believe can meet their needs). These are important factors in deciding the kind of service your clients need and what you can offer, within the constraints and opportunities offered by the resources you have available to you. In the report based on the experiences of the five services we evaluated, we observed that while all services had some success in supporting children, those who were most likely to bring about observable changes were:
- Child focussed;
- Whole family oriented (worked with more than one member of the family including the child if over 5 years old );
- Therapeutic (i.e. were not solely respite or leisure focussed);
- Evidence/experience based;
- Long term (engaged with clients over a minimum of 5-6 months, or sometimes for longer sometimes for more than one cycle);
- Flexible (adapted to the expressed and felt needs of the clients);
- Involved universal services, especially schools.
Ask yourself the following questions:
- Do you have, or can you develop the capacity to work with more than one generation within the same family, whether parent, grandparent, carer or sibling and child or young person?
- Can you offer support to parents who are misusing alcohol or who have lived with or are still living with a partner who misuses alcohol?
- Do you have a strong and willing partner agency who can offer support to adults if your intervention is focused specifically on children?
- Can you work closely with the universal services commonly accessed by your client group e.g. schools, GPs?
- Is the intervention you propose aimed at changing health and wellbeing outcomes for children even if your primary client is an adult?
- Do you plan to work with clients over a period of 6 or more months? Are you able to extend the period according to client needs? Can your clients return for further support and advice at a later stage?
- Is our service flexible enough to adapt to emerging issues and needs of clients once they have begun to engage with the service? (Flexibility may be needed with respect to family members you work with, location, other agencies and or specific aspect of the intervention).
- Do you have evidence and experience which supports your approach? If not, where can you access the evidence?
If the answer to any of these questions is no, you may need to re-think your intervention, as the experience of the five alcohol hidden harm projects funded by Comic Relief demonstrated the value of these elements.
In addition, the most successful projects were:
Planned and coherent
New services need a clear action plan to follow when getting started, but even when you adapt what you offer from your original proposal, you are more likely to be successful if you do so in a way which is based on experience, through reflective practice, but also on evidence and after discussion with other practitioners, managers and senior leaders. In this way your service will evolve in a way which is coherent with your original aims and objectives even if the service is implemented in a different way from that expected. Less successful services do not learn from their early experience and are less able to justify their choices with evidence of either need or effectiveness.
Case study: Keeping faith with original evidence and planned outcomes
Some of the changes were positive and reflected the acute needs of the clients at an early stage of an intervention (e.g. to feel safe and not judged), however, once clients felt safe accessing the service and had engaged with staff, sustaining change proved difficult. Clients did not progress to more therapeutic interventions but at times remained dependent on particular workers for one to one mentoring and support. This provided children and young people with wider networks of support and a safety net, but adult clients would regularly relapse which had a negative effect on children and young people.
Focused on clients’ needs
As professionals it is easy to make decisions based on your knowledge of a subject, national data, national and local press and formal evidence (normative and comparative need). You may not know your client base well at the beginning of a new piece of work. The more referrals you gain and the more your clients and other agencies value and respect the work you do, the more you will be challenged to do things differently to meet previously unmet or unspoken needs of your clients (felt and expressed needs). It is important to record this information as systematically as possible and discuss proposed changes at an early stage with service users, staff and volunteers, but also crucially with funders, who may be more or less open to changes to your original proposals. Comic Relief funded the five alcohol hidden harm projects on which this toolkit is based as ‘learning projects’ and anticipated the need for flexibility of delivery of the services they funded. However, the funders appreciated being kept in touch about proposed changes rather than learning about them after the event. See also Needs Assessment.
Evidence and experience based
You should always be able to justify your intervention and how it has been adapted to meet the needs of your clients by reference to up to date evidence and through reflection on how that intervention is working in practice.
In some cases several practitioners may be offering some aspects of the service and it is vital that you know that the quality of the work undertaken meets internally and externally agreed standards. Some of the quality assurance systems you could consider are:
PQASSO the most widely used quality assurance system within the voluntary and community sector, which uses a self-assessment approach, involving people within an organisation in making judgements about its performance against the PQASSO standards.
[Investors in People[(http://www.investorsinpeople.co.uk/Facts/Pages/default.aspx) is a management standard framework which provides independent assessment to track your progress and enable you to become an accredited Investors in People organisation. Assessment is based entirely on interviews with people across your organisation.
Hear by Right is a framework developed by the National Youth Agency to assist you in following best practice on the safe, sound and sustainable participation of children and young people in developing and running the services and activities they take part in.
Investors in Volunteers is a UK wide quality standard for all organisations, public or private, which involve volunteers in their work.
As well as these external quality standards you should also agree quality standards with staff and volunteers through consultation and training. If you service relies on Motivational Interviewing (MI) techniques with clients, for example, does everyone share the same definition of MI? See Intervention styles for more about MI. Is everyone working with clients using MI in the same way? How would an outsider observing the session know that a particular session was based on MI techniques? What forms of training, support and supervision are in place to identify where staff or volunteers may need support to offer a higher quality service to clients?
Case study: 'How-to' guide
"We decided together that the most important things to prioritise in an initial telephone call are:
- Introduction: Introducing yourself and why you are calling.
- Check out that they knew the referral had been made and what they understood it was about?
- Try and be friendly / real / empathetic.
- Check in with how things are at the moment? Use open questions and try to use some reflective listening! Encourage change talk! What worries them most about their situation? Loosely where would they like to see themselves in the future?
- Try to start to establish a rapport.
- Summarise concerns and goals and confirm that we can explore these further together;
- Discuss any concerns that they might have about the family support service, time, location, relationships. Would anything make it easier to meet with them?
- Lastly check that they have your number saved in their phone and a reminder of your name.
If at any time you encounter any resistance to treatment; encourage the client to meet with you and have the assessment and then if they decide that’s it’s not for them, that’s okay and you can discuss what other options they have. Remember ‘willing, not keen’ is OK!
Ideally these quality standards would be reviewed by checking with clients that they received a friendly welcome to the service, if not by direct monitoring of calls between practitioners and clients.
Many organisations have several forms of accountability and governance and it is important to make sure that reporting of outputs and outcomes do not become excessively bureaucratic, to the detriment of the work itself. The best systems can achieve a good balance of internal reporting to managers, senior leaders and trustees while also providing a good opportunity for staff and volunteers to reflect on what is going well and not so well for their work with clients. In medium to large organisations these internal accountability structures provide a good mechanism for initiating change in other aspects of the work they do. Routine reporting to the funders and to the external evaluators is also often more manageable when there is a culture and clear internal systems of accountability. N.B. Where possible, funders and evaluators should make use of routine reports rather than duplicate internal systems.
Effective services ensure that there are clear boundaries between the services they offer and those offered by other providers. This avoids duplication and competition for scarce resources, but also helps to identify gaps and potential for developing specialisms by services. Sometimes, even in the same organisation, there can be confusion about where one intervention or service begins and another ends. This can lead to problems for commissioners and partners, who may not be clear who is responsible for what.
Case study: Crossed lines
However, boundaries should not become barriers for clients to overcome if all they want is a holistic service which meets most of their needs.
Appropriate onward referral
As you work with a client and their family it may become apparent that you cannot meet some or even all of their needs. At this point you may be in a position to make a general or specific referral to another agency. If appropriate it may be possible through the Common Assessment Framework or other locally agreed procedures to pass on case notes for the client, which helps clients see the service as seamless and avoids them having to tell their story again and again. In extreme cases you may find it necessary to make an immediate referral for child protection purposes.
Case study: Problems with referrals
Managers are responsible for establishing and maintaining safe working environments and practices. Policies to address issues of lone working and home visits are particularly important in the context of alcohol hidden harm. In addition, good clinical supervision should ensure that practitioners maintain a professional distance between themselves and their clients. There should be clear procedures for clients who may need to contact an agency in an emergency or out of hours. Clients should not have the personal phone numbers of practitioners, nor should practitioners make themselves available ‘at any time’. Managers should also do all they can to ensure that their staff and volunteers adhere to procedures for maintaining a healthy and safe workforce, whether on or off the premises.
Case study: Safety of practitioners and volunteers
None of the interventions funded by Comic Relief were exactly the same at the end of three years as they were described in their funding proposals although some had changed very little. Funders should encourage projects to learn from the early stages of their projects and to continue to develop their understanding of the needs of their clients so that the service evolves to meet those needs more effectively. Evaluators should see change, based on the steps above, as a sign of an effective service.
Alcohol hidden harm services have the potential to intervene early in the lives of some vulnerable children. However there are some major challenges to these services at a time of austerity. The lessons learned from the Comic Relief funded projects have identified some key qualities which the service providers demonstrated which helped some to make a difference and be sustainable.