Introduction
Inappropriate and problematic use of alcohol by sections of the population that leads to alcohol-related crime and disorder is acknowledged as being a major and growing problem in the UK. In response, under the auspices of the National Alcohol Harm Reduction Strategy and its Safe, Sensible, Social document (DoH, 2007), the government has launched sets of initiatives each with different approaches to the overall aim of reducing alcohol consumption. Some can be seen as situational, aimed at addressing where, when and by whom alcohol is consumed, and others as social, aimed at addressing individuals’ consumption patterns and the cultural acceptance of inappropriate use of alcohol. Situational programmes are generally law-based and use the legal system and various enforcement agencies to address alcohol-related crime, disorder and anti-social behaviour. Examples include the Alcohol Misuse Enforcement Campaigns (AMEC) and the creation of ‘alcohol free’ zones. Law-led campaigns tend to ignore the social and cultural aspects of inappropriate alcohol use. This is to be expected, as very few police officers are trained or equipped to offer advice about inappropriate drinking. Moreover, in the context in which such schemes are delivered, it is often the case that police officers and drinkers will be in conflict when they meet. The social programmes tend to be primary prevention messages and include campaigns such as the recent ‘super hero’ advert run on television.
However, as crime prevention and public health literature informs, primary prevention campaigns (which are public health campaigns aimed at the general population) have limited impact. It is acknowledged that targeted secondary and tertiary campaigns, both of which are designed to impact on the life-styles of specific target groups, have greater potential to become the catalyst for significant changes in behaviour (Hughes, Reference Hughes1998). The problem is that there are very few such programmes in operation. This is recognised by central government in the National Alcohol Harm Reduction Strategy for England (DoH, 2007), which has called for “more information . . . on the most effective methods of targeted screening and brief interventions, and whether the successes shown in research studies can be replicated within the health system in England”. Further, the strategy charges the DoH “to set up a number of pilot schemes . . . to test how best to use a variety of models of targeted screening and brief intervention in primary and secondary healthcare settings, focusing particularly on value for money and mainstreaming.” The DoH has now done this and is about to launch a series of pilot schemes (for more information see www.sips.iop.kcl.ac.uk).
This paper reports on the findings of a precursor to the DoH schemes – the Screening and Brief Intervention (SBI) pilot project that ran in the Charles Cross custody suite in Plymouth from March 2007 to March 2008. As such, the findings discussed below are both timely and instructive. This paper will be structured in the following manner. It will provide a brief overview of SBI programmes before moving on to the methods used to obtain the data; it will then outline the process used to screen detainees and outline the aims of the SBI project; from there it will provide data on the project. It will conclude with some thoughts about the overall impact of the project and the extent to which it achieved its aims and solved problems in replicating the Plymouth project elsewhere.
SBI: some background history
Shilo and Burke (Reference Shilo and Burke2000) note that it is not the alcoholic that causes major problems for society, rather it is the hazardous and harmful drinkers that cause most social harms. Moreover, it is often the case that this group's treatment needs are unmet because they do not come to the attention of the treatment providers, yet are clearly in need of some form of intervention. As the US Department of Health and Human Services (2005: 1) note, “moderat[ing] a person's alcohol consumption to sensible levels . . . helps to reduce the negative outcomes of drinking’. However, facilitating change can be problematic, not least in cases where individuals fail to recognise they are using alcohol in a way that could lead to harm. One way to overcome this is to use opportunistic contacts with potential patients to screen their alcohol use and once this has been assessed they can be offered a selection of interventions and information regarding their alcohol use. This practice is known as Screening and Brief Intervention (SBI).
SBI programmes have a long history in primary health care. For example, the World Health Authority have been advocating and using SBI since 1982 (WHO, 2003 and for a review see Moyer et al., Reference Moyer, Finney, Swearingen and Vergun2002). However, SBIs need not be confined to the health setting. Kubiak et al. (Reference Kubiak, Arfke, Swartz and Koch2006) note that arrest, located as it is at the front end of the criminal justice process, may be the critical moment to screen for excessive alcohol consumption. It is certainly the point where the vast majority of contacts are made and can be the most fleeting, making it the ideal setting for a SBI to take place. Moreover, detention in the custody cells often involves ‘dead’ periods where nothing is happening to the detainee, giving them contemplative space. Equally, as Prochaska and Di Clemente (Reference Prochaska and DiClemente1984) note, the act of being arrested may become the catalyst for change within an individual and/or it may motivate others to encourage changes in behavior in the detainee. In the view of Kubiak et al. (Reference Kubiak, Arfke, Swartz and Koch2006: 8) effective screening and brief intervention at the point of arrest and detention may predispose offenders to change, enhance treatment readiness and thus be fiscally and resource prudent.
SBI comes in the shape of an enquiry by health professionals about the patient's life style and the subsequent provision of information and counseling aimed at changing hazardous or harmful behaviour, and is generally acknowledged to be based on a high volume, quick turnover approach with each intervention lasting around five minutes (Babor et al., Reference Babor, Higgins-Biddle, Saunders and Montiero2001). SBIs are very effective when delivered to non-treatment-seeking individuals who find themselves in situations where information can be provided and there may be an impetus for change (Wilk et al., Reference Wilk, Jensen and Thomas2002). Thus the arrest can propel detainees into treatment and longer-term behaviour change. There are a number of screening tools available, however, and one of the longest-established screening tools is the Alcohol Use Disorders Identification Test (AUDIT) developed by the World Health Organisation (WHO). The AUDIT test was initiated in 1982 and has been subsequently refined to the point where WHO is able to claim that it provides ‘an accurate measure of risk across gender, age and cultures’ (Babor et al., Reference Babor, Higgins-Biddle, Saunders and Montiero2001: 4).
WHO notes that alcohol consumption takes place on a continuum which moves from safe to dependent, and, as drinking moves along this continuum, so does the concomitant potential for health and social harms. WHO identify four types of alcohol consumption:
1 safe, where alcohol is consumed in a manner that does the drinker and those around them little harm;
2 hazardous, which is where the pattern of alcohol consumption increases the risk of harmful consequences to the user and others;
3 harmful, whereby alcohol consumption results in consequences for mental and physical health (it is also possible to add negative social consequences here);
4 dependent, which is where there are clusters of behavioral, cognitive and physiological phenomena that may develop with repeated alcohol use. These can include strong desire to consume alcohol, limited control over its use and increased tolerance amongst other symptoms.
(Adapted from Babor et al., Reference Babor, Higgins-Biddle, Saunders and Montiero2001: 6)
Methods
The data discussed in this paper come from an evaluation study that was commissioned by the SBI project and funded by a grant from the British Academy. Data were collected over the period 15 January 2007 until 31 May 2008. Quantitative data were collected from the Plymouth SBI forms that recorded the detainee's answers to the AUDIT tool plus some demographic data that included offence type, age, gender, ethnicity and occupation (n = 3,900). These were analysed using the SPSS software package. In addition, the research team collected qualitative data, which were obtained by attending and observing SBI project management meetings, from semi-structured interviews with police officers, alcohol workers, staff from a variety of agencies involved in the management of the project and a small number of unstructured interviews with detainees who had elected to enter structured alcohol programmes as a result of being screened in the custody suite. The team also observed SBI screening and interventions being conducted in the custody suite. It is important to note that the project did not screen detainees aged under 17 years.
Charles Cross SBI – aims and processes
The SBI project is part of a suite of programmes that fall under the generic title of ‘Plymouth After Dark’. Plymouth After Dark is a police-led multi-agency initiative aimed at reducing alcohol-related crime and disorder in the ‘Clubland’ area of Plymouth. As SBIs work on the principle of a high volume throughput, the SBI project set the following process target: engage with, screen and provide the appropriate intervention to at least seven detainees per day with a target time of five minutes to complete the process. Beyond that, the SBI project had the broader aims of:
1 reducing alcohol-related violence, public order and criminal damage as part of a suite of interventions outlined above;
2 as a public health intervention, alerting people to the negative impact of their drinking behaviour on their health and social well-being;
3 providing a baseline figure for the city of the numbers of people presenting as at least hazardous drinkers
SBI workers made contact with detainees as part of the general custody process. Once the detainee agreed to take part in the scheme, they were screened using the WHO Alcohol Use Disorders Identification Test (AUDIT) tool. Depending on the AUDIT score, the alcohol worker provided an intervention which ranged from information regarding alcohol consumption for low-risk drinkers, through to more detailed information and counselling for those classified as hazardous and harmful drinkers, and on to the provision of information on further assessment and treatment services for those classified as having moderate to high levels of dependence. It is important to reiterate the point that all participation in the screening and intervention process was voluntary. The project screened a broad cross section of offences, with the exception of those being held on immigration offences. In most cases, the team chose not to screen these detainees because there were often problems with language and understanding.
For the first three months of the project's operation, police officers who had been trained by the specialist alcohol service provider in the delivery of the SBI tool undertook the screening, as there was a delay in recruitment of the specialist alcohol workers. It is important to note that these police officers were not the arresting or charging officer; rather they were a group of officers who had received training from the alcohol service provider in using the AUDIT tool. There was a further operational problem once the alcohol workers were appointed, which revolved around fitting the alcohol workers into the daily routine of the custody suite. In effect, the detention officers had to accompany the alcohol workers to the cells, which at times proved a difficult and time-consuming task, in what was an already crowded work schedule. The detention officers were not present in the cells during the administration of the screening tool. However, escorting the SBI workers was not always possible and at times this led to a fall in the number of throughputs. Whilst this did not affect the screening process, in the sense that the AUDIT tool was being used in the manner in which it was planned, it did have the effect of reducing the number of throughputs and the range of interventions that could be offered. This was resolved over time and the alcohol workers and the project became fully embedded in the day-to-day work of the custody suite from around September 2007.
An overview of the initial findings
The evaluation generated a large amount of statistical data, which, at the time of writing, is still undergoing detailed analysis. Below are some initial findings as an overview. The SBI project made contact with 4,721 detainees, of those 3,900 (82.61 per cent) agreed to take part, which equates to a screening of 35 per cent of all those detained at Charles Cross for the period of the project. The project screened the equivalent of 10.68 detainees per day (although it is important to note that the daily totals varied, with the highest numbers of contacts taking place at the weekends); 77.2 per cent interventions were completed within five minutes. Most screenings took place between seven a.m. to midday to allow sufficient time for those who were drunk at the time of arrest to sober up and to fit in with the routine of the custody suite.
The research also enabled a detailed breakdown of the demographic profile of the detainees who agreed to take part in the SBI project and Table 1 shows the group that was screened most frequently were the under 24 year olds; 47.3 per cent of those seen were aged 17–24 with those aged under 30 accounting for two-thirds of all of those seen (65.1 per cent). Of those screened, 84.9 per cent were male with 15.1 per cent being female.
Age range of detainees
Offences were grouped into 11 generic types: violent crimes (for example ABH, GBH, affray, assault); domestic violence; public order; criminal damage; driving related (including drink driving); drug related; drink related; acquisitive crimes; sexual; administrative (breach of bail, arrested on warrant) and other. Violent crime was the most common offence, with 37.2 per cent of detainees being held for either violence (29.9 per cent) or domestic violence (7.8 per cent).
In terms of alcohol use, 35.8 per cent of detainees were low-risk drinkers, 32.1 per cent were hazardous drinkers, 10.9 per cent were harmful drinkers and 21.2 per cent were dependent drinkers. Table 2 provides more detailed data by breaking down drinking behaviour into age groups.
Alcohol use by age group
The majority of those detainees seen by the SBI project (64.2 per cent) were using alcohol in a manner at least putting them into a medium-risk category. Within the youngest age group, 71.0 per cent of detainees were recording at least medium-risk drinking behaviour and thus this group is the largest group of drinkers whose alcohol consumption can be classified as being at risk. However, whilst 20.9 per cent of the 17–24 year olds fall into dependent drinking, it is those aged between 41 and 55 who provide the highest percentage of dependent drinkers. Arguably, those detainees in the 41–55 age group who are in the dependent range are long-term chronic drinkers, whose treatment needs differ from the younger detainees.
In terms of the age of respondents and how many units they consumed in a typical day when they drank alcohol, it is clear that heavy drinking is taking place in the 17–24 year old age group, but it is not the preserve of the young drinker. Whilst we found that the 17–24 year old category consumes 10+ units of alcohol in a typical day's drinking. more often than any other age group, all the age groups reported heavy drinking, meaning that binge drinking is not the preserve of the young.
It is equally clear that the under 30s are more likely to commit violent offences. This is demonstrated in Table 3, which shows that 33.6 per cent of those screened aged under 24 and 31.7 per cent of those screened aged under 30 were arrested for violent crimes. The under 30s clearly dominate the violent offences, accounting for 72.8 per cent of those arrested.
Offence type with age
The research examined the relationship between the different offence types and ‘binge drinking’, and this is demonstrated in Table 4. The recommended daily intake of units of alcohol is two to three units for females and three to four units for males, so for our purposes alcohol intake that exceeds six units per day for males is classed as binge drinking. What is evident from the findings is that those who engage in binge drinking are more likely to commit acts of violence than any other group. It is also interesting to note that for the weekly binge drinkers, the propensity to commit public order and criminal damage offences is high.
Age groups within offence types
We used the National Statistics Socio-Economic Classification (NS-SEC) to categorise the employment of those detained. As Table 5 shows, two groups dominate and they are the ‘never worked/long-term unemployed’ and the ‘technical and craft’ categories (for example building and allied trades, printers, train drivers and so on). However, our research allowed for more detail than the NE-SEC and what became apparent was that builders and allied trades dominated the ‘technical and craft’ group of detainees. In detail:
Employment status of detainees
In addition to the statistical evidence, we can also point to the results of the interviews with the clients. For example, client ‘B’, a 44 year old male, started drinking heavily four years ago following the break-up of a long-term relationship. He was screened by the alcohol workers in the custody suite following his second arrest for affray within a 12 month period. At the time, he was drinking between six and 18 cans of bitter per day and often ended a drinking session with either port or spirits ‘whichever was cheapest in the supermarket’. ‘B’ is a self-employed builder and was able, just, to keep in work, although directly prior to the SBI screening this had become sporadic. Whilst he realised that he was drinking too much, and his drinking had begun to have a serious and negative effect on his life, in his own words ‘B’ ‘never saw himself as an alcoholic – alcoholics are the men in dirty coats sitting on the bench drinking out of a paper bag’. However, he had reached the stage in his life where he recognised the need to change, but was at a loss as to how to begin. In short, prior to the SBI intervention, ‘B’ had no idea of how or where to go to address his drinking problem. However, as a direct result of the SBI screening, ‘B’ realised that his alcohol use was a major problem and was offered a structured and supportive environment in which to begin to address his alcohol use. ‘B’ now attends sessions at the Harbour Centre and at the time of interview had been dry for 14 weeks.
There are a number of key points that emerged from the case studies. First, people like ‘B’ may realise that their drinking is causing them a problem, but either cannot or will not engage with services of their own volition. Second, once accessed, services have a major impact on the offender's behaviour in terms of alcohol-related problems. Third, accessing SBI via the criminal justice system was the vehicle through which change was facilitated. Fourth, offending behaviour, which is alcohol related, has ceased in these cases.
Discussion
Above, it was stated that the project had three main aims: to reduce alcohol-related violence, public order and criminal damage offences within the city, to impact on public health in terms of drinking patterns and to provide a base-line measurement for the city. This section of the paper will assess how successful SBI has been in addressing those aims.
Devon and Cornwall police have made a concerted effort to reduce violent crime and, as stated above, SBI is part of a larger project designed to reduce alcohol-related violence within the night-time economy. Police statistics for 2007/08 show a 5.8 per cent fall in violent crime and a 14.7 per cent fall in criminal damage since the Plymouth After Dark programme, of which SBI is a major part, has been in operation. The semi-structured interviews with key stakeholders indicate that the SBI project has been seen as a success within the city. Before considering details it is important to note that the SBI project is a ‘social crime prevention’ project; that is, its main purpose is not to deal with the where and when an offence takes place, rather it seeks to change attitudes and behaviour over time. As such, it is recognised that evaluating the impact of social crime prevention initiatives is fraught with difficulties, not least because it is almost always a combination of other circumstances working alongside the social crime prevention intervention that becomes the catalyst for change within the individual.
However, we do know that the project has enabled more people to access alcohol-related services. Once the specialist alcohol workers were in place in July 2007, the SBI project could refer offenders into a specialist alcohol agency. Thus, from July 2007 until March 2008, 163 people were offered the chance to access a more detailed alcohol-use assessment after the initial SBI screening and of those 52 people accessed this service as a direct result of being screened in the custody suite. It is instructive to note, given what we said above about the initial problems with the detention officers impacting on the range of interventions being offered, that the number of these interventions has risen since October 2007, with 39 of the 52 people (75 per cent) accessing additional alcohol-related services doing so between October 2007 and March 2008. Interviews with this group uncovered some interesting points. For example, many of the people screened by the project had no idea that the amount they were drinking or the manner in which they consumed alcohol was potentially harmful to them and those around them, and that some people who were defined as dependent had realised they had a problem with their alcohol use, but had no idea where or how to access alcohol-related services. Finally, the project was charged with creating a baseline data set. As a result of this evaluation, the city can now draw on a series of reports based around a sample of 3,900 people.
Whilst the statistics and case studies indicate success in terms of reducing crime, improving health and providing a base-line measurement, we would argue that it is the unforeseen ‘value added’ impacts of the SBI project that has been most interesting and arguably will be of longer-term value to both crime and disorder and public health in the city. We have identified three ‘value added’ impacts’.
First, quarterly findings of the SBI project were presented to the BCU's multi-agency violent crime steering group, which helped to raise awareness of the contributory factor excess alcohol consumption plays in violent crime and anti-social behaviour. Delegates have gone from this group back into their own agencies and as a result there has been an increased awareness of the need for a joined-up approach to resolve the problems associated with alcohol across the city, in organisations such as the city council, the strategic health authority and local businesses. However, raised awareness has not been confined to agencies; due to the numbers being screened and interest in the project being taken up by the local media, there has been a raised awareness of alcohol use in the city generally.
Second, alongside that is the recognition that like every other city in the UK, Plymouth has a problem with alcohol and, to date, has probably under-invested in alcohol-related services. Whilst the findings cannot be extrapolated across the city, the SBI findings highlighted that there are a significant number of people in the city whose alcohol use needs some form of intervention, ranging from simple targeted advice to a residential treatment service. At the time of writing, the Drug and Alcohol Action Team (DAAT) has employed a specialist alcohol liaison person with the remit of engaging with, and providing services for, the under 30s marking the beginnings of more investment in alcohol services.
Third, including employment status into the demographic analysis has made it possible to construct a picture of the most ‘at risk’ groups in health terms and the most ‘dangerous’ groups in terms of public order and violent offending in the city, as well as highlighting the times when those groups are most likely to come into the custody suite. Some of the findings are not surprising – the age range and the surge of detainees at the weekend for example. However, identifying key problem groups has made it possible to begin to construct targeted secondary and tertiary information campaigns. For example, many of those arrested and detained work in the construction industry and there have been discussions about targeted campaigns in the city colleges where construction training takes place, as well as exploratory discussions with the major construction firms in the city. Equally, the high numbers of Not in Education, Employment or Training (NEET) detainees have seen some initial discussions around targeted campaigns being held in benefit offices.
Conclusions
The problems highlighted in this paper are not unique to Plymouth. Equally, our research has confirmed that there is no single solution to problematic drinking; rather central government's proposed strategy of using a multi-agency approach that offers a mix of short-term, immediate impact situational interventions (that seek to control where, when and which people consume alcohol), and, a long-term social approach that aims to change the manner in which people use alcohol would appear to be best practice. Our conclusions are that the SBI project has been a success in achieving its aims, but also, and we would argue more importantly, it has provided a stimulus for a review of the way in which the city deals with alcohol-related problems, thus playing an important role in the planning and implementation of long-term strategies to deal with an entrenched social problem.
Our concluding thoughts regarding SBI projects that are particularly germane to the DoH pilot projects and any subsequent roll out of screening and intervention projects nationally are both technical and cultural. The technical point is that local planners need to utilise a range of data collection agencies to conduct large-scale screening. In our study, the SBI involved only those detained in a custody suite. As a result, we would suggest that the findings are of more use for crime prevention initiatives than public health policy because they do not accurately show alcohol consumption amongst the over 30s due to their under-representation as detainees. We would suggest that using a single data collection agency provides a skewed picture based on which agency did the screening. Multiple data collection agencies, using the same screening tool, would provide a more holistic and, therefore, more valid picture of alcohol consumption in the locality.
Secondly, and our experiences with the media coverage of the project supports this, using the criminal justice system as a vehicle to promote alcohol awareness skews the perception of what constitutes ‘problem’ drinking to that which is associated with crime and disorder. We feel the real strength of the project was its ability to raise alcohol awareness across the city. However, the potential to act on this public health point was subsumed by the concentration on alcohol and offending. What SBI could not do, because it was located in the criminal justice system and focused on crime reduction, was to meaningfully engage with law-abiding hazardous and harmful drinkers who had been made aware of the project via the media but were unable to access services or advice. Thus, in its present criminal justice-based format, SBI is inadequate as a means of reaching the wider population.
This may be important in the long term: as the Academy of Medical Sciences (2004: 8, original emphasis) concludes ‘the scientific evidence indicates that, for the health of the public, action is required to reduce the consumption of alcohol at a population level’. Using the criminal justice system to lead alcohol reduction strategies risks focusing too heavily on the relationship between alcohol and offending, thus producing long-term strategies which over-concentrate on the anti-social activities of the under 24 binge drinker at the expense of engaging with older, law abiding, problem drinkers.
