Research and analysis

Project ADDER evaluation: Report for practitioners

Published 12 February 2025

Applies to England and Wales

Authors

Verian authors Priya Menon and Holly Captainino in partnership with the Institute for Criminal Policy Research and Revolving Doors.

Acknowledgements

Verian is a world-leading independent research, evidence, evaluation and communications agency, providing services to government and the public realm. Verian was commissioned by the Home Office as the lead evaluation organisation for Project ADDER and worked with consortium partners to prepare this report.

Our thanks go to our consortium partners, Dr Gavan Conlon and Jack Booth at London Economics, Lauren Bennett at Revolving Doors and Professor Mike Hough and Dr Bina Bhardwa at the Institute for Crime & Justice Policy Research (ICPR) at Birkbeck, University of London, for their collaboration and continued support with subject matter expertise, guidance and advice throughout the design, fieldwork and analysis stages of the evaluation.

We are also grateful to the Home Office Analysis and Insight team for their regular guidance and feedback: in particular, Molly Watts, Lauren Comber, Alison Green, Katherine Weaver and Anna Reed. In addition, we received valuable support from our colleagues at the Office for Health Improvement and Disparities (OHID): in particular, Dylan Kerr.

Our thanks also go to the anonymous peer reviewers who provided us with comments during the reporting stage and, finally, to all the ADDER project stakeholders and service users who gave their time generously to the evaluation process.

Glossary

Buprenorphine: A medicine used to treat dependence on opioid (narcotic) drugs such as heroin and morphine, often referred to by the brand names ‘Buvidal’ and ‘Sublocade’. Depot buprenorphine is administered (after titration) either weekly or monthly via sub-cutaneous injection and marks a significant shift in opioid substitution therapy, which relies on daily doses of either methadone or buprenorphine.

County lines: Gangs and organised criminal networks involved in exporting illegal drugs to one or more importing areas using dedicated mobile phone lines or other forms of ‘deal lines’.

Cuckooing: Cuckooing is when drug gangs take over the home of a vulnerable person through violence and intimidation and use it as their base for selling/manufacturing drugs.^{[footnote 1]}

Delivery partners: Organisations, services and professionals involved in the delivery of Project ADDER. For example, treatment services, police forces, and the National Crime Agency (NCA).

Diversion: Initiatives that use the criminal justice system to divert people who use Class A drugs away from offending (and criminalisation) into health interventions, through programmes such as drug testing on arrest, community resolutions and Out of Court Disposals (OOCDs).

Drug testing on arrest (DToA): Police are able to test suspects in custody for Class A drugs, namely opiates and cocaine, to better understand whether it is suitable to refer an individual for support, and also to understand the role of drug misuse in certain crime types. Testing is currently used for a range of ‘trigger offences’ that are defined in law.^{[footnote 2]}

Individual Placement Support (IPS): A service that is designed to support service users to find paid employment, typically consisting of intensive individual support in relation to searching for a job and throughout the job placement.^{[footnote 3]}

Middle market targets: Criminal networks and individuals operating within the sphere of activity that lies between bulk importation traffickers/wholesalers and retail-level dealers.^{[footnote 4]}

Naloxone: Naloxone is the emergency antidote for overdoses caused by heroin and other opiates or opioids (such as methadone, morphine and fentanyl).

Organised crime group (OCG): An OCG is defined as a group which has as its purpose, or one of its purposes, the carrying on of criminal activities, and which consists of 3 or more people who agree to act together to further that purpose. ^{[footnote 5]}

Out of Court Disposal (OOCD): OOCDs are a set of cautions or orders that the police are able to give when individuals are caught for low-level offences, and which prevent the individual from being formally prosecuted or having a criminal record. OOCDs include, but are not limited to, referrals for individuals to engage with a support service, and some types of caution.

Outreach: Outreach refers to activities that target and seek to engage a specific group for treatment or support services.

Recovery support: Ongoing interventions that include intensive employment, tenancy, and peer support, which occur after structured treatment support.

Service user: Refers to an individual who is a beneficiary of, or who is in receipt of, an ADDER-funded activity or service. In a few cases the term ‘people using drugs’ is used in this report to refer to individuals who are eligible for ADDER-funded activities due to drug use.

Treatment: Within Project ADDER, drug treatment encompasses a broad spectrum of interventions/activities, including tier 1 to 2, that is, harm reduction approaches (for example, needle exchanges), GP/primary care interventions and signposting. The programme was primarily focused on getting people using drugs into tier 3 to 4 structured treatment, which means activities designed to reduce harm for service users, often involving pharmacological and psychological treatment.

Trauma-informed practice: The aim of trauma-informed practice is to raise staff understanding about the wide-ranging impact of trauma and to prevent the re-traumatisation of clients in service settings that are meant to support and assist healing.

Whole systems approach (WSA): This involves responding to a complex issue by working across multiple stakeholders and ways of working, to deliver a single system response. WSA aims to bring about sustainable, long-term change. For ADDER, this refers to working with enforcement, treatment and recovery partners to tackle drug misuse.

Executive Summary

1. Policy context and introduction to Project ADDER

Project ADDER (addiction, diversion, disruption, enforcement and recovery) aims to promote an intensive WSA to tackling drug use and its consequences. The funding from Project ADDER was used to implement interventions across treatment and recovery, enforcement, and diversion, with the overall aim of reducing the prevalence of drug use, drug-related offending, and drug-related deaths. The project initially focused on opiates and crack cocaine but over time local areas were able to expand their focus to other drugs (primarily Class A), co-use of alcohol, and preventative interventions.

Five local areas (Blackpool, Hastings, Middlesbrough, Norwich and Swansea Bay) were initially invited to bid for ADDER funding due to their high levels of drug-related deaths and opiate and crack cocaine use. Implementation on a phased basis in the different areas began from January 2021, with projects originally scheduled to run until March 2023. A further 6 local areas were invited to bid at a later stage – referred to as ‘Place-based Accelerators’. These areas were Bristol, Hackney, Tower Hamlets, Merseyside (itself comprising the sub-regions of Liverpool, Knowsley and Wirral), Newcastle, and Wakefield. Phased implementation for these areas began from April 2021. Through the 10-year Drug Strategy published by the Conservative government in 2021, From harm to hope: A 10-year drugs plan to cut crime and save lives, funding was extended by the Conservative government for all areas until March 2025.

Based on available evidence, a range of interventions were proposed by the Home Office, classified into 3 broad groups: treatment and recovery, diversion, and enforcement. Each of the local areas were invited to prepare tailored project proposals according to these interventions which reflected their local contexts. As a result, the interventions delivered by each area differed significantly. In delivering these interventions, local projects sought to adopt a WSA, whereby enforcement, diversion, treatment and recovery partners function as a coherent ‘system’ to meet the needs of service users holistically.

The implementation of Project ADDER was significantly affected by the outbreak of COVID-19 and pandemic prevention measures, such as social distancing, lockdowns and mobilisation of treatment staff to COVID-19 care. The pandemic affected Project ADDER in various ways, as outlined below in the key findings section.

2. Evaluating Project ADDER

The Home Office has commissioned Verian to conduct an independent evaluation of Project ADDER, working in partnership with London Economics, Revolving Doors and the Institute for Crime & Justice Policy Research (ICPR) at Birkbeck, University of London.

This evaluation covers the original funding period for Project ADDER up to March 2023. The objectives of the evaluation are to measure delivery against the stated project’s aims, investigate experiences of delivery and provide recommendations on designing or rolling out a similar programme, and provide recommendations on continuing to evaluate the effects of Project ADDER.

This report presents the findings from the scoping and process evaluation of Project ADDER, and shares examples of best practice from, and challenges faced by, local area projects throughout. The findings from the impact evaluation strand can be found in: Project ADDER: Impact evaluation report.

The scoping phase and process evaluation comprised a series of deep-dive, holistic case studies for each Project ADDER area. The primary methodologies used were in-depth interviews and workshops with stakeholders (such as strategic leads and other staff involved in delivery).

3. Key findings

3.1 The whole systems approach

Across local areas, the WSA was considered to be an important facilitator for delivering Project ADDER. In particular, stakeholders reported that the approach was critical for:

• arranging appropriate and fast referrals for service users into holistic and appropriate support services, by collaborating as partners to make joint referral decisions
• improving the effectiveness of enforcement activity, as teams had greater access to intelligence relating to criminal activity and public health data, making action more informed and targeted
• reducing competition and duplication of work between treatment partners
• aligning approaches between treatment and enforcement partners to ensure all organisations functioned as a ‘system’ and service users received a consistent service

However, the success of this approach was highly dependent on the work and dedication of strategic individual(s). Stakeholders also suggested that it is likely to take some time to embed a WSA, particularly where partners within and between treatment and enforcement have a history of significantly different languages, cultures or practices. Stakeholders often reiterated the need for continued and long-term funding and support in order to ensure that the established approaches are resilient.

3.2 Best practice summary

Stakeholders also outlined a number of activities or ways of working that they felt facilitated the delivery of Project ADDER interventions. These were:

• establishing steering/task groups
• setting up strong partnerships and multi-disciplinary teams
• designating funding for ADDER-specific personnel, services and equipment
• reducing caseloads and providing assertive outreach
• establishing a trauma-informed and client-centred approach

3.2.1 Establishing steering/task groups

Steering groups and task and finish groups to oversee specific workstreams were critical for interacting with a broad number of partners, driving engagement and spearheading innovative ways of working. Attending steering and task groups was a priority for many partners, given their practical focus on information sharing and organising implementation collectively.

3.2.2 Setting up strong partnerships and multi-disciplinary teams

Project ADDER funding allowed for existing relationships to be improved and new partnerships to be created and brought a sense of common purpose between key organisations across treatment and enforcement in the local area, to the benefit of service users. Using multi-disciplinary teams was critical to making appropriate and rapid referrals for service users into appropriate support services. Having partner organisations involved in the design stage, or as early as possible, was seen as a critical facilitator for establishing strong communication between partners.

3.2.4 Designating funding for ADDER-specific personnel, services and equipment

Having a designated strategic lead to oversee the local implementation of the programme enabled a cohesive ‘identity’ to be built around the aims of Project ADDER. This approach was reported to have resulted in stronger relationships, increased trust and more regular information sharing between key organisations and partners.

Assigning operational staff to focus solely on Project ADDER was critical for:

• ensuring appropriate capacity for interventions, and also for commissioning functions, such as administration and business support
• reducing the number of competing priorities for staff
• reducing the number of individuals a service user would need to interact with to access multiple services
• providing specialist new services, such as support for women experiencing domestic abuse, support for young carers, and homelessness outreach
• increasing the intensity of support provided, and speeding up referral or diversion to appropriate support services
• ensuring that the design and conduct of interventions was evidence-led: for example, with the use of analytical hubs that handled public health and police data

Having dedicated Project ADDER equipment improved intelligence sharing between enforcement partners (for example, drug testing equipment and digital forensic investigate tools). This allowed for more proactive and targeted enforcement activity that would otherwise have been difficult to ring-fence capacity for.

Recruiting dedicated roles for knowledge exchange was a core facilitator of the WSA: it allowed partner organisations to both share with, and learn more about, other parts of the system.

3.2.5 Reducing caseloads and providing assertive outreach

Recruiting additional treatment staff reduced caseloads, and allowed organisations to offer more intensive, structured, wraparound support. This approach was felt to be more ‘client-centred’ and more focused on the ‘human element’ of treatment and recovery. Being able to actively engage with service users through ground-based assertive outreach work, and having increased visibility in the community, was a key benefit of Project ADDER funding.

3.2.6 Establishing a trauma-informed and client-centred approach

Across all case study areas, there was a focus on adopting a more client-centred approach. This included running multi-disciplinary staff training on trauma-informed practice and offering multiple treatment pathways based on service user needs. In many cases, stakeholders highlighted that using ‘lived experience’ teams was particularly useful for establishing this approach.

It was reported that the use of trauma-informed and client-centred practice supported faster diversion of service users towards treatment services and earlier access to the treatment pathways that worked best for their needs.

3.3 Barriers and challenges

Stakeholders also reported experiencing barriers and challenges throughout the implementation journey. Where possible, local projects sought to adapt or mitigate these as they arose. These challenges related to the following areas:

• approving delivery plans and reporting to the Home Office
• establishing data sharing agreements and processes
• allocating funding
• recruitment and training
• retention and absence
• engaging individuals who have traditionally been disconnected from services
• managing competing priorities and shift work
• embedding partnerships and aligning project ethos
• a lack of leverage over wider systemic issues

The greatest challenge experienced across local projects within the programme was recruiting staff. This was exacerbated by late confirmation of programme funding, increases in agency prices related to COVID-19, and a lack of suitably skilled individuals following on from a lack of investment in the sector historically.

3.3.1 Approving delivery plans and reporting to the Home Office

Stakeholders reported that they did not receive adequate guidance on the level of funding that could be allocated to different intervention groups, and that there was insufficient lead-in time to collate delivery plans. Submitting monthly data returns, in addition to attendance at expert panels and communication groups, as well as financial reporting, put further strain on resources, and stakeholders often felt expectations were unrealistic.

To address this issue, the Home Office could consider extending timelines for needs assessments and for the design of interventions. At the outset, the Home Office could provide clear, early guidance on any prescribed funding allocations, and look to streamline reporting mechanisms. The Home Office could consider increasing the flexibility in using funding: for example, allowing resources to be used to support the process of reporting to the Home Office.

3.3.2 Establishing data sharing agreements and processes

At setup, it was not always clear whether data or information sharing agreements (DSAs) would be needed, and, if so, for what types of information or data. In some cases, the absence of DSAs hampered intelligence sharing and the ability to track individual support journeys.

In some cases, local projects elected to share data on the legal basis of ‘consent’, rather than a DSA, although it was noted that doing so relies heavily on having strong working relationships and can slow the process of information sharing. The Home Office and local projects could consider funding dedicated roles or resources for strategic support, coordination and information sharing.

3.3.3 Allocating funding

Processes for providing funding to partners at the local level were often found to be burdensome and lengthy, leading to delays in implementation. Initially, it was challenging for strategic leads to ring-fence the parameters and responsibilities of partners who provide similar services within the same local project.

Arranging office, co-location and other physical spaces in line with the WSA proved to be a challenge where there was not a designated budget to do so. At the outset, funding was not approved for use for preventive interventions and service users aged 17 and under, or for alcohol treatment services. The Home Office and local projects could consider a more flexible approach to funding that allows local projects to use funding for interventions targeted to needs, and also for dedicated roles or resources, such as strategic support, coordination and information sharing.

Some local areas settled on using grants for funding allocation rather than contracts, although this notably reduces the flexibility of what the funding can be used for at a granular level. The Home Office could consider extending timelines to account for local authority processes for allocating funding. Involving partners as early as possible in design is likely to help the process of scoping out the different roles of organisations that offer similar support or services. The Home Office could consider allowing local projects greater flexibility to use resources for logistics, administration and rental of physical spaces.

3.3.4 Recruitment and training

Common across all areas were difficulties in recruiting staff into post, resulting in significant delays to local interventions and causing an initial underspend. This was particularly the case for roles requiring advanced clinical skills across opioids and non-opioids, lived experience, and/or those requiring additional permissions or accreditation, such as Disclosure and Barring Service (DBS) checks. This was primarily due to an overall shortage of skilled professional workers, but also because local projects were seeking to hire from the same limited pool of candidates simultaneously.

Furthermore, the outbreak of COVID-19 resulted in increased agency prices, and greater preferences for secure longer-term contracts among eligible staff, which could not be provided under Project ADDER.

To adapt to the recruitment difficulties, local projects hired individuals who did not fully meet the original criteria for the role and trained them to meet the requirements. However, this meant that additional resources, investment, and time were needed before staff could begin in post. The Home Office could coordinate across areas to stagger recruitment by area, or facilitate shared resources across neighbouring areas.

Practitioners should anticipate challenges in recruiting key positions due to a historical shrinkage in investment in the treatment sector. Steps to prepare for this could include recruiting positions as early as possible, anticipating lengthy processes of sign-off from the Home Office, the OHID and also within the local authority, expecting that there may be long lead-in times before staff can start, tailoring job descriptions to adapt to the existing skills base, anticipating additional delays for accreditation, or ring-fencing resources for technical training.

3.3.5 Retention and absence

There was some concern among stakeholders about staff retention due to late official confirmation of funding extensions. There was a high degree of reliance on strategic leadership and coordination roles, meaning that turnover or a lack of capacity in these roles posed a risk to delivery.

During the outbreak of COVID-19, a considerable number of staff involved in the implementation of ADDER were at risk of exposure to the disease, and implementation was disrupted when staff were sick. The Home Office should give official notice as early as possible about whether funding is being extended, to support staff retention and to allow local projects to plan for ongoing implementation.

For strategic roles or other positions that are highly reliant on a small number of staff, it may be useful to have an established ‘plan B’ for unanticipated absences.

3.3.6 Engaging individuals who have traditionally been disconnected from services

There were some challenges in engaging cohorts of people who had never engaged with services or who had traditionally been disconnected from services. Significant preparatory work or engagement was needed with some service users before they could meaningfully engage with services. For others, they needed ‘convincing’ that the help was available for them when it had not been previously.

Local projects could not offer some in-person services when COVID-19 pandemic restrictions, such as lockdown or social distancing, were being enforced. Assertive outreach for specific cohorts will require extended periods of time or funding, to conduct preparatory work for service users and to ensure that they can access support services.

3.3.7 Managing competing priorities and shift work

The nature of shift work in the police posed a challenge for building intelligence and then acting on it quickly. Some enforcement activity, such as covert operations and the provision of naloxone, required high-level permission before it could be implemented and was at greater risk of delay or non-implementation.

Treatment services reported that there was a lack of capacity within their organisation in cases where there were no dedicated ADDER roles, where greater resources were diverted to training, or where there were significant levels of staff illness.

During the COVID-19 outbreak, many treatment and support organisations were mobilised towards pandemic mitigation, preventing them from working on ADDER interventions.

Assigning operational staff to focus solely on Project ADDER was critical for mitigating capacity constraints, by reducing the number of competing priorities for staff.

In some cases, the challenges of managing shift work and competing priorities eased over time.

3.3.8 Embedding partnerships and aligning project ethos

Project ADDER allowed local areas to set up a WSA, but stakeholders reported that further time and support may be needed to embed partnerships and trauma-informed, client-centred approaches for the long term. In particular, this was thought to be the case where changes to organisational cultures, languages or communications were needed to ensure alignment across organisations.

Training has proven to be a useful tool for aligning treatment and enforcement partners who have historically had different cultures, languages, and approaches. This includes training on trauma-informed practice, identifying drug use and harms, understanding available referral options, or making referrals that are appropriate for the needs of service users. Lived experience teams were perceived as being particularly useful for the delivery of trauma-informed training.

The Home Office could consider extending funding for a longer period in order to support local areas in embedding a WSA for the longer-term.

3.3.9 Lack of leverage over wider systemic issues

For areas looking to provide integrated housing support, stakeholders reported that there was a lack of housing support that could be offered via ADDER. This was typically attributed to a lack of involvement by housing services in the design phase, a lack of suitable housing supply, or uncertainty about what could be funded via ADDER as compared to other funding streams, such as the Rough Sleeping Drug and Alcohol Treatment Grant (RSDATG).

Individual Placement Support (IPS) implementation may have been hampered by employer stigma against service users, particularly those with a history of drug use or experience of the criminal justice system.

Other policy or legislative environments also affected the conduct of ADDER: for example, the re-nationalisation of the probation service, changes to Out of Court Disposal (OOCD) to a 2-tier system, and laws dictating the circumstances under which drug testing on arrest (DToA) can be conducted.

The Home Office could look to utilise partnerships with OHID, the Joint Combatting Drugs Unit (JDCU) and other government departments to map out related funding streams and identify how wider systemic issues could be addressed.

3.4 Reflections

Project ADDER has paved the way for some new and refreshed ways of working in local areas, and allowed for a strategic WSA that spans enforcement, treatment and diversionary organisations, practices and interventions. However, there were evident barriers to programme implementation, some compounded by the COVID-19 pandemic and the results of a longer history of budget cuts and a shrinking skilled workforce.

Evidence from this evaluation highlights the need for continued Home Office long-term funding and support in order to embed this WSA for the long term. In doing so, the Home Office should consider:

• increasing projected timelines for local projects to engage in delivery design, needs assessments, funding allocation or local authority processes, and recruitment of staff; early communication of funding extensions is critical for ensuring stability of delivery
• providing clear guidance on any prescribed funding allocations, and the reporting mechanisms that will be required throughout the programme; reporting mechanisms may benefit from being streamlined or co-produced with practitioners
• recognising that local projects may need to use funding more flexibly to meet local need: for example, allocating resource specifically for the purposes of coordination, logistics, administration, physical spaces and Home Office reporting. Providing additional mechanisms for local projects to consult with each other may also be beneficial, particularly for those that neighbour each other

For practitioners, this evaluation provides insights into what types of activities can be implemented and how the implementation journey can be facilitated. It also identifies key challenges that can be anticipated, and possibly mitigated or overcome, going forwards. These include:

• preparing for significant difficulties in recruiting positions, particularly those with advanced clinical skills, lived experience, and those that require additional permissions or accreditation
• bringing partners together as early in the design stage as possible to establish strong relationships and arrange funding allocation; across all local projects, multi-disciplinary teams, strong partnerships, and information sharing created the bedrock of successful implementation
• consider funding dedicated roles or resources for strategic support, coordination, information sharing and analysis, logistics and Home Office reporting; this may include establishing ‘plan Bs’ for unanticipated staff absences

Introduction and methodology

4. Introduction to Project ADDER

In July 2021, Professor Dame Carol Black published her final report as part of an independent review of drugs in the UK.^{[footnote 6]} This report made recommendations for refreshed action across government to address the societal costs of drugs, and the detrimental impacts that funding reductions and budget constraints, in both the enforcement sector and the treatment sector, have had on drug-related harms. While this is difficult to quantify, the review estimated the social and economic cost of illicit drugs in England at around £19.3 billion per year, with Class A heroin and crack cocaine causing the most harm and associated crime (that is, county lines, acquisitive and violent crime). The review’s recommendations were accepted by the Conservative government in 2021 and are addressed in the Drugs Strategy From harm to hope: A 10-year drugs plan to cut crime and save lives^{[footnote 7]}, published by the Conservative government in 2021.

Project ADDER was initially planned to be a 3-year pilot programme, operating between November 2020 and March 2023. It was later extended to March 2025. It is led by the Home Office and OHID^{[footnote 8]} within the Department of Health and Social Care. Further support was received from the Department for Levelling Up, Housing and Communities, the Department for Work and Pensions (DWP), the Ministry of Justice (MoJ) and the Welsh Government. The programme aims to promote an intensive WSA to tackling drug use – and in doing so, to reduce the prevalence of drug use, drug-related offending, and drug-related deaths. In total, £43.5 million has been invested in the programme at the time of writing.

Five local areas (Blackpool, Hastings, Middlesbrough, Norwich and Swansea Bay) were initially invited to bid for ADDER funding on the basis of their high levels of drug-related deaths, and opiate and crack cocaine use. Implementation on a phased basis in the different areas began in January 2021, with projects scheduled to run until March 2023. A further 6 local areas were invited to bid for the ‘Place-Based Accelerators’ programme at a later date (Bristol, Hackney, Tower Hamlets, Merseyside (itself comprising the sub-regions of Liverpool, Knowsley and Wirral), Newcastle, and Wakefield). Phased implementation in the Accelerators areas began in April 2021 and ran until March 2023.

The Place-based Accelerators programme closely mirrors the original ADDER programme – the main difference being that locations are more complex. For example, these areas may have overlapping local authority boundaries, meaning that the landscape within the defined local Accelerators area can differ significantly (for example, by different drug treatment providers), while other elements might be shared (for example, courts, police force).

Given the similarities between Project ADDER and the Place-based Accelerators programme, the wording ‘Project ADDER areas’ is used throughout this report to refer to both ADDER and Accelerators areas. Where a distinction is made between them, this will be made explicit, by using either the term ‘ADDER areas’ or ‘Accelerators areas’.

A range of evidence-based interventions were proposed by the Home Office and classified into 3 broad groups: treatment and recovery, diversion, and enforcement. Each of the local areas was then invited to prepare project proposals which reflected their local contexts, population characteristics, models of existing service provision, existing partnership structures and preferred delivery models. Local areas were able to choose a selection of activities from this ‘menu of interventions’ but were also given the discretion to propose alternatives in the design stage.

5. Evaluation approach and objectives

5.1 Objectives

The key evaluation objectives are to:

• measure delivery against the stated project’s aims
• investigate experiences of delivery and provide recommendations on designing or rolling out a similar programme
• provide recommendations on continuing to evaluate the effects of Project ADDER

5.2 Approach

Verian developed a holistic evaluation design that combines various approaches, all underpinned by a flexible and iterative way of working together across the evaluation consortium partners, the Home Office, OHID, and all the local authority stakeholders. The overall design and specific methods align with the established Magenta Book and Green Book approaches^{[footnote 9]} and draws on a variety of data sources to inform the process and impact evaluation strands.

The evaluation is made up of 3 distinct but overlapping work streams, including:

• scoping and immersion: to produce a detailed evaluation strategy to inform all following work strands of the evaluation; this phase also included the production of a comprehensive programme-level ToC model, which is available in Annex A, as well as project-level ToCs for each area
• process evaluation: to explore how Project ADDER has been implemented across all areas, to assess the extent to which delivery progressed as planned, and to identify facilitators of, and barriers to, successful implementation
• impact evaluation: to measure whether Project ADDER interventions have produced or contributed to the desired outcomes, to understand how outcomes have occurred, and to explore any unintended outcomes; a literature review on the impacts of similar interventions was also conducted to contextualise the findings
• economic evaluation: to understand the costs and benefits of Project ADDER at the project and programme level, and to assess whether the programme is representing value for money; the results of the economic evaluation are not being published at this stage; this is due to the findings from the economic evaluation only reflecting the early stage of this programme where upfront investment was required and which were impacted by delays in fully mobilising due to COVID

An overview of the methods used for each workstream is provided in Annex F. This report covers findings from the scoping and immersion and process evaluation streams of the evaluation. The findings from the impact evaluation strand can be found in: Project ADDER: Impact evaluation report.

5.3 Scoping phase and process evaluation

The content in this report provides the findings from the scoping and immersion phase and the process evaluation. In both years of the evaluation, this entailed a series of deep-dive, holistic case studies in each Project ADDER area, using in-depth interviews and workshops with stakeholders and service users to gain an understanding of the implementation journey of each local project.

There are 3 key limitations that need to be considered in order to interpret the insights from the process evaluation. These are as follows:

• the timing of the process evaluation: due to delays in implementation, year 1 stakeholder interviews took place at an earlier stage in implementation journeys than was originally intended; although efforts were made to cover additional insights in the year 2 stakeholder interviews, some experiences relevant to the process evaluation may have been missed; the evaluation only covers activity up to the end of March 2023, when the final interviews were conducted
• sample selection bias – stakeholders: all area-level stakeholders were recommended to Verian by the strategic lead in each area; this meant there was a risk that stakeholders involved in abandoned or less successful activities would be less likely to be recommended as contributors to the evaluation by strategic leads, or would be less likely to engage with it if they were recommended; there were some individuals that Verian was unable to get in contact with due to individual capacity issues, turnover of staff, or other reasons specific to the person
• sample selection bias – service users: all service users were recruited via support service staff working on programme activities; this means that there is a risk that the service user sample is skewed towards those with positive experiences, those with greater digital access, those working with less-burdened support staff, and those leading lives with lower levels of disruption; more detail can be found on selection bias for the service user sample in the separate; the findings from the impact evaluation strand can be found in Project ADDER: Impact evaluation report.

For more detail on the scoping and process evaluation methodology, please refer to Annex G.

Bid development and preparing for implementation

6. Overview of pre-implementation activities

Local areas were selected by the Home Office for Project ADDER and were invited to prepare project proposals which reflected their local context, population characteristics, model of existing service provision, existing partnership structures and preferred delivery models. In producing their delivery plans, the areas focused on assessing local needs and bringing together relevant partners.

After producing delivery plans, areas proceeded to prepare for implementation, which included beginning to recruit staff into post and establishing governance arrangements.

For detailed information about pre-implementation steps, including needs assessments, producing delivery plans, and additional local project examples, please refer to Annexes H to J.

7. Pre-implementation good practice

Stakeholders referred to a number of practices they conducted before the implementation of the programme started that went on to be critical for successful delivery. These have been arranged into 3 key areas:

• setting up successful partnerships with a shared vision and purpose
• establishing steering/task groups
• designated funding for ADDER personnel, services and equipment

7.1 Setting up successful partnerships with a shared vision and purpose

Overall, areas reported that communication between partner organisations went smoothly; partners were positive about the aims of Project ADDER and there was a general consensus on the priorities, aims and vision among senior staff. Having partner organisations involved in the design stage, or as early as possible, was seen as a critical facilitator for attaining early buy-in for the overall purpose of the programme. Most ADDER partnerships had established contracts or grants.

Strategic leads reported that ADDER ‘made sense’ to many partners involved in the planning conversations, leading to minimal disagreement on what the priorities for funding should be, and the scope of work for each organisation. Stakeholders shared a sense that the additional resource was welcome, and the notion of a WSA was understood and acknowledged as a core component of project design – with the additional benefit of reducing competition between treatment providers and simplifying referral pathways. However, in a few cases it was pointed out that Project ADDER did not initially allow for funding to be spend on preventative interventions: for example, interventions to address alcohol use or aimed at young people.

Discussing appropriate communication channels in the early stages of implementation was also considered essential to reach partners across multi-disciplinary teams and to facilitate strong partnership working. Once such relationships were established, informal communication channels, typically using Teams or Zoom, facilitated the ease and comfort of joint working. Ongoing regular communication and meetings were important for collectively discussing local demands and needs from different perspectives, and ensuring that all relevant partners were on board with proposed solutions or approaches.

Communication between partners was particularly effective where there was consistency of individuals of appropriate decision-making authority involved in the project from design to inception and implementation, and also where there were pre-existing relationships between organisations. The outbreak of COVID-19 meant that some partners faced difficulties communicating in person, though remote working was quickly instituted as a temporary measure.

For many stakeholders, these strong partnerships, combined with recruiting dedicated roles for sharing knowledge between partners, were a core facilitator of whole systems working. This allowed partner organisations to both share with, and learn more about, other parts of the system (for example, treatment providers learning more about tackling drug market supplies, and vice versa).

Case study: setting up successful partnerships in Bristol

Bristol’s substance misuse treatment services and the mental health NHS service recognised that pre-Accelerators, there was a lack of mental health support, and resource to provide it, for those with a dual diagnosis of substance misuse and mental health issues. The Accelerators project therefore provided an opportunity for the mental health service to work together with the substance misuse services to reach a cohort of service users who they would previously not have been able to help. This provided both services with a shared vision: to offer psychological therapeutic support to service users.

The shared purpose and vision enabled the drug treatment and mental health services to set up new, clear referral pathways and communication channels between them, to improve access to psychological therapy for those with a dual diagnosis.

Implementation was focused on building strong relationships between key referrers into the mental health services in Bristol (the Avon and Wiltshire mental health Partnership (AWP)). Key referrers were Developing Health and Independence and the Nelson Trust. Initial meetings were set up to discuss how referrals should work from the outset in a way that would minimise friction for service users. Regular meetings were then held roughly once a month to review referrals and see if anything could be done differently to increase referrals. The Nelson Trust also allowed the AWP to co-locate so as to use their facilities to deliver group interventions.

AWP reported that the Nelson Trust has made quite a few referrals to their service, and also that they have seen less attrition between referrals and first appointments as a result.

“We have worked hard on our relationship with key referrer. We had meetings to set up how referrals would work initially. We are currently discussing having joint case discussions to think about clients together.”

Managerial, Treatment

Case study: setting up successful partnerships in Middlesbrough

Public health and the NHS trust conducted initial meetings to formulate a delivery plan that would benefit the community and service users in a more integrated manner. The NHS trust allocated harm minimisation nurses and near-fatal overdose workers to ADDER interventions, to provide primary and clinical support to the service users. This expanded access to other treatment and medical services, such as mental health services, GP surgeries, and hospitals. These collaborations have helped identify people experiencing drug overdose and misuse coming into A&E.

“Multi-agency working has been very useful, especially in cases where nurses are being employed by partner agencies, so Middlesbrough council doesn’t need to focus on that aspect.”

Strategic, Treatment

The partnership between treatment services and police has also helped galvanise the WSA. The preliminary meetings between public health and enforcement stakeholders enabled the process of introducing diversionary schemes for individuals in custody, especially young people involved in drugs. Senior management in the police force pushed the agenda for more interface between officers and ADDER staff like Barnardo’s, assertive outreach and youth justice workers to create a comprehensive pathway for people in custody. As a result, young individuals found in possession of drugs were given the opportunity to engage in diversionary or treatment services.

“We’ve definitely seen a change in the development of the relationship that we have with the Cleveland police … and I think it’s been massively under-estimated in the past how important it is to work closely with them.”

Managerial, Treatment

7.2 Establishing steering/task groups

Steering groups of senior staff and task and finish groups were established in some form in most Project ADDER areas and met regularly to oversee specific workstreams. Individuals attending these meeting ranged from operational implementers through to strategic leads, but they typically included at least one senior representative from each relevant partner organisation.

These were widely considered to be a key facilitator of successful programme delivery and the achievement of high standards. These groups were reported to be critical for interacting with a broad number of partners and driving engagement and were also responsible for spearheading innovative ways of working between partners.

Case study: establishing steering/task groups in Newcastle

The partnership steering group met monthly from the start of the project. It represented all key stakeholders and was seen as a major facilitator of partnership working at strategic, managerial and operational levels.

The group had representation by all key stakeholders and developed an action plan to support focus and delivery. The group included lived experience and recovery organisations, as well as family and carer support services. It also acted as an overarching group for other funding streams: for example, IPS, and Rough Sleeping Drug and Alcohol Treatment Grants.

The group ensured that work was data- and intelligence-led. It developed an action plan to support focused delivery. For example, intelligence updates were provided, and dates of targeted enforcement activity were communicated by the police to public health, with public health then cascading these to treatment services. This meant that if, for example, the police were carrying out warrants in the community, the treatment strategic lead would brief the drug treatment services to ensure there was sufficient staff resource available to work with individuals who were referred to their services as a result.

In addition, several task and finish groups were set up to report to the steering group. These included a criminal justice task and finish group, which was led by providers in treatment services, police, courts, and the probation service. It also included an employability task and finish group, which involved treatment services, DWP, and other partners as and when needed.

“The employability task and finish group is working with leads in the economic development team in the local authority to make sure they connect with the broader agenda around employability, rather than us recreating something just for drugs and alcohol. We’ve been mindful not to duplicate and try to keep things as simple as possible, but also to try and get the drug and alcohol agenda into other bits of mainstream conversation as well.”

Strategic, Treatment

Case study: establishing steering/task groups in Middlesbrough

Steering group committees were set up among the ADDER core committee members, which was then expanded to liaison with different agencies. A working group was also established between police and treatment services. Having frequent meetings between ADDER public health staff and Cleveland police improved collaboration and brought into focus the importance of custodial services in providing referrals to individuals that are involved in low-level criminal activity and drug use. The working group was also important for arranging the distribution of naloxone kits among the police. Over time, these meetings expanded to involve more police officers and partnered with different organisations for training.

These groups have also undertaken continuous review of the projects, with different partners providing their input, such as NHS services, Recovery Connections (a rehab facility), social care coordinators, and the voluntary and community sector (such as Seen, Heard, Believe). This approach has helped create services that suit the needs of people in a more holistic manner, as well as expanding their reach in the community.

“Over the last year, the team has spent time developing these services as they didn’t exist before ADDER. This includes targeting the community, especially non-opioid users who would never otherwise access support.”

Managerial, Treatment

“We used to, historically, shy away from enforcement. It used to be them and us. But now they’re invited to all of our multi-disciplinary meetings.”

Operational, Treatment

7.3 Designated funding for ADDER personnel, services and equipment

Having a designated strategic lead to oversee or spearhead local implementation and manage a senior team of partner representatives enabled a cohesive ‘identity’ to be built around the aims of Project ADDER. This approach was reported to have resulted in stronger relationships, increased trust and more regular information sharing between key organisations and partners. For further information about the different approaches taken refer to Annexes H to J.

Assigning treatment staff to focus solely on the implementation of Project ADDER was critical for ensuring appropriate capacity and reducing the number of competing priorities staff were handling. Stakeholders particularly highlighted the capacity to improve intelligence gathering and make improvements to working practices and training (for example, the development of more holistic, trauma-informed approaches and psychosocial support).

Furthermore, stakeholders reported that dedicated resource for the implementation of Project ADDER resulted in improved service user experiences. This included:

• reducing the number of individuals a service user would need to interact with, to access multiple services
• providing specialist new services
• increasing the intensity of support provided
• speeding up referral or diversion to appropriate support services

This was corroborated by service users, who also reported that they had recently seen noticeably greater and faster access to a range of support services, although a few noted that there was not enough communication with them about support they were being referred for.

Enforcement leads also noted that having dedicated ADDER resources and equipment (for example, drug testing equipment or digital forensic tools) significantly improved access to, and increased intelligence gathered within the police force. This, combined with additional practices for information sharing, allowed for more enforcement activity that would otherwise have been difficult to ring-fence capacity for. Stakeholders reported that enforcement action was therefore more frequent, proactive, targeted and efficient than it was previously.

Where there is not dedicated resource for the project, it can lead to staff capacity difficulties for both enforcement and treatment partners.

In some cases, dedicated ADDER staff were used to deliver ‘analytical hubs’ that conducted significant analysis of public health and police data to inform the design and conduct of interventions, and ensure that these were evidence-led. In Newcastle, for example, the Partnership Analytical Hub was used to create a drugs market profile that directly informed enforcement action.

Case study: designated funding for ADDER personnel, services and equipment in Bristol

The Accelerators funding was used in Bristol to create a criminal justice team at the drug treatment service. This new resource was able to provide tailored support that could better meet the needs of service users who had been through the criminal justice system. Previously, this cohort of service users would have been supported by the general drug treatment service team.

The criminal justice team were able to work in partnership with other dedicated Accelerators services, such as IPS and psychological therapy services, to provide individuals with the holistic and more intensive support that they needed to sustain a life no longer dependent on drugs.

As referral partners became aware of the new criminal justice-specific team at the treatment service it encouraged them to increase the number of referrals they made, as they knew that there would be allocated resources to support individuals. As an example, the probation service encouraged the judiciary to utilise Drug Rehabilitation Requirements (DRRs) more frequently, as there was a higher-quality treatment resource available to deliver them than had been available pre-ADDER.

“Before Accelerators started there wasn’t a criminal justice team, and Drug Rehabilitation Requirements (DRRs) were just floating about in drug treatment, lots hadn’t been seen. So the criminal justice team have worked really well with probation to move people to the team and now we are at the point where the communication is fantastic, they are very supportive of the project. Probation have really supported them to change how the judiciary view DRRs, as in to use them more instead of short custodial sentences.”

Managerial, Enforcement

Accelerators has also funded a civilian investigative role to carry out the investigative case file, work which is ring-fenced for ADDER cases only. This role includes interviewing, and liaising with the Crown Prosecution Service (CPS), to build intelligence and support investigations that result from ADDER enforcement activity. This case file work is very time-intensive, but it is critical to ensuring enforcement activity has a successful outcome. As such, it is a resource that is highly valued by the enforcement team.

Case study: designated funding for ADDER personnel, services and equipment in Merseyside

ADDER funding was used by treatment services to create roles with the sole remit of establishing and maintaining new referral pathways and partnerships. For example, in Wirral the treatment service was able to dedicate resource to provide outreach to the homeless community, including hostel residents. The outreach team were able to enhance partnership working to improve the support they could offer to individuals, including those who were most vulnerable. The outreach team went on patrols with local police teams to identify and engage with individuals who would be suitable for treatment.

This enabled the service to provide harm reduction support, assess and engage individuals in drug treatment, provide healthcare clinics for residents that offered pulmonary disease testing, and engage with a local mental health service provider which ran health and wellbeing sessions for hostel residents. Overall, the impact of this dedicated resource for a particular cohort enabled a more holistic and intensive support to be provided to individuals that was tailored to their individual needs.

“Before ADDER there was a gap in support offered to hostel and street homeless clients. Caseloads were high so these service users who needed more intense support weren’t getting it. So, under ADDER we have 2 dedicated keyworkers that manage hostel and homeless outreach to provide that intense level of support. We’ve brought the treatment service to the hostel and homeless community and so we have created better access to the service.”

Managerial, Treatment

8. Pre-implementation barriers and challenges

Throughout the process of bid development and preparing for implementation, local areas experienced 4 key barriers or challenges:

• approving delivery plans and reporting to the Home Office
• allocating funding to partners
• recruiting staff into post
• establishing data sharing agreements and processes

8.1 Approving delivery plans and reporting to the Home Office

Strategic leads for a few of the local areas involved in programme design felt there was inadequate guidance from the Home Office, and specifically on the level of funding that could be allocated to different intervention groups. This led to a greater number of iterations and reviews of the delivery plans, delaying implementation. It should be noted, however, that other areas reported that the guidance they received was sufficient.

Many stakeholders involved in the design stage of Project ADDER suggested that the time available to collate and submit design plans (around 2 weeks) was insufficient, given the resource constraints among those involved in decision-making, that some of the metrics chosen were challenging to collate and, also where implementation was delayed. It was also reported that the lack of lead-in time reduced the opportunity to institute internal processes and develop job descriptions.

It was noted by key stakeholders that setting up ongoing mechanisms for reporting to the Home Office and OHID, such as monthly data returns, expert panels, communication groups and Single Point Of Contact (SPOC) meetings, put a strain on resources. This was particularly the case where local authorities were implementing multiple grants at the same time with different reporting requirements.

Case study: approving delivery plans and reporting to the Home Office in Bristol

It was reported that a lack of sufficient time to carry out a comprehensive needs assessment forced the strategic lead to rely on delivery partners to carry out their own needs assessment and design their own part of the intervention, which the strategic lead then collated. The strategic lead also found there was a lack of sufficient time to account for the internal local authority governance processes, including workforce assessment, contracting and recruitment processes that were required to set up and implement the project.

A lack of time for governance, procurement, recruitment and contracting processes added further pressure on strategic leads and their relationship with delivery partners. Strategic leads felt stuck between the Home Office’s processes and the local authority’s processes. This meant that strategic leads had to ask partners to begin implementation and delivery before contracts were in place.

“We would have liked more time to do a more in-depth needs assessment. But we had to draw on partners and providers to get this information on where the needs were… the Home Office wanted things up and running within months, which didn’t align with any local authority processes. Procurement were up in arms saying they couldn’t make direct awards, our bosses didn’t want to be left with all these initiatives for only one year. They were concerned about carrying the risk of this if the funding didn’t continue after the year. … At first, it was all based on good will with partners because we couldn’t get them contracts so we asked the providers to crack on in good will and promised them they would get the contracts and would get paid. Those we already had good partnerships with were happy to do that, but those we didn’t, it caused delays getting them to approve it at top level.”

Strategic, Treatment

Case study: approving delivery plans and reporting to the Home Office in Merseyside

A strategic lead reported that they had only 10 working days to write the bid, which did not allow for the various internal governance processes at the local authority. The lack of time allowed for writing the bid meant that the strategic lead at the local authority had to rely on the needs assessment provided by the treatment service provider.

“There wasn’t much time to really analyse whether the plan was what we needed … [or] pull the information together. There’s lots of governance that we have to go through… There has to be a realisation by OHID moving forward that we have our own time scales and restrictions.”

Strategic, Treatment

A strategic lead reported that ongoing reporting requirements for Accelerators were overly frequent and burdensome, creating duplication and putting a strain on resources.

“The other week we had 7 ADDER meetings … [the frequency of those meetings] has been a major challenge, and the need to prep for [every one]. It often feels like there is duplication in terms of what is being discussed. There is not enough time between meetings to do anything. We need more time for delivery. The demands of the project on our time is more than expected and than we were told at the beginning, and it’s unfeasible. It’s not our day job. OHID expect we drop everything, for ADDER.”

Strategic, Treatment

8.2 Allocating funding to partners

A few strategic leads noted that processes for providing funding to local partners were burdensome. For example, providing partners with contracts required the local authority to go through a tendering process, giving multiple agencies the opportunity to submit bids which would each need to be evaluated. This was highlighted as overly time-consuming when partners with a history of strong delivery with the local authority had been identified in advance and had been involved in co-creating delivery plans.

To adapt to this challenge, some local areas utilised grants to allocate funding, rather than contracts. However, strategic leads pointed out that this reduced flexibility for treatment partners in how they could choose to use the funding provided.

A few strategic leads reported challenges in ring-fencing the parameters and responsibilities of partners who provide similar services to service users in the same area. This was more likely to be the case for larger or complex geographical areas that engaged with a greater number of partner organisations.

Case study: allocating funding to partners in Wakefield

Wakefield stakeholders reported that having an existing network of partners helped when establishing the Accelerators programme; however, the new model involved a different financing process whereby partners received funding from the local authority as a grant rather than a direct contract. A direct contract allows the receiving organisation to make decisions about how to spend the money within a specific timeframe. However, with a grant through the local authority, the money has technically been supplied for a specific purpose and should be returned if key performance indicators are not achieved. This had the effect of restricting what partners could spend money on, and also required them to report and justify spending monthly to the local authority.

Reporting requirements for the grant were particularly challenging as partners found that the ADDER reporting timetable did not align with the local authority reporting timetable, meaning that the spend could not be reported due to invoicing processes.

“Our grant usage is never right, they never match, and it is because of how the grant system was set up, which is at odds with how the usual grant systems work, which is creating a lot of pressure on local authorities and our time.”

Strategic, Treatment

8.3 Engaging partners and boards

In some cases, strategic leads found it challenging to engage key partners across treatment and enforcement in the design process due to competing priorities or low capacity. A lack of capacity for key individuals to engage in board and group meetings was exacerbated by the COVID-19 pandemic, which pulled key individuals and organisations into other forms of more urgent work, increased turnover, and resulted in staff illness.

As a result, it became challenging to ensure that attendees at board and group meetings in the design phase had sufficient decision-making authority to be able to represent the organisation and respond quickly to identified issues and make decisions about service users, as needed. It was commented that when authority was not present and there was a need for attendees to check decisions with their individual agencies, this could delay multi-disciplinary action. It was also reported that having too many individuals present in meetings could cause delays and create an unproductive environment. Strategic leads reported that the project was highly reliant on them to manage large groups of partners and organisations to make sure the right individuals were in the right meetings at the right times.

Case study: engaging partners and boards in Middlesbrough

Strategic leads reported that establishing partnerships at the beginning of the project was very challenging, as services were engaged in COVID-19-related issues. The NHS trust, which was an important partner for treatment services, was restricted on the types of work it could do, meaning it could not recruit people or spare resources for ADDER interventions. Mental health services were also extremely stretched at the starting of delivery period, as demand for mental health services increased significantly during the pandemic. This situation was worsened by years of cuts to public health budgets, with stakeholders reporting that they had to mobilise the programme with very limited resources. Most services were also facing high staff turnover, which further exacerbated the capacity concerns and limited the resources that could be allocated to the project.

Social distancing also limited face-to-face interaction, which reportedly made it challenging to stimulate newly established partnerships, communicate new systems, and maintain regular contact with colleagues.

“Even though we maintain regular contact with our colleagues, it is online, which is a barrier in terms of maintaining relationships and connections.”

Strategic, Enforcement

“If I’m honest it’s not been the best time to start a new service in the middle of a pandemic … with the turnover of staff and trying to get ourselves known in the hospital has been challenging.”

Operational, Treatment

8.4 Establishing data sharing agreements and processes

Where information or DSAs were not already in place between partners, stakeholders were not always clear whether these would need to be implemented, and, if so, for what types of information or data. For example, some areas reported difficulty in accessing data from the probation service, courts, and the NHS. This was notably raised with regard to ‘near-miss death’ data and understanding the health needs of probation cohorts. This was particularly the case where new partnerships or new forms of information sharing were being established via Project ADDER, as opposed to a continuation or revival of existing ones.

Stakeholders fed back that the absence of a DSA slowed information sharing, as the only alternative was to operate with ‘consent’ as a legal basis. They felt this hampered some areas of work, because without access to necessary data it was difficult to identify whether an enforcement or treatment intervention was working. This also made it challenging to track individuals through multiple referrals, and therefore to identify service user needs.

Areas with a larger number of organisations involved in the programme may have found this more challenging compared to those that had ADDER services centralised under a few treatment providers. For example, Wakefield uses a small number of treatment providers and has a long history of data sharing, which has facilitated whole systems working. However, in Bristol, for example, they have struggled to receive information on drug-related deaths and records of death ‘near-misses’ from particular partners, such as the National Ambulance Service and the Coroner’s Office. In Norwich, it was intended to put in place a joint data sharing system, but a suitable one could not be agreed on, and therefore the whole systems working there had a greater reliance on strong partnerships and co-location.

Case study: establishing data sharing agreements and processes in Norwich

As part of their ADDER project, Norwich had planned to set up an information sharing agreement (ISA), with a view to creating a central case management system for them to share intelligence about at-risk individuals and to relieve service users of the burden of having to retell their story to each worker they encounter. Although the original plan was to have 12 partners on the ISA, police wanted to extend it to a much wider range of organisations, which meant sign-off did not occur.

Not having an ISA in place means the process of getting information from different organisations is slower than it would be otherwise, as they are having to share by consent. For the police, this has meant that they have been unable to compare the outcomes of individuals referred through DToA with the outcomes of the general population of individuals purchasing drugs, or with those who received referrals into ADDER via other pathways.

Furthermore, they have not been able to create a central case management system. However, the downsides of not having a central case management system have largely been overcome by strong partnership working and co-location.

“It’s still not sorted… Our long-term ambition is to set up a service user record that could be accessed by all organisations that are working with that individual, so someone doesn’t have to keep retelling their story.”

Managerial, Treatment

9. Whole systems approach (WSA)

‘Whole systems working’ refers to the mobilisation of a diverse range of stakeholders or organisations to act as a holistic and cohesive system to respond to complex individual needs. For Project ADDER this typically referred to collaboration between enforcement, diversion, treatment and recovery partners to meet the needs of service users.

Among stakeholders there was some discrepancy on the focus of whole systems working. Some – typically those closely engaged with service users – approached this from a ‘client service’ perspective, whereby a successful WSA is one in which clients can access all of the appropriate referral systems and receive the support they need. Others – typically those with coordination or information sharing roles – approached it from an ‘organisational’ perspective, focusing on facilitating cooperation between different organisations or agencies. These perspectives were not always mutually exclusive.

Stakeholders across both perspectives reported similar benefits from the WSA, including the following:

• arranging appropriate and fast referrals for service users into holistic and appropriate support services, by collaborating as partners to make joint referral decisions
• improving the effectiveness of enforcement activity as teams had greater access to intelligence relating to criminal activity, making action more informed and targeted
• reducing competition and duplication of work between treatment partners
• aligning approaches between treatment and enforcement partners to ensure all organisations functioned as a ‘system’ and service users received a consistent service

However, the success of this approach was highly dependent on the work and dedication of strategic individuals. Stakeholders also suggested that it may take some time to embed the WSA, particularly where partners within and between treatment and enforcement have a history of significantly different languages, cultures or practices.

This chapter outlines how local areas implemented a WSA, and the effect of individual mechanisms. For more information on the pre-implementation phase, please refer to the section titled ‘Overview of pre-implementation activities’.

10. Information sharing and co-location

One key element of whole systems working is sharing information easily and quickly across a range of organisations and stakeholders. In many areas, this was achieved by establishing DSAs, which allowed organisations to send and receive confidential information. Some difficulties were encountered in setting these up initially, but by the second year of the programme most local areas had established an appropriate system of processes for receiving necessary information. There were some exceptions, and more detail about this can be found in the ‘Implementation barriers and challenges’ section.

A few Project ADDER areas chose to use co-location to facilitate information sharing, where staff from multiple organisations would work in the same physical space alongside one another. Examples of this included locating substance misuse workers and youth services in custody suites, and situating treatment and recovery services in the same building or hubs.

The success of co-location was attributed to a lack of spatial and physical barriers, including being based in the same office, being familiar with their co-workers and understanding each other’s procedures and processes. Treatment stakeholders also found it useful to discuss specific cases face-to-face with other treatment or enforcement partners. For these reasons, co-location may prove to be a useful tool in overcoming organisational differences in culture, language or outlook going forwards.

Co-location was not always feasible throughout the programme due to the institution of pandemic prevention measures like social distancing, with many local projects pivoting to remote working practices at least temporarily. There were positives and negatives to this, as some stakeholders highlighted that it was easier to arrange meetings (and at shorter notice) online. However, the lack of a shared working environment in some cases may represent a lost opportunity for more ‘organic’ and ‘serendipitous’ gains that come from having a shared physical workspace.

Case study: information sharing and co-location in Merseyside

IPS staff are co-located with the treatment service, and this has been found to enable smoother pathways between services.

For example, the probation service has their own employment support team, but through partnership working and information sharing IPS and the probation service work together to share the support role in relation to an individual service user. IPS can help the service user with employer engagement and providing interview clothes, while the probation service’s employment support team can help the service user to access a training course. Through close liaison the services ensure they are not duplicating support and the service user receives the range of holistic support they need.

Co-location with the treatment service also enables treatment service staff to easily and quickly make referrals to IPS, as they can do so in person when they are sat in the same office.

“You might have a recovery worker who wants to refer a client in to IPS … so the referral would be either a quick email or phone call or even a shout across the office: ‘I’ve got somebody for you!’ And that IPS worker can walk over and pick up that person straightaway.”

Treatment, managerial

Case study: information sharing and co-location in Swansea

Information sharing between partner organisations has been pivotal in reaching the most vulnerable (such as sex workers and homeless people) through outreach. Service users who are suitable for targeted outreach are identified from a wide range of sources, including Drug Poisoning Task Force monthly meetings, police information, the sex worker outreach project (SWAN), Barod and Adveriad (drug support agencies), and health partners (for example, homeless nurses, mental health nurses, or hospitals). Once within ADDER, treatment workers liaise with healthcare professionals to help with service users’ physical health (for example, sexual health, blood-borne viruses and wound care) and psychosocial activities run by G4S.

11. Workforce training

Training sessions run within and between enforcement and treatment partners were also instituted as part of the WSA across Project ADDER areas, on a range of topics. These training sessions were selected and designed to align the approaches of various partners and to help reduce ‘knowledge gaps’ between partners.

Training sessions supported under Project ADDER included the following:

• training for frontline workers (including the police) on trauma-informed approaches to improve understanding of the fact that the difficulties faced by service users may be deeply entrenched and due to a range of factors and past experiences, including adverse childhood experiences, mental health issues, and longstanding issues with substances; in some cases this was delivered by lived experience teams
• standardising an approach for using OOCDs
• using naloxone kits and identifying drug use
• mental health awareness and response
• upskilling of service providers (such as adult and children social care, GP surgeries, and hospitals) to improve their understanding of drug-related issues and to help them direct individuals to the right support

Stakeholders widely reported that the training given was successful in reducing knowledge gaps and aligning the language, culture and practice of different partners, particularly when delivered by lived experience teams. However, there was acceptance that in some cases culture changes can take time to embed within organisations and may require ongoing work.

Case study: workforce training in Middlesbrough

The police officers were trained by the harm minimisation team to carry naloxone kits and clean needles, conduct DToA, and also to identify children at risk of exploitation. As a result of the training, enforcement stakeholders reported being better equipped to deal with drug harm issues in the community and to refer young people at risk or harm to the relevant services. It was reported that the training had changed the mindset of the police, away from a prosecution-focused perspective to a victim-support approach. Stakeholders from both the treatment and enforcement sectors reported witnessing early signs of increased trust between the community and law enforcement as a result.

The outreach workers and harm minimisation team received extensive training on identifying drug harms and providing mental health support, designed to equip them to provide service users with initial support before referring them into the appropriate services. Stakeholders reported that this resulted in service users being more receptive to accessing support.

12. Collaboration, partnerships and multi-disciplinary working

Stakeholders across treatment, diversion and enforcement in all Project ADDER areas used funding to enhance partnership working, establish multi-disciplinary teams, and collaborate across organisations to collectively respond to complex service user needs. Across areas, stakeholders reported that strong partnerships and multi-disciplinary working was critical for implementation. The precise nature of this differed significantly by local projects.

Project ADDER was considered to be a positive force for enhancing existing relationships, creating new partnerships, and bringing a sense of common purpose to different local organisations, to the benefit of service users. Factors that were critical to ensuring this were strategic-level coordination, strong central oversight, consistent communication, establishing channels for information sharing, and regular meetings with partner representatives to share progress and knowledge, identify any changes that needed to be made strategically, and also ensure partners were working towards the same goals.

Areas reported the benefits of weekly or bi-weekly multi-disciplinary team meetings across various partners in regard to discussing referrals, giving an overview of what services can be offered, highlighting when barriers to treatment are presenting and discussing ways to mitigate barriers for clients. In some cases, multi-disciplinary teams were also used for enforcement activity: for example, having treatment staff present at suspected cuckooing addresses. Additionally, having a single point of contact for strategic consultation and coordination was also important for ensuring multi-disciplinary teams functioned well.

As a result, police and treatment services were able to work together to better understand the nuances of each client’s need. This allowed for service users to be diverted into more appropriate services at an earlier stage and eliminated the need for service users to start again at different points of the system and/or navigate the system themselves.

Case study: collaboration, partnerships and multi-disciplinary working in Bristol

AWP, the provider of psychological therapeutic support, collaborates with other treatment service providers to deliver services to service users. AWP delivers group therapy sessions at one of the treatment providers’ sites with groups of their service users. This allows the service users to access psychological therapy at a site that they are familiar with and feel safe in.

Similarly, AWP is working in partnership with Eden House, an approved premises for women who have come out of prison. As well as establishing a new referral pathway from Eden House to AWP, AWP is delivering trauma stabilisation group therapy on the Eden House site to groups of residents.

Case study: collaboration, partnerships and multi-disciplinary working in Blackpool

In Blackpool, the pathways between services have been strengthened and improved. The multi-disciplinary team meet bi-weekly, providing an opportunity for everyone to come together and discuss everything holistically.

The impact of the multi-disciplinary team is that important actions can be mobilised quickly and efficiently, and it provides a key touch point to align thinking and ensure everyone has the relevant context. For example, it meant information sharing and logistics could be resolved quickly at the start of the project. The multi-disciplinary meetings also provide an opportunity to discuss referrals and provide an overview of what services are doing.

The success of the multi-disciplinary team is also due to the commitment of the team to multi-disciplinary working and an appreciation of the importance of other roles and organisations in providing effective support. It also recognises that traditional treatment services were not working, so a different and more multi-disciplinary approach is needed.

“There is a much faster, easier and more joined up approach. The relationship is there and so you know who to email and they’re all so helpful and supportive.”

Operational, Treatment

“Sometimes we get a referral without much info as to who they are and so we don’t know any of the other risks. It’s been so helpful to have all those other services involved who can shed some light on the risks.”

Operational, Treatment

Implementation

13. Overview of interventions and implementation

The funded programmes of interventions in each of the local areas were tailored to the individual local challenges, respond to the locally identified gaps, and enhance or add to the suite of pre-existing services. Consequently, each of the Project ADDER areas delivered a different collection of projects, with different localised delivery mechanisms and governance structures. However, interventions typically included the following:

• enforcement: interventions typically related to increasing drug testing capabilities, conducting targeted local enforcement, providing reassurance policing, improving intelligence gathering, sharing and analysis, and running targeted communications to users, dealers and young people; detailed descriptions of these activities, and local-level examples, are available in Annex C
• diversion: interventions were focused on diverting service users from criminal justice pathways and into treatment; these typically included increasing DToA and greater use of OOCDs; detailed descriptions of these activities, and local-level examples, are available in Annex D
• treatment, outreach and recovery: interventions typically included activities related to recovery support, harm reduction, pharmacological and psychological treatment, enhancing treatment capacity, and integrating and improving care pathways; detailed descriptions of these activities, and local-level examples, are available in Annex E

A list of local-level activities is available in Annex B.

Most project areas initially reported a significant underspend during the first couple of months of implementation, a development that was mostly driven by late confirmation of funding, risks and challenges related to COVID-19, and initial recruitment difficulties. By spring 2022, however, project underspend had fallen considerably. Areas with an underspend at the time of writing have submitted revised delivery plans.

14. Implementation good practice, and facilitators

Across all case study areas, there was a focus on adopting a more client-centred approach. This included:

• reducing caseloads
• increasing capacity for outreach
• introducing greater flexibility in the delivery of support services
• conducting trauma-informed training

Stakeholders felt these activities facilitated the client-centred approach and meant they were better able to meet the needs of service users. Although service users were not asked to comment directly on these activities, they did report benefits resulting from the support that they received, including:

• improved engagement with support and support communities​ than previously took place
• more stability and support to receive essential documents, property or equipment​
• decreased distress, depression and anxiety​
• improved personal relationships, including re-connecting with children and families​
• feeling ‘better’, having a ‘brighter outlook’, experiencing greater self-care and engagement with hobbies, and feeling like they could live a ‘normal life’​
• finding employment, training or volunteering ​
• feeling supported, safe or cared for​, coming out of a cycle of exploitation or criminality

14.1 Smaller caseloads and assertive outreach

Recruiting additional staff and reducing existing staff caseloads was an important part of the project design in all areas under Project ADDER, in order to offer more intensive, wraparound support.

Stakeholders working in treatment services stated that having smaller caseloads had given them the necessary time to make more contacts, establish rapport, improve engagement, and provide support for wider needs. This included supporting clients to attend appointments with healthcare providers, social services, and housing services. Stakeholders described this approach as being more ‘client-centred’ and as focusing on the ‘human element’ of treatment and recovery, and reported that it allowed them to be more flexible and innovative in their approach to meeting service user needs.

Greater capacity for outreach work was seen as a critical aspect of successful delivery. A number of stakeholders across the local project areas stated that actively being able to engage with service users through ground-based assertive outreach work, and having increased visibility in the community, was a key benefit of Project ADDER funding. The assertive outreach model was in turn key in reaching those who historically had not engaged, and demonstrated commitment from staff in providing support.

Case study: smaller caseloads and assertive outreach in Merseyside

The treatment service in Knowsley highlighted the value of the prison release pathway’s role in providing intensive, wraparound support to meet the wider needs of individuals and to support their engagement with treatment.

Due to smaller caseloads, roles such as these were able to devote more time to assertive outreach towards, and support of, individuals, providing personalised support that was tailored to the needs of the individual. This type of support hinged on the quality of the relationship built between the support worker and the individual. Time spent building this relationship was found to reap extensive rewards, as it served to build trust between the individual and treatment service worker, which encouraged the individual to engage with treatment.

“One service user was in and out of prison, she would never collect her prescription when out of prison. When she came out, we managed to get her into the local hostel. We trained the hostel in naloxone. She had an unintentional overdose and she was administered with naloxone, so it was great results. She works with the prison release worker… The prison release pathway gave us someone to ‘hand hold’ her, take her to a GP, ferry her to appointments, enhance her quality of life and self-worth like buying her a birthday card. Small things that really are important to individuals. We now know her as a person and I think she has benefitted from so much of ADDER. We got her to A&E after she experienced a sexual assault. We sat with her from evening to the following morning. She would only have done that with the relationship she had with the service worker”.

Managerial, Treatment

Case study: smaller caseloads and assertive outreach in Norwich

Staff work from the recovery hub and in the community, with assertive and targeted outreach taking place daily via hostel visits, going to homeless services and going out to street sex workers with a local charity. Staff have smaller caseloads, and so are able to provide intensive support.

Outreach has meant workers are able to get people on prescriptions without them having to reach out for support, therefore reaching those who have historically not engaged and enabling people to get stabilised on prescriptions more quickly. Small caseloads have enabled the outreach approach as workers have more time and can be more flexible. It also means they can spend more time with service users and allow them to provide extra help: for example, going with people to healthcare appointments – this ‘hand holding’ is useful until service users are confident enough to go on their own.

“With the main service it’s really difficult if you’ve got caseloads of 60, 70, 80 people to go out there if someone hasn’t turned up, but the ADDER model is very much if someone doesn’t turn up, the workers make phone calls, go to people’s addresses or going to places where they know they hang out and re-engaging them.”

Managerial, Treatment

“I can dedicate a lot more time to them, so I can go with them to GP appointments and just spend that extra time I wouldn’t have had before.”

Operational, Treatment

14.2 Flexible approaches to implementation

Flexible approaches were applied to interventions in order to make services both more accessible and more effective, in terms of meeting client needs. For example, in Newcastle, previously a service user could only access employment support if they were in treatment. This was amended so that if a service user ended treatment (for example, left rehab) they could still access employment support/IPS. Another example is the carer support service in Newcastle, which extended the length of time support is provided for. This longer-lasting support is considered a more effective approach to meeting the complex needs of this cohort.

14.3 Trauma-informed training

Stakeholders across the local projects also reported that trauma-informed training with the police and other relevant partners has allowed them to refer service users towards appropriate treatment services earlier on. This is because stakeholders now have an increased understanding of the multiple challenges faced by this cohort and the different services available to support them. As a result, stakeholders reported an increased number of referrals from courts, probation, police custody, and ADDER outreach, and from clients themselves.

Case study: trauma-informed and client-centred approach in Blackpool

The trauma-informed approach (that was already well-established in Blackpool) has involved a representative lived experience team.

The trauma-informed approach has helped in multiple ways, including managing expectations in regard to working with service users, given that they may have entrenched behaviours and it can take time to build up trust and for them to engage, as well as building understanding that this cohort have deep-seated trauma which cannot be fixed overnight. The approach emphasises the importance of maintaining consistency and giving them choices.

The lived experience team are key to this approach as they understand service users’ experiences and find it easier to relate to the cohort and they provide a tangible source of hope for the clients that they will ‘get there’ eventually. The lived experience team are also involved in training the police.

“Lived experience team are a very important resource working alongside the police. It took time to build good relationships to a point where they were willing to share intelligence.”

Operational, Enforcement

“When they know that you have lived experience it gives them hope that if you can do it, I can do it too. The trust is there immediately. These people don’t engage well with services, but they are engaging well with ADDER. There’s an unspoken language about connecting with these service users and they tend to be more open.”

Operational, Treatment

Case study: trauma-informed and client-centred approach in Swansea

The Rapid Access Prescribing Service (RAPS) has taken a client-centred approach by focusing on flexibility and outreach. If service users do not attend an appointment, workers will rearrange it (even if they have missed appointments multiple times) or go out to meet them in community locations or their home. RAPS has also taken on service users’ partners where relevant, acknowledging that if the partner of someone in treatment is still using, this makes recovery much more difficult.

The client-centred approach has reportedly improved the quality and reach of support. For service users it has helped them to stay on their prescriptions or to get on them quickly if they have fallen off, whereas if they were being treated by the non-ADDER community Drug and Alcohol Team service they would be discharged for not attending appointments. Taking on service users’ partners has made it easier for them to engage in treatment and recovery services.

“I think the approach to people is very different in RAPS… we’ve just kept trying, trying and trying and if they’ve missed 3, 4, 5 appointments with me I still phone them and ask ‘When can you come in? How can we make this easier? Can I come to you?’ and that’s really working.”

Operational, Treatment

“RAPS is targeting those who are often disengaged from services, so the service has gone out to them to actively give them what they need rather than them having to come in for appointments.”

Managerial, Treatment

15. Implementation barriers and challenges

Local projects encountered a number of barriers and challenges when implementing ADDER interventions, which are captured below. While several factors were cited as barriers, recruitment was reported by all areas as being a primary challenge. Barriers and challenges included those in the following areas:

• recruitment
• onboarding, training, capacity and retention
• logistical and administrative burdens
• embedding partnerships and aligning project ethos
• engaging individuals who had been traditionally disconnected from services
• managing competing priorities and shift work
• a lack of leverage over wider external factors

Many of these barriers and challenges were impacted in various ways by the outbreak of COVID-19, and pandemic prevention measures, such as lockdowns and social distancing. These are addressed in each subsection below, where relevant.

The greatest challenge experienced across the programme was recruiting staff. This was exacerbated by late confirmation of programme funding, increases in agency prices related to COVID-19, and a lack of suitably skilled individuals following on from a lack of investment in the sector historically.

15.1 Recruitment

Common across all areas were difficulties in recruiting staff members, which resulted in delays to local interventions and contributed significantly towards an initial underspend. Recruitment was often seen as the most challenging element of delivering Project ADDER.

One critical reason for difficulties in recruitment was the shortage of professional workers (largely on the treatment side) with the requisite skills, such as experience across opiate and non-opiate use. Stakeholders reported that these skills are no longer being taught, as a result of years of disinvestment. Many areas were looking to hire from this small pool of people simultaneously, essentially creating a competitive environment between local projects for staff. In Tower Hamlets, stakeholders pointed out that this competitiveness was exacerbated by the fact that they are geographically close to another local ADDER project, Hackney. Merseyside similarly reported a high degree of competition between the 3 sub areas of Liverpool, Knowsley and Wirral. Some stakeholders reported that this may have been alleviated by longer lead times for recruitment, or staggering recruitment across the local projects, particularly those bordering each other.

Some stakeholders pointed out that public sector recruitment is already a slow-moving process, as positions must be graded (with corresponding pay scales) before they can be advertised and recruited to. For Project ADDER, this delay was exacerbated by the COVID-19 pandemic, which led to an increase in agency prices and a preference for permanent, more stable positions, rather than shorter, fixed-term contracts. When project implementation was delayed, recruitment difficulties then became increasingly challenging. Funding was only initially confirmed for a year, which meant that the longer recruitment challenges persisted, the shorter open contracts became, and the more challenging they were to recruit for.

Certain professionally regulated roles, including nurses, non-medical prescribers, social workers and clinical psychologist positions, remained challenging to fill through the early part of the implementation period, as did posts that required additional permissions: for example, DBS or prison vetting. Given that the delay in recruitment was unexpected, this often meant that the resources being inputted into the recruitment process were greater than originally intended, and this forced local projects to adapt and find alternative solutions.

One solution considered was to allocate some existing staff time to ADDER, alongside their original roles, but these individuals were then at risk of working severely over capacity.

Another solution used by local projects was hiring individuals that did not meet the original criteria for the role, but who they could train up to meet the requirements of the role. For example, staff with experience of service users with opiate use could be trained to respond to service users using non-opiates, as many of the skills used for the former are transferrable to the latter. This did alleviate recruitment challenges to an extent, but training up individuals to perform the necessary roles required additional resources, investment and time before staff could begin in post.

Case study: ongoing recruitment in Merseyside

Merseyside Accelerators areas had to recruit a high number of roles to post (over 40 new posts in Liverpool). Recruitment of such high numbers of skilled staff took much longer than expected. By the end of July to September of the first year of Accelerators, Merseyside areas had typically recruited around 90 to 95% of roles to post, but many of these had only recently been appointed, so they spent the early part of 2022 in training and getting up to speed.

It was noted that the 3 separate Accelerators areas in Merseyside were effectively competing to recruit for the same type of posts, requiring the same skill set. COVID-19 also delayed recruitment, with interview candidates who tested positive for the virus having to delay their interviews. Further delays were caused by the panel approval process in regard to obtaining DBS checks on candidates with lived experience.

Project implementation and delivery could not get underway until roles were in post. Delays in recruitment therefore caused delays in establishing relationships and referral pathways with partner organisations, with the knock-on effect of delays in referrals of individuals to treatment.

“Disinvestment in recent years has depleted the skills and knowledge of potential recruits, so we’ve had to look at transferrable skills or people who could be developed more than we initially planned to. This has meant there is a greater training requirement than expected, so we’re providing more training out of the Accelerators funding. Most of the new recruits have lived experience too, so we’ve had to go to panels to approve their DBS checks, which has added further delay.”

Treatment, Managerial

Some posts remained unfilled throughout the 2 years of the Accelerators project, including a project support officer for the enforcement lead, and a mental health worker in Wirral. Adverts for job vacancies were posted multiple times but each time the vacancies could not be filled.

In addition, it was reported that local authorities became more nervous about their liability if they recruited to roles part way through the project, by which time funding for the roles was only guaranteed for the short term.

Case study: ongoing recruitment in Norwich

There was a perception among strategic enforcement stakeholders that they were pulling from a limited pool.

“When we started looking at recruitment across the Board …we were stealing from each other. When you have lots of projects that are all starting at the same time, those good candidates that you want, those really enthusiastic positive people were limited in numbers, and I think you were then starting to pull on a limited pool.”

Strategic, Enforcement

Recruiting for youth offending team workers who would be based in custody was time-consuming because new job descriptions had to be written (as there were no comparable roles) and graded. Changes in resourcing requirements (such as the need for more senior candidates) led to further delays in the recruitment process.

Recruiting mental health workers (specifically psychiatric nurses and a clinical psychologist) was especially challenging because of the location and bad publicity around the local mental health trust (it had been rated ‘inadequate’ by the Care Quality Commission). Despite this challenge, they eventually managed to recruit a clinical psychologist, who came on board in September 2022.

Challenges in recruitment meant they were under budget in year 1 and the youth offending team project was somewhat slower to get started. While the underspend was re-purposed to fund other interventions (such as a physical health nurse and equipment), the lack of mental health provision was problematic because waiting lists for mental health support were very long and there was no one in place to implement psychological interventions and train recovery workers on a clinically informed approach.

“It’s a clinical psychologist so obviously he’s got that knowledge to assess someone from a clinical perspective and assess where they’re at and what type of psychological intervention is best for that person, so it’s a more clinically informed approach.”

Operational, Treatment

15.2 Retention and absence

Stakeholders also reported that they were concerned about retaining staff that they had managed to recruit. Late official confirmation of funding extensions from the Home Office meant that staff would begin looking for new jobs as their contracts ended, and stakeholders were not able to confirm extension of contracts until a relatively late stage. Where staff were not able to be retained, the recruitment process had to start again.

Furthermore, during the outbreak of COVID-19, many of the staff involved in the implementation of ADDER were at risk of exposure, and staff sickness reduced the capacity of the team and delayed decision-making.

Case study: ongoing recruitment in Hackney

The short 2-year delivery period made the process of recruitment and retention difficult, as there was never a period when the project was stable. The first year of the project was impacted by recruitment delays, and then the second year was impacted by retainment issues as individuals started to look for new opportunities due to their current position coming to an end. This meant that there was never a period in which all individuals were secure in their positions across all parts of the delivery programme, and in which all parts of the programme could therefore be fully operational at the same time. This led to an uneven and lopsided delivery across different parts of the programme, which was ultimately not as joined up as it could have been.

“[Having a] 3 or 4-year programme may have helped to avoid the worst of this problem and allow for a more stable setup to be established for a longer period.”

Strategic, Treatment

Case study: ongoing recruitment in Swansea

The Service User Involvement Coordinator left the ADDER short-term position for a permanent role elsewhere. This person was instrumental in developing the ‘peer to peer’ programme in the area (naloxone, needle and syringe exchange, dried blood spot testing of blood-borne viruses).

“I’m mindful that something that seems to have been observed across all ADDER sites is staff recruitment and retention. Whilst we still have 2 more years of ADDER funding, I think the preference for a lot of people is to find permanent positions, particularly when they know things such as mortgage renewals are due.”

Managerial, Treatment

15.3 Administrative and logistical burden

Arranging office, co-location and other physical spaces for the conduct of services proved a challenge for some areas, particularly where a designated budget for this had not been set, and whilst areas of the UK were in lockdown or social distancing was in place. These challenges included finding and renting spaces, and establishing compatible IT, information sharing and finance systems.

Case study: administrative and logistical burden in Norwich

Norwich faced a few challenges relating to the prescriptions programme. For example, the reduced availability of prescribers on specific days and the need for treatment workers to physically deliver prescriptions limited the project’s ability to provide a flexible and convenient service to service users.

“We’ve got really skilled recovery practitioners playing prescription Deliveroo, running around the city with prescriptions, and I’m thinking this shouldn’t be such a significant part of the role. I think it is standing in the way of them being able to do some more psychologically informed behaviour change or recovery planning work.”

Managerial, Treatment

“The only practical issue we have is on a Friday when we don’t have a prescriber: for example, if we have a prison release, they want their script and we can’t print prescriptions here because we don’t have a prescriber, so we have to send them to the main service which is just a faff for our clients and they will get bit lost.”

Operational, Treatment

15.4 Embedding partnerships and project ethos

Project ADDER funding allowed for partnerships to be established and revived, and helped ensure greater whole systems working across various organisations. However, some stakeholders reported that ensuring these partnerships and the trauma-informed, client-centred approaches remain consistent in the long term may be challenging: for example, in the face of staff turnover, organisational change, reduced funding, or various other possible circumstances that would test the resilience of the system. This is thought to be particularly so in cases where organisational cultures, language or communications have differed historically between partners, and the partnership is in its relative infancy.

Furthermore, it was often noted that the local projects had a high degree of reliance on strategic leadership and coordination roles, meaning that changes, low capacity or turnover in these roles poses a risk for the future of the projects.

Case study: embedding partnerships and project ethos in Blackpool

In Blackpool, training was used to align the approaches of enforcement with a trauma-informed approach: for example, managing expectations of police officers working with service users, given that they may have entrenched behaviours and given that it can take time to build up trust or engagement. The approach emphasises the importance of maintaining consistency and giving service users choices. The lived experience team are key to this approach as they understand service users’ experiences and are easier for that group to relate to.

“Our mindset has changed… ! We understand that they’re vulnerable. We’re more in tune. We do more safeguarding visits and offer help rather than treat them as suspects. And they trust us more and share risky information as it’s about helping.”

Operational, Enforcement

“Lived experience team are a very important resource working alongside the police. It took time to build good relationships to a point where they were willing to share intelligence.”

Operational, Enforcement

“When they know that you have lived experience it gives them hope that if you can do it, I can do it too. The trust is there immediately. These people don’t engage well with services, but they are engaging well with ADDER. There’s an unspoken language about connecting with these service users and they tend to be more open.”

Operational, Treatment

Case study: embedding partnerships and project ethos in Merseyside

There was a sense that the ADDER project ethos could conflict with the priorities of certain partners, such as children’s social services. It was explained that in cases where a service user has a child and is involved with children’s social services, the priority of social services will always be the child, whereas the focus of the ADDER project is on the parent’s recovery.

It was suggested that including children’s and adults’ social services in the ADDER partnerships from the beginning would have helped to ensure the 2 pathways were better integrated and individuals could be supported more holistically, through a shared ethos across all partner organisations.

“It would have been good to have had children’s services and adults’ social services at the table from the planning stage to understand what is required of them from a statutory perspective. Having a child seems to disadvantage some individuals going through the ADDER programme. They are already in a different pathway. The focus is on them as an adult and the child being cared for in the safest place, not on them being supported for their addiction. If we could bring those pathways together we could support them holistically.”

Strategic, Treatment

Case study: embedding partnerships and project ethos in Norwich

Language and cultural differences between police officers and youth offending team workers have been a challenge. For example, while the youth offending team will refer to all people aged 17 and under as children and avoid stigmatising language, police typically use words like ‘detained person’ rather than ‘child’ and ‘cell one’ rather than ‘room one’. Although the police have started to change the language they use, some at operational level still feel that what children do is their choice and they need to be punished. They are less interested in understanding exploitation and how certain factors, such as prefrontal cortex development or other things outside of their control, may increase children’s risk.

These differences have posed a barrier to a ‘child first’ approach becoming embedded. The youth offending team think that the cultural shift will be limited going forward and there may be a regression because of staff changes. Knowledge and buy-in among police is not felt to be deep enough to be sustained.

“Some people have responded to it [training] a lot better than others. There has been a lot of questioning.”

Operational, Diversion

“There will be some people it sticks with, but it will probably regress back a little bit. The shifts there have been, aren’t yet deep and strong enough to take that further and keep it going.”

Managerial, Diversion

15.5 Engaging individuals who have traditionally been disconnected from services

Some stakeholders reported challenges engaging with individuals who had traditionally been disconnected from services (for example, reaching those living rurally, or targeting ‘hidden affluent’ service users). With service users who had not previously engaged with the system, stakeholders reported that significant preparation work was sometimes needed before they can engage with other support services.

Among service users who had engaged with the system before, stakeholders also reported that users needed ‘convincing’ that the help or a more flexible approach to support was available for them when it had not been previously. The issue of parity of access to support between ADDER and core service users was also raised by treatment services.

Some stakeholders also reported lower than expected rates of attendance at support services from criminal justice referrals, pointing out that many of these were voluntary and not enforceable. Stakeholders were divided on whether or not criminal justice system referrals should be enforced or not, with some pointing out that forcing attendance may actually be worse in terms of getting meaningful engagement from service users. Additionally, local projects could not offer some in-person services when COVID-19 pandemic restrictions, such as lockdown and social distancing, were being enforced.

Case study: engaging individuals who have traditionally been disconnected from services in Bristol

The mental health service providing psychological treatment to service users has received a significant number of referrals for treatment naïve clients. Although this is seen as a sign of the success of the project, one consequence of this is that some of those referred are not ready to engage in psychological treatment, requiring pre-engagement work to be conducted by the psychologists.

“There’s a reason why they haven’t been in treatment before. So the psychologists have done a lot of proactive engagement work, they’ve been really flexible around appointment times, lots of cancelling and rearranging, so it has been more challenging to engage them in structured treatment. But this is always an issue with this cohort, delivering interventions in a way that are accessible. So, for example, if we are running a group, we can’t deliver that at a time that suits individuals, it has to be a set time… Committing to get to the same place at the same time once a week for 4 weeks is too challenging for lots of people.”

Managerial, Treatment

DToA was implemented at the end of the first year of the Accelerators project. Since then, arrestees who test positive for drugs are signposted to treatment services and they can attend a voluntary appointment. However, there has been a low rate of attendance at the treatment service among this group. The DToA referral pathway has therefore not been as effective as hoped.

“The challenge is that a lot of people aren’t ready to be diverted or don’t want to be. So the number of successful diversions is lower than we would like: for example, for DToA. Some partners didn’t want DToA to be enforced, so we have taken on a slightly different model where attending onward referral to treatment from DToA is not compulsory. This means that we lose a lot of cohort between test, assessment and onward referral.”

Strategic, Enforcement

Case study: engaging individuals who have traditionally been disconnected from services in Tower Hamlets

Stakeholders have struggled to engage individuals in the Bangladeshi community as much as they hoped to do. This is perhaps due to the lack of a partner that can specialise in engaging individuals in this specific community, and because their core services perhaps do not currently engage with this community as much as they do with other communities. It is a problem the [local authority] is aware of and which it is seeking to address moving forward.

15.6 Managing competing priorities and overtime

Much of the enforcement activity conducted under Project ADDER utilised police overtime. In some areas, stakeholders reported that this could make it challenging to build intelligence and to act quickly on that intelligence. For example, several police officers gather intelligence and identify where a phone is located; however, they may not be able to act on this intelligence immediately due to a change in their shift pattern, which can result in delaying active investigations. Similarly, the need to act quickly and in the moment was described by stakeholders as key to addressing county lines. A quick response is necessary to identify the ownership of a phone line and to gather intelligence on where someone is located. Left untouched, a phone is likely to be moved on or swapped out.

For enforcement stakeholders, some other non-ADDER enforcement activity took priority. This particularly affected covert operations which required high-level permission before they could be implemented and held a risk of delayed or refused permission if another investigation or operation was considered to be of greater importance.

Treatment stakeholders also faced difficulties managing competing priorities. In particular, COVID-19 pandemic prevention took precedence over ADDER activities at times. Generally, treatment services reported a lack of capacity within the organisation where there were no dedicated ADDER roles, where greater resources were diverted to training, or where there were significant levels of staff illness.

Case study: managing competing priorities and shift work in Bristol

In Bristol, ADDER funding was only to be used to fund enforcement activity through overtime, rather than officer roles. This placed a limitation on the level of enforcement activity that could be carried out via days of action, as these relied on sufficient numbers of officers volunteering to work overtime. This was a particular challenge during periods when there were other demands on police resources, such as national events held during the summer of 2022.

Further, it was explained that drugs enforcement work required particular officers who had some experience and knowledge of this type of work and the local issues affecting drug enforcement activity. It was not always possible to find officers who had both the experience and availability to work overtime on the days of action.

“You can’t fund police officers’ roles with ADDER money, but officers don’t always want to do the overtime. You also need officers who understand the issues and the local community to work on drugs work. Over the summer we saw the force take a step back from proactive policing due to all the festivals and peak demand as more people are out and drinking. So policing is a little bit seasonal. And officers want their time off over the summer.”

Strategic, Enforcement

Case study: managing competing priorities and shift work in Middlesbrough

In treatment services, there was an initial plan to include more robust clinical services in ADDER, through partnerships with NHS specialist services. However, due to COVID-19, they were not able to implement pathways for a secondary care lung clinic as the clinical staff were pulled into pandemic-related services. Treatment stakeholders also reported that there is limited capacity for NHS staff to train care coordinators on re-engaging with people out of treatment, as this role is extraneous to their day jobs.

15.7 Lack of leverage over wider systemic issues

A number of wider systemic issues were identified as being a challenge for delivery that it was difficult or impossible to address within Project ADDER funding.

Housing was one area outside of Project ADDER’s influence that nonetheless posed a challenge to delivery. Stakeholders often reported that a critical part of supporting long-term recovery is stable housing, particularly for the most vulnerable clients. This was accounted for in the menu of interventions for Accelerators areas; however, these areas found that there was a lack of housing support that could be offered via Project ADDER. This was typically attributed to a lack of involvement from housing services in the design phase, or a lack of suitable housing supply.

Similarly, societal stigma may have reduced the effectiveness of services. A few stakeholders reported that the level of IPS success was hampered by employer stigma against service users, particularly those with a history of drug use or a criminal record.

Notably, during the outbreak of COVID-19, significant additional efforts were made nationally to house those experiencing homelessness, in order to prevent the spread of the disease. As a result, people using drugs who were also experiencing homelessness were temporarily easier to access for treatment and recovery services working on Project ADDER. As pandemic prevention measures were eased, this support provided to those experiencing homelessness was rescinded and ease of access reportedly returned to previous levels.

A few stakeholders also reported that policy and legislative environments affected the conduct of ADDER. For example, the change to OOCDs, with the move to a 2-tier system, meant that approaches to expanding the use OOCDs changed during implementation, and laws dictating the circumstances under which DToA can be conducted restricted how often testing could be conducted.

Case study: lack of leverage over wider systemic issues in Bristol

The IPS lead reported that engaging employers was a challenge, as it was difficult to encourage them to employ people with criminal convictions.

Similarly, the treatment service provider identified a criminal record and prison sentence as a significant barrier to finding employment.

“They can do a lot of training in prison but it’s never transferable: for example, you can’t get a [Construction Skills Certification Scheme] card in prison, and you have to have a DBS for pretty much every job now and it’s not realistic for someone to be offered a job with a criminal record. There needs to be work done with employers to change their attitudes to employing people with a criminal record. There needs to be a national cultural change around employment. This is a real barrier for our clients to resume a quality of life and stability off drugs. It’s very limited in what people can do. The prison system fills their heads with unrealistic expectations and you can’t use the training when you come out.”

Managerial, Treatment

Case study: lack of leverage over wider systemic issues in Blackpool

A lack of suitable housing was reported in Blackpool, in addition to challenges with housing providers. Emergency or temporary accommodation, such as hostels, are not always suitable for various reasons, including because users are unable to use in them and, conversely, because being around other service users can trigger a relapse.

A lack of housing was a problem for service users who had made progress but were still using. Housing providers lack a trauma-informed approach and understanding around the time it takes for users to detox and rehabilitate. For example, some housing providers have said they have no duty to house people who have already been evicted due to past behaviour. When ADDER clients are unable to find suitable housing, it can affect the trajectory for recovery.

“To work with this client group, policies and procedures need to be more flexible. If we’re going to prevent a revolving door we need to recognise the challenges that these individuals face. They’re not going to comply with all the rules and regulations that a housing provider sets. They need somewhere safe to drink and use.”

Operational, Treatment

“There can be a lack of understanding between clients and housing providers – accommodation may be pushing someone to detox and rehab when they’re not actually ready to… You need to navigate each individual client.”

Strategic, Treatment

Final reflections and recommendations

Project ADDER has paved the way for some new and refreshed ways of working in local areas, and has allowed for a strategic WSA that spans enforcement, treatment and diversionary organisations, practices and interventions. This evidence makes the case for continued funding and support in order to embed this WSA for the long term.

For practitioners, this evaluation has provided insights into the types of interventions that can be implemented and what factors facilitate delivery. It has also identified key challenges that can be anticipated – and possibly mitigated or overcome going forwards. Some challenges to Project ADDER were compounded by the COVID-19 pandemic and the results of a longer history of disinvestment and a shrinking skilled workforce.

16. Practitioners

This section summarises key recommendations for practitioners who are looking to implement a similar programme of activities to Project ADDER.

1. Expect challenges in rapidly recruiting into key positions, due to a historical shrinkage in investment in the treatment sector – particularly for those with advanced clinical skills and lived experience, and those that require additional permissions or accreditation. Steps to prepare for this could include recruiting positions earlier (which would require earlier sign-off from the Home Office, OHID, cabinet and the local authority), anticipating long lead-in times before staff can start, tailoring job descriptions to adapt to the existing skills base, anticipating additional delays for accreditation, or ring-fencing resources for technical training. Where possible, it may be appropriate to consult with other neighbouring local projects to apply a joint or staggered approach to recruitment.
2. Bring partners together as early in the design stage as possible to establish strong communication, relationships and alignment from the outset. Establishing steering and task groups was reported as being particularly effective in driving implementation forward. Meeting regularly, with strategic oversight, was reported to be important for sharing information, discussing specific cases, and applying flexible approaches to delivery. Consider at an early stage how funding allocation should be arranged under local authority processes.
3. Easy, fast and accurate information sharing between partners, combined with the use of multi-disciplinary teams, was critical for implementation. This WSA was integral in integrating care pathways, enhancing and increasing referrals, and targeting enforcement activity. Information sharing was aided by co-location and establishing DSAs (where possible).
4. Consider funding dedicated roles or resources for strategic support, coordination and information sharing between partners, analysts, logistics, administration, physical spaces and Home Office reporting. This could include establishing ‘plan Bs’ for unanticipated absence of key strategic and managerial stakeholders. This would reduce both the burden and reliance on strategic staff. The specific roles or resources needed are likely to differ significantly by local area.
5. Training and co-location can be useful tools for aligning treatment and enforcement partners who have historically had different cultures, languages, and approaches. Training could be provided on trauma-informed practice, identifying drug use, and understanding available referral options, as well as on making referrals that are appropriate for the needs of service users.
6. Home Office SPOCs could share examples of DSAs and other useful templates in order to inform similar programmes of delivery in the future.

17. Policy-makers

This section summarises key recommendations for policy-makers in the sector who are looking to fund or design a similar programme to Project ADDER.

1. Where possible, develop timelines for project design that account for the fact that stakeholders need to conduct needs assessments and adhere to local authority processes. This could be done by consulting with stakeholders directly on appropriate design timescales.
2. Provide mechanisms or forums for local project leads to consult with each other on practical actions that can be taken to improve the experience of delivery (for example, conducting recruitment and arranging the most efficient use of resources across neighbouring areas). Identifying need and pre-existing ‘best practice’ at a local level is likely to be critical in setting up any future programmes for success.
3. At the outset, provide clear, early guidance on any prescribed funding allocations, and the reporting mechanisms that will be required throughout the programme. Consider that local projects may need to allocate resources specifically for the purposes of coordination, logistics, administration, physical spaces and Home Office reporting.
4. Greater collaboration between the Home Office, OHID, the Joint Combatting Drugs Unit and other departments to map related funding streams may be helpful for reducing the level of duplication between them, and aligning reporting processes for local projects. These may include the National Drug Strategy, published by the Conservative government in 2021, the Rough Sleeping Drug and Alcohol Treatment Grant, and IPS.
5. Give official notice as early as possible on whether funding is being extended, in order to support staff retention and allow local projects to plan appropriately for ongoing implementation.
6. Expanding the scope of the programme funding to address wider systemic issues, such as making appropriate housing supply available, could potentially have supported the successful delivery of Project ADDER. It may be more appropriate to fund this via a related funding stream (see recommendation 4). In addition, any extension of Project ADDER is likely to benefit from funding that allows a greater focus on preventative interventions, and alcohol or non-Class A drugs, which are often co-used.
7. Involve evaluators as early as possible to allow for support with scoping and immersion. This could involve support with mapping funding streams, consulting with projects about timescales and reporting mechanisms, and establishing a useful pre-implementation baseline.

Annex A – Programme-level Theory of Change

See the programme-level Theory of Change for enforcement and treatment and diversion here.

Annex B – Local area-level activities

Blackpool – enforcement

• creation of ADDER taskforce
• analytical work identifying the repeat locations of drugs overdoses/near-fatal overdoses
• analytical work focusing on the vulnerabilities of those involved with county lines in Blackpool
• analytical work focusing on the hierarchy and structure of drug supply within Blackpool
• researching police and partner agencies systems to identify intelligence opportunities
• researching near-fatal overdoses and dissemination to Public Health England
• enhanced activity on financial investigations and money flows, including a focus on seizing proceeds of crimes
• high-visibility policing
• police engagement and support with the young ADDER cohort
• acting on police intelligence to develop the knowledge around the county lines groups operating in Blackpool
• increased police presence via ADDER taskforce
• communications
• utilisation of Drug Dealing Telecommunication Restriction Orders to close county lines and communicate public safety messages to service users
• communicating to Public Health England when high-risk drugs are seized, to facilitate public safety messages

Blackpool – treatment and diversion

• ADDER taskforce carry naloxone
• arm reduction and buprenorphine injections​
• physical health management and preventative care ​
• identification of crack and heroin users who are not in treatment and with a history of criminal activity, through cells, probation, drug-related death and non-fatal overdose panel ​
• pathways between services strengthened and improved​
• outreach/key workers​
• assertive outreach and lived experience team engaging with service users throughout treatment journey​
• expanding OOCDs​

Hastings – enforcement

• creation of ADDER taskforce​
• enhanced capacity to analyse seized mobile phones​
• enhanced drug analysis capacity and fingerprint DNA analysis​
• enhanced crime enforcement analysis targeting criminal drug supply associations, upstream suppliers and organised crime group (OCG) networks implemented​
• intelligence-led policing​ targeting line holders and street-level dealing​
• high-visibility policing​ – directed uniformed patrol activity targeting visible signs of drug harm, including anti-social behaviour
• execution of drug warrants​
• cuckooing checks​
• social media campaign; out-of-home marketing; design of physical and digital assets

Hastings – treatment and diversion

• creation of a delivery model which encompasses a WSA, providing a holistic package of care
• specialist outreach ADDER team (Seaview) created and pathways to treatment established
• specialist outreach team identify at-risk substance mis-users and engage with them to support into treatment
• care navigation workers establish referral pathways to key services which address the root causes of substance misuse
• Criminal Justice Intervention Team post to work alongside the aged 18 and under treatment provider
• substance heroin and crack keyworkers providing specialist support (assessment, referrals, case management, key working) to substance mis-users
• SWIFT specialist nurse (part of outreach) delivers a consultation and screening clinic to early help staff and service users in local children’s centres on a weekly basis
• partnering with Change, Grow, Live to ensure naloxone is readily available through community partners and Hastings custody
• increased residential rehab places and in-patient detox places
• clinical psychology treatment delivered to patients in rehab
• OOCDs for adults and young people, including DToA expanded to 7 days a week

Middlesbrough – enforcement

• effective investigation strategies, especially for drug arrests and county line; including the use of software like Chorus that enables police officers to conduct basic county line investigation
• coordination between police units and ADDER staff in enforcement; organised crime team had been supporting the arrest of high-harm individuals; the new violence reduction unit also works with ADDER staff to reduce drug-related violence
• the police conducted Operation Arrow – uncovered child exploitation, as well as disrupted operations of a major OCG; the police deployed cover activities like renting different cars
• the intelligence unit also works with prisoners to inform intelligence about county lines, including juveniles, as well as having a dedicated intelligence analyst since year 1 on Project ADDER
• 250 to 300 police officers have been trained on carrying naloxone kits to reduce the risk of overdoses and on distributing clean needles to reduce the risk of blood-borne viruses; increased distribution of naloxone kits and clean needles on streets and in custody
• activities in tandem with the treatment services; DToA; the Introduction of many diversionary schemes, supported by police and senior management (to reduce re-offending)
• Automatic Number Plate Recognition (ANPR) equipment was bought in year 1 and has been used for gathering intelligence
• police also conduct outreach in schools to raise awareness about drugs and drug-related harm through these collaborations
• police patrols for surveillance (operation stay safe), along with neighbourhood policing working with the community
• increased engagement with the community by the neighbourhood policing team
• police identifying people in custody and those committing low-level crimes, to refer them to diversionary services; partnerships have also facilitated the reporting of issues in a timely manner, and sharing intelligence; more intelligence on drug supply, exploitation, and criminal networks
• identifying premises involved in the supply of controlled drugs or associated with ASB and liaising with local authority to close these
• Crimestoppers (independent agency) campaigns related to county line awareness, and encourages people (vulnerable and exploited) to report criminal activity to the police
• get connected scheme: this scheme has been implemented in the hotspot area, whereby agencies conduct various workshops on partnership working and WSA

Middlesbrough – treatment and diversion

• creating a website that provides information to a wider audience, such as open-source information on drug harm, exploitation, early signs of drug misuse and accessing early intervention workers for advice; telephone support team who triages the caller to the right service, such as the housing team, substance use
• information and brief advice training is a part preventative work stream where the trainer recruited provides training to various organisations, such as schools, professionals, voluntary and community sector organisations, family and peer support groups on drug harm, early signs of use, and the remit of treatment services and referral services that can be accessed; trainings are tailored according to the organisation
• assertive outreach workers and collaboration with Barnardo’s workers to identify young people in custody or prisons
• the outreach team distribute cards across localities, pharmacies, GP surgeries, police stations, and primary care to get more referrals from organisations and reach people using drugs through various areas and services; they then refer the users to respective services based on need, like housing, mental health, employment, and recovery rehabs; alongside this they also deliver referrals pathways and support to the families of people using drugs
• individuals who have suffered loss or removal of children are supported through rapid access and are provided with enhanced harm minimisation work to reduce the risk of drug-related deaths
• a lived experience worker conducts fieldwork in custody, prisons and other hotspots in the community to encourage users to get involved in treatment
• a lung health clinic has also been established: it provides primary care to those who smoke drugs, along with health check-ups, lung health advice and chronic obstructive pulmonary disease tests; it also refers people with more severe health issues to smoking cessation pathways; however, top-level services with the NHS specialist have not been implemented; still engaging in dialogue with the trust to revisit
• harm minimisation team has also created a mobile needle exchange programme (additional element), which involves distributing clean needles through a mobile vehicle and a dedicated phone line for people to send in requests for equipment
• the 2 harm minimisation nurses have also been onboarded as a part of outreach to provide primary care to service users in the community and refer them into treatment when necessary; however, they do not have the ability to prescribe medicines and refer people to the NHS foundation instead
• the harm minimisation team has also recruited near/non-fatal overdose workers, who have been working with primary healthcare to identify service users who have had near-miss overdoses, to provide recommendations for treatment as well as to refer them to other relevant services; they are also in the process of developing more pathways for people who visit A&E due to overdose
• the council has also onboarded a charity called Seen Heard Believed, which is delivering more trauma-intensive practices to service users (youth and adults), which include basic counselling and further referrals
• the transformation worker has been delivering services to service users through caseloads and consistent support, along with liaising with mental health services, GP surgeries, hospitals, domestic abuse services, rehabs; the worker handles complex cases such as sex workers, individuals with high levels of drug use, the homeless population, and youth with safeguarding and social care needs
• a nutrition health clinic (for youth and elderly in care homes) was established in partnership with Recovery Connections; they have trained/upskilled their staff, who are taking forward the initiative
• young people outreach worker goes into custody to get referrals and to provide advice for young people

Norwich – enforcement

• using data and technology to target police activity on the identification of and enforcement against line supply lines into the county
• utilising counter reconnaissance behavioural detection tactics
• deploying police officers to transportation hubs, county lines recruitment areas, drug misuse and drug-related hotspots

Norwich – treatment and diversion

• targeted communications to users
• enhanced outreach using engagement workers from education and training providers and local employers
• voluntary community interventions for young people not already in statutory services or early help
• specialist support for vulnerable women, including assessment, referral and support
• assertive and targeted outreach team engaging with service users throughout treatment journey
• recovery support for people aged 18 to 25
• OOCDs for minor and first offences
• drug testing on arrest or in custody, with referral to Change Grow Live in-reach workers
• engaging children aged 10 to 17 who are arrested and taken to PIC
• court disposals via Community Sentence Treatment Requirements (CSTRs)
• working with other organisations to engage individuals who are not in treatment
• enhanced recovery support
• providing naloxone in police and community hotspots and opiate substitute therapy to those that use illicit heroin
• improving pathways between the criminal justice system and drug treatment

Swansea – enforcement

• intelligence-led targeted activity/visible presence within known hotspot areas
• disrupting organised crime/gang-related criminality by targeting county lines, street gangs and middle market dealers
• proactively pursuing any escalation in threats/violence amongst the wider drug markets
• working closely with other forces, agencies and proactive teams to disrupt criminal activity both locally and nationally
• working with British Transport Police and National Express (or similar) to target the train and road networks
• effective and ethical use of stop and search
• proactively patrolling areas that are most affected by drug criminality
• conducting regular unannounced checks on those subject to cuckooing
• supporting the use of ancillary orders
• purchasing new ICT equipment
• using media to promote the success of the operational teams whilst providing consistent messages to reassure the public
• hiring an analyst and 2 case file builders (admin roles)

Swansea – treatment and diversion

• contributing to community safety through sharing intelligence with partners in order to focus on vulnerability and provide support to build resilience with those at risk
• RAPS
• Post-Criminal Justice Prescribing Maintenance Programme (now called Recovery+)
• Community Mental Health Treatment Requirement (MHTR)
• Service User Involvement Coordinator position (developed peer-to-peer naloxone programme, needle and syringe exchange and dried blood spot testing for blood-borne viruses)
• naloxone carried by police and peer volunteers
• additional Dyfodol worker (x 2) in police custody suites and pre-custody to provide early intervention to those identified (via DToA) as needing support.

Bristol – enforcement

• targeted local enforcement and an increase in targeted drug warranty activity, including interception of illicit drug supply to HMP Bristol
• intelligence gathering, sharing and analysis to inform targeted enforcement activity
• safeguarding and reassurance policing
• DToA (started October to December year 1)
• enhanced partnership and whole systems working
• targeted communications and awareness raising approach to schools, dealers, users and local community
• ASB ADDER workers support property closures and ASB orders where diversions to treatment fail
• ADDER detainee investigators specialise in drug investigations and boost charge/remand rates

Bristol – treatment and diversion

• employment and training support for people using drugs not in structured treatment
• enhanced benefits and employment support for people in recovery
• enhanced outreach and engagement
• enhanced/piloted nasal naloxone provision
• piloted buprenorphine provision
• enhanced psychological therapeutic support
• intensive family support
• respiratory and renal service risk assessment for opiate dependents
• prison in-reach and community working
• drug testing for people on DRRs
• criminal justice substance misuse workers
• joint investigations of drug-related deaths and non-fatal overdoses
• housing support for people using drugs who are not in structured treatment
• trauma-informed workforce training
• naloxone roll-out to police (300 in Bristol)
• deferred prosecution scheme (Call-In) for those involved in drug supply
• working with schools to ensure safeguarding leads have a good understanding of drug misuse and how to refer
• enhanced mentoring offering for young people (and those on remand in prison)

Hackney – enforcement

• supporting drug-related deaths panels and non-fatal overdose partnership investigations
• enhanced partnership working and whole systems working, including through monthly multi-agency meetings
• improved systems to support information sharing, with dedicated staff working alongside local authority and other partners and develop pathways into treatment and out-of-court initiatives
• greater intelligence gathering, sharing and analysis to inform targeted enforcement activity
• targeting the market drivers of drug activity through the use of electric pedal cycles and vehicle car hire, reflecting local organised drug profile
• funded overtime for police investigators and officers to support drug trafficking investigations and reduce drug-related offending through the recovery of greater quantities of drugs and assets
• training for and acquisition of cell site analysis suite bulk data analytical software to upgrade police ability to analyse organised criminal networks through interrogation of bulk telephony data

Hackney – treatment and diversion

• new forensic/clinical psychologist to help improve and shape health and criminal justice pathways
• enhanced recovery support: provision of legal support services, peer mentoring, and in-reach initiatives
• delivery of enhanced prison in-reach – is progressing but behind on delivery objectives
• psychosocial interventions and key working delivered by new criminal justice recovery workers
• enhanced harm reduction provision, targeting groups that are at risk

Merseyside – enforcement

• increase in targeted drugs warranty activity
• enhanced activity on financial investigations and money flows; drug market profiling, dark web analysis
• increase in use of ANPR, drug wipes and testing kits to disrupt trafficking
• workforce training to increase understanding of services offer and referral pathways
• increase in reassurance policing and safeguarding
• whole systems coordination and collaboration between treatment, diversion and enforcement
• targeted communications approach to schools, dealers and users
• working with Crimestoppers to increase intelligence on drug-related activity
• increased DToA and OOCDs, diversionary support
• procurement of drug testing equipment

Merseyside – treatment and diversion

• enhanced outreach and engagement​
• expanding naloxone provision, needle exchange programmes (Knowlsey and Liverpool)​
• increased residential rehab (Liverpool) and housing support (Wirral)​
• enhanced prison release pathway support​
• piloted/enhanced buprenorphine provision​
• enhanced diversion from criminal justice pathways​
• enhanced offer for dual diagnosis ​
• improved continuity of care from non-criminal justice settings (for example, hospitals)​
• enhanced role of community pharmacists to support health interventions and harm reduction (Wirral)​
• physical health clinics (Wirral)​
• development of/strengthened recovery community and peer support network (Knowlsey and Liverpool)​
• enhanced support for families of people using drugs (Liverpool and Wirral)​
• whole systems coordination and collaboration​

Newcastle – enforcement

• working with a range of key partners to increase actionable intelligence linked to the harms associated with drugs
• increase in targeted drugs warrants based upon intelligence, data and evidence-led approach
• increased police visibility in high-harm areas linked to harms associated with drugs
• increased proactive use of ANPR
• development of covert proactive tactics to target serious and organised crime
• creation of a detailed partnership drugs market profile
• re-introduction of DToA within custody
• improve education awareness within schools around the harms associated with drugs, alcohol and improved understanding of vulnerability
• enhanced activity linked to financial intelligence and maximising investigative opportunities to identify and seize criminal property
• targeted communications to drug dealers and users
• provision of nasal naloxone to officers

Newcastle – treatment and diversion

• family intervention workers supporting the family and carers of people using drugs – dedicated posts and pathways
• Breaking Free online platform access for people using drugs
• additional focus and capacity for outreach and engagement
• increased buprenorphine provision
• established post to improve pathways into residential rehab
• dedicated criminal justice intervention team, which included carer/family support, prison interface, probation, courts worker and women’s worker
• creche budget for parents in recovery groups
• psychosocial role – counselling support and other clinical capacity
• OOCD pathway and assessments of DToA cases
• payment to support and expand recovery community, including recovery coaching
• short-term accommodation clients staffing support to encourage engagement in recovery services
• enhanced naloxone provision
• complex needs team for those with co-occurring mental and physical health needs
• a focus on training and workforce development
• physical healthcare team – focusing on outreach, low-threshold interventions, increasing naloxone, blood-borne virus testing, physical healthcare checks, smoking cessation
• research report on changes in drug supply and criminal exploitation and serious violence

Tower Hamlets – enforcement

• supporting drug-related deaths panels and non-fatal overdose partnership investigations
• enhanced partnership working and whole systems working, including through monthly multi-agency meetings
• improved systems to support information sharing, with dedicated staff working alongside local authority and other partners and develop pathways into treatment and out-of-court initiatives
• greater intelligence gathering, sharing and analysis to inform targeted enforcement activity
• targeting the market drivers of drug activity and through the use of electric pedal cycles and vehicle car hire, reflecting local organised drug profile
• funded overtime for police investigators and officers to support drug trafficking investigations and reduce drug-related offending through the recovery of greater quantities of drugs and assets
• training for and acquisition of cell site analysis suite bulk data analytical software to upgrade police ability to analyse organised criminal networks through interrogation of bulk telephony data

Tower Hamlets – treatment and diversion

• improved key working and case management interventions led by the Community Safety Response Team (CSRT) to provide intensive care to people aged 18 to 24
• enhanced Recovery Support: New Youth Coach, Case Manager and Sessional meeting/group accommodation to help implement Education, training and employment support and specialist training for people aged 18 to 24 within the treatment system
• delivery of enhanced prison in-reach to support transition from HMP Thameside back into Tower Hamlets, and using Through the Gate Workers to provide support to residents due for release into community services
• improved continuity of care from non-criminal justice settings, ensuring treatment continued between community drug treatment services and other settings (for example, hospitals), led by women’s criminal justice pathway coordinator

Wakefield – enforcement

• procurement of drug testing equipment (DToA)​
• creation of neighbourhood impact team​
• overt operation focused on disruption and deterrence​
• covert intelligence operation targeting wholesale market and drug dealing​
• increased use of ANPR for disruption​
• digital investigative tool for recovering and analysing iPhone data; detainee visits; analyst for analysing information from police and partners in support of operations

Wakefield – treatment and diversion

• homelessness and accommodation outreach (including training in use of naloxone)​
• pilot use of buprenorphine for criminal justice clients​
• residential rehabilitation​
• specialist mental health support for people using drugs in the criminal justice system​
• increased clinical capacity, prescribing, and treatment resources focusing on prison leavers and interventions for criminal justice system clients​
• provision of group work interventions to criminal justice cohort to deliver across various settings​
• court liaison to assess and encourage appropriate use of Drug Rehabilitation Requirement, including training and education of court staff​
• prison in-reach to support release into the community​
• increased use of OOCDs

Annex C – Enforcement activities and local project examples

Drug testing capability

Accelerators areas were offered funding for the expansion of drug testing capabilities in the menu of interventions (see Annex J). This included the purchase of new drug testing equipment and additional staff for forensics and drug testing support, with the intention of facilitating DToA and reducing the testing burden on external testing services.

Not all areas sought to expand drug testing capabilities, and this was not offered in the menu of interventions for ADDER areas.

Case study: drug testing capability in Merseyside

Merseyside Police used Accelerators funding to allocate additional drug testing staffing resource, in order to increase the number of arrestees tested for drugs. Funding was also allocated to one forensic support officer to resource the increased caseload as a result of higher numbers of drug tests. In addition, Accelerator funding was allocated to purchase more drug wipes to be used by roads policing.

As well as increasing resource, a task and finish group was set up to explore and improve the process when an individual is stopped and a drugs wipe is used, to ensure officers use their powers to maximum effect.

“We have paid for a lot of drug drive wipes but they don’t record the use of a drugs wipe, whether it has positive or negative results. So we’ve been looking at how to record this better and we’ve looked at the quality of the process when someone is stopped and a drugs wipe is used. We’re working on a process map on key areas. So, for example, if a drug wipe is negative they won’t be arrested, whereas really if they’re impaired they should be arrested and in custody they can do blood tests. So we’re trying to raise awareness among officers that they do have the power to arrest and bring people in for blood tests. We want to enhance the training to ensure officers are using drug wipes and their powers properly.”

Strategic lead, Enforcement

Targeted enforcement activity and reassurance policing

Local areas were also given funding to conduct reassurance policing, and increase targeted drugs warranty and seizures. This typically manifested in police ‘days of action’ or the establishment of ‘neighbourhood impact teams’ dedicated to conducting warrants and seizures, using overtime. In many cases, these teams worked closely with treatment partners to ensure that any potential service users identified during enforcement activity were suitably diverted into support services.

All areas conducted some form of targeted enforcement activity with the intention of increasing arrests of high-harm individuals, disruption of cuckooing, and seizures of drugs, cash and other assets to disrupt organised crime groups.

Case study: targeted enforcement activity and reassurance policing in Middlesbrough

Operation Stay safe has been developed through the ADDER funding to increase community policing and patrols on the streets during ASB hours (7 pm to 3 am) and weekends to identify young people who are on the street and at risk of exploitation through criminal gangs. Some patrols also include partners like Barnado’s workers to accompany the police and provide advice to users on the streets. Police officers who are trained in naloxone kits have also conducted patrols in hotspot areas with high levels of drug supply to form connections with the community and users. Neighbourhood policing teams are also trained on how to communicate effectively with service users and how to gain access to service users in supported housing via housing associations and providers.

“There’s a problem-solving approach to it, not just focusing on prosecution … it’s a focused response where not every suspect of a drug offence is a suspect as such, we also look at them as a victim.”

Managerial, Enforcement

Case study: targeted enforcement activity and reassurance policing in Norwich

Police have been using counter reconnaissance behavioural detection tactics to spot suspicious behaviour at train stations, with the aim of spotting those carrying drugs. They have also been deploying police officers to transportation hubs, county lines recruitment areas and drug misuse and drug-related hotspots. These activities were taking place prior to ADDER and have continued throughout.

A new development since ADDER is that police have been carrying out cuckooing visits together with treatment workers to show that police are trying to help – rather than target – those being cuckooed and to increase the chance of being let into the property

Intelligence gathering and analysis

Dedicated resources were utilised for intelligence gathering, sharing and analysis between enforcement partners. This supported both ongoing investigations and targeted enforcement action.

Case study: intelligence gathering and analysis in Newcastle

A new role of financial investigator at the police was funded by the ADDER project. This role produces outputs such as confiscation orders after cash seizures, and so plays an important role in the prosecution process. This resource also enables enforcement work to be carried out into financial investigations and money laundering, rather than limiting it to the drugs supply side of enforcement.

“We can apply to the court and say we think this is criminal proceeds, and then look to get the cash confiscated. Having financial investigators involved improves the quality of the intervention, it means we can look at the money laundering side and not just the drugs supply and mechanics.”

Strategic, Enforcement

In addition, a key area of intelligence gathering analysis activity under Accelerators in Newcastle is the drug market profile and analytic hub. This is a common data platform that incorporates quantitative and qualitative data from treatment service providers, crime data and other types of data from other partners on both the treatment and enforcement side. The data is compiled by a team comprising data analysts at the local authority public health team and in the police’s drug testing team. Overall, the ADDER hub is about ensuring that all interventions are intelligence-led, which includes targeted enforcement activity with key partners, developing early warning notifications of drug-related deaths, and providing a comprehensive summary of the drug market in the city, its commodities, and supply dynamics.

The data can be used by any relevant party to carry out their own analysis. It is expected that the database will provide a comprehensive profile of the drugs market which can be used to inform drug strategy.

“This is not just about cocaine and heroin, it’s about poly-use, that’s the higher harm context of drug-related deaths. The drugs market profile is a comprehensive document that will be a baseline that will be refreshed on a regular basis. It provides an ever-moving picture of drugs harm. It will allow us to have an evidence base to see where intelligence gaps are and how to close those gaps, where the greatest harms are in terms of markets and drug products, such as fake benzos, and the supply methodology, like what drugs are couriered in from abroad, and which are dealt at a local pub, so it includes OCG activity. The profile intelligence will inform drug strategy.”

Strategic, Enforcement

Case study: intelligence gathering and analysis in Swansea

Police purchased a GrayKey mobile phone download kit which allows them to crack phones and access mobile data. Prior to ADDER they only had access to one device based in Cardiff but now they have it in Swansea, meaning they can download the data straight away while suspects are in custody, without incurring travel and waiting time for officers to go to Cardiff and therefore facilitating faster evidence building for investigations.

More licences for an intelligence software called Chorus were also purchased, which supports analysts, investigators and frontline officers to conduct digital investigations. Whereas previously only analysts had access to this, it is now available for the organised crime teams to use as well. This has allowed the police to build an intelligence picture using mobile phone data and to collect evidence for investigations more quickly.

“We’ve purchased some analytical software and it’s been game changing for us in terms of analysing communications data… when we have got hold of mobile data or downloads we can very quickly throw it through the software and build up an intelligence picture of frequent numbers, location the devices have been and get together an evidential product that we can put forward to CPS to help show conspiracies and attribution of devices.”

Strategic, Enforcement

Communication campaigns

A few local projects ran targeted communications campaigns, aiming to disrupt offending and prevent drug use. Campaigns were targeted to each area, with some aimed at the general public and some aimed at specific groups, such as young people, service users, or those involved in organised crime groups.

These communication campaigns were intended to encourage the public to report drug-related crimes, boost the profile of reassurance policing, and educate target populations on harms caused by drugs and organised crime groups. For example, both Norwich and Swansea have set up communications directly to users when a county line has been taken down or during periods of heavy enforcement by sending out texts to all people within the supplier’s phone book, signposting them towards treatment.

Case study: communication campaign in Newcastle

ADDER funding was used to create 2 new education and awareness officer roles in the violence reduction unit of Northumbria Police, who delivered a drugs education and awareness package to around 1,300 children in approximately 25 schools.

The police also carried out targeted activity in the university student community during freshers week, as this is a community that is vulnerable to drug suppliers and there have been drug-related deaths in the student community. Alongside enforcement operations, educational packages were delivered to students to raise awareness around issues such as county lines and drug harms, including the impact on their future of being arrested for a drug-related offence.

“They are educating students around health harms, the impact of being arrested and convicted on their ability to travel and to get jobs. And in schools, there has been really good engagement and fantastic work there”

Strategic, Enforcement

Case study: communication campaign in Middlesbrough

Through ADDER funding, the police, in partnership with Crimestoppers (an independent charity), conducted campaigns related to county line awareness, drug harm, and exploitation. They were targeted at the community, especially the vulnerable population, to encourage people to report criminal activity to the police. They have also developed Crimestopper zones to conduct targeted marketing of campaigns in a hotspot area with bespoke messages. Police also train partner agencies to stress the importance of identifying issues as early as possible and of signposting accordingly.

The harm minimisation team and young people’s team funded under ADDER engage with people in custody through various informative leaflets and conversations to spread awareness about drug misuse and harm, along with sexual health. The prevention and early intervention team also work in schools to conduct education training around drug harm, targeting teachers and young people.

Funding has also been used to develop a website for people who have basic queries about drug harm and want to access early intervention workers for advice. It also provides open-source information on drug harm, exploitation, early signs of drug misuse. Additionally, prevention campaigns are disseminated through local football clubs, police vans and taxi services to mobilise young people and the community, as well as to spread information on the support provided by the team (with links to the website). Recovery stories from rehabs are also distributed to people in prisons through police partnerships to spread awareness about treatment and recovery pathways.

“The police has been more than happy to look at what intervention we [the early intervention team] want to do and to promote the material on police van and vehicles, so people will look at the support services that are available to them.”

Strategic, Enforcement

Annex D – Diversion activities and local project examples

Out of Court Disposals (OOCD)

OOCDs are a set of cautions and orders that the police are able to give when individuals are caught for low-level offences and which prevent the individual from being subject to a formal prosecution or having a criminal record. These include, but are not limited to, referrals for individuals to engage with a support service, and some types of caution. Under Project ADDER, local areas were funded to expand their use of OOCDs for minor and first-time drug-related offences. The intention with the expansion of OOCD use was that more individuals would be referred into treatment and support services and, as such, avoid having a criminal record.

Case study: OOCDs in Merseyside

The strategic lead attributes an increased use of OOCDs, and compliance with them, to internal police officer training and awareness raising initiatives on the ADDER aims and treatment provision. This is believed to have resulted in increased knowledge and understanding of how to use OOCDs across police and treatment services.

Previously, most OOCDs were referrals for a 2-hour online intervention, whereas Accelerators funding allowed for the provision a more intensive, personalised, face-to-face service to individuals given an OOCD. Police officer training in this referral pathway is believed to have encouraged officers to use OOCDs more as a result, because they are aware of the high-quality ADDER treatment offer that is now available.

Furthermore, improvements have been made to the IT system used by officers so that they can more easily utilise OOCDs when they encounter an individual on the street, rather than needing to put them in custody first. The force has already shared good practice in this area with the Metropolitan Police.

In addition, treatment services have found that individuals who are referred to them via OOCDs are more likely to be aware of the treatment offer due to the improved communication from police officers. In turn, there is a perception among stakeholders that individuals who have received an OOCD are more likely to engage with treatment because they have a good understanding of the terms and conditions and rationale for their referral to treatment.

Case study: OOCDs in Norwich

ADDER funded a temporary worker on the Offender Diversion Team with the aim of generating more OOCDs. The Offender Diversion Team’s role is to process Conditional Cautions and Community Resolutions issued across Norfolk. Conditions varied, but the aim was to ensure that most had a Red Snapper Intervention Hub (learning programme) condition relevant to their criminogenic needs.

Management information (MI) data showed a clear upward trend in the number of service users being issued with OOCDs. However, stakeholders felt that this increase was driven more by the force-wide decision to phase in the Ministry of Justice’s 2-tier adult OOCDs framework than by ADDER per se. The framework reduced the number of adult OOCDs from 6 to 2 by removing the options for Penalty Notices for Disorder, Simple Cautions and Cannabis/Khat warnings.

Drug testing on arrest (DToA)

Project ADDER funding was also used to increase DToA, typically from saliva or urine samples. Generally, these drug tests are able to identify use of heroin, cocaine or crack cocaine. DToA was designed to identify who may be suitable for an OOCD, refer individuals into treatment or support services where appropriate, and expedite the process of prosecuting people arrested following targeted enforcement activity.

Case study: DToA in Newcastle

DToA was implemented under the Accelerators project as it was not operating pre-ADDER. They now have 2 roles in custody suites carrying out DToA and this is reported to have had a wide range of diversionary outcomes. Individuals who are tested for drugs on arrest include people from neighbouring local authorities which are not Accelerators areas. This is seen to provide legacy benefits as there is a plan to set up DToA referral pathways for residents of neighbouring local authorities, as well as those from Newcastle, in the future.

Case study: DToA in Middlesbrough

Drug testing has been introduced widely across the force through Project ADDER. ADDER enforcement staff act as a conduit between police and treatment partners to facilitate coordination and connecting treatment pathways to users through these drug tests on arrests. They also train staff on drug testing, which has allowed for an increased number of people in custody being tested for drugs. Public health has helped the police force to create a local drug testing pathways by leveraging the testing capabilities of a local laboratory.

Annex E – Treatment activities and local project examples

Enhanced recovery support

Under ADDER, local areas were funded to enhance recovery support services, such as IPS, housing support, peer support networks, and supporting recovery communities. The intention was that service users would have greater access to appropriate services to achieve their goals and support them to live a life that is no longer dependent on drugs.

Case study: enhanced recovery support in Hackney

Recovery support programmes are predominantly split across 3 organisations (St Giles, SWIM and Turning Point), who all apply their own specialisms and expertise to target specific communities.

St Giles focuses on targeting those groups identified as typically the hardest to engage, using their lived experience team to help achieve this. SWIM focuses on engaging individuals from black backgrounds and is looking to expand and engage more with those from Asian, Eastern European, and Orthodox Jewish communities:

“SWIM – absolute jewel in the crown – we’ve got so many people signed up to receive support who had nothing but animosity towards Hackney and our drug treatment system previously.”

Strategic, Treatment

Hackney also arranged for the presence of an LGBT worker at Turning Point, although evidence on success in engaging this community so far through Accelerators is less clear.

Case study: enhanced recovery support in Merseyside

In Knowsley, individuals can be referred by the drug treatment service to an organisation called Flourish and Succeed, which runs a range of activities to build a recovery community for people in recovery from substance misuse. Once individuals have completed their treatment, they are at high risk of relapse, so diversionary activities are offered to build individuals’ resilience and support their sustained recovery.

There are a broad range of activities offered 6 days a week, including a music group, men’s groups, fitness, mental health and wellbeing groups, cooking, personal development, bowling, camping and museum trips, and an allotment group, and other ideas for groups are suggested by participants based on their interests. Some activities allow participants to gain a qualification, such as an NVQ in horticulture through the allotments group.

Some individuals have built up the confidence to lead a group or activity after having participated for a while, and thrive on the new-found confidence that the leadership role gives them.

The individuals attending the activities build a relationship with the staff at Flourish and Succeed, and sometimes contact them first when they feel they are at risk of relapse. Flourish and Succeed staff can refer individuals back to the treatment service if they feel it would help them sustain their recovery.

Case study: enhanced recovery support in Newcastle

Activities were offered to service users and their carers as a part of contingency management to provide them with diversionary activities that can support their recovery. This was part of a structure, care-planned prevention – all aimed at increasing access, engagement and retention in a structured plan of support. Activities on offer included sessions on nutrition and diet,, crafts, jewellery making sessions and exercise groups – all based on improving wellbeing.

There was significant work to re-develop user and carer involvement and engagement, working with the treatment services and recovery community. An anthology was developed as part of this work to support others and promote recovery.

Within family intervention support, sessions were delivered where service users and their loved ones could carry out activities together. The aim was that this would support the service users’ relationships with loved ones and further build their recovery capital.

Alternatively, relatives and carers of service users who had not engaged with treatment and recovery services were able to attend the activities without the service user, in order to receive support as a carer. In some instances, this encouraged the service user to attend the activities and/or the treatment service themselves.

“This breaks down some of those barriers and they are doing something fun and interesting rather than thinking about the reason they are accessing the service. That’s been a significant change that carers are being invited into the activities that the treatment service are providing. Which means that the carers can go home and say [to the service user] they were doing an activity with the treatment service which breaks down the barriers for the service users to also going in to the treatment service.”

Managerial, Treatment

Case study: enhanced recovery support in Middlesbrough

The ADDER treatment services have been able to create better linkages with detox facilities, which enables the harm minimisation and assertive outreach workers to refer more people into these services. The case workers funded by ADDER provide users in treatment with support in attending appointments regularly, making lifestyle changes, and engaging them in activities (employment and recreational). The ADDER teams have also created partnerships with the local rehab facility, called Recovery Connections. They share outreach workers as well as other resources with recovery connections to share knowledge and increase the ease of rehab/recovery referrals.

The public health services had initially planned to provide secondary housing to provide recovery support to people coming out of rehab. However, this element was delayed and will now be implemented in 2024 to 2025.

Enhanced harm reduction

A number of interventions designed to reduce drug harm and death were implemented under Project ADDER, including enhanced naloxone provision and needle and syringe programmes. Outreach activities were also conducted, designed for key workers to engage with specific groups known to be at particular risk of harm in the area. These included parents, young people, those experiencing homelessness, and those experiencing exploitation, violence or abuse.

Case study: enhanced harm reduction in Bristol

Bristol aimed to enhance naloxone provision under the Accelerators project. It wanted to increase the level of supply of naloxone, and training in nasal naloxone administration, for various organisations, including housing associations and the police, to supplement the existing supply of injecting naloxone.

ADDER allowed an online training component on administering nasal naloxone to be added to the pre-existing overdose prevention training workshop that was run fortnightly and offered to any organisation. The target was to distribute 100 doses of naloxone per month.

Case study: enhanced harm reduction in Hackney

Harm reduction in Hackney has centred around a number of core activities. The first of these is naloxone provision, with 200% more naloxone supplied under Accelerators funding. Stakeholders associated this directly with a perceived reduction in drug-related deaths, and an increase in tier 1 interactions with service users who had previously rejected services.

Needle exchange programmes have also helped to reduce harm (most significantly in relation to hepatitis C infections). Individuals can then also be engaged and referred to further support services through these provisions, therefore providing extra opportunities to interact and engage with individuals who are using drugs to get the specific support that they need.

Increasing outreach and interaction between services has also been effective, with more people now being referred to services in general, and greater interconnectivity between services across both treatment and diversion also increasing referrals due to improved communication and understanding of the services being provided. This approach has also been extended to referrals to services and programmes that are already being provided outside of the ADDER-funded services (such as mobile health units that can deal with issues such as wound care, rough sleeping, and street service users), which can help prevent users from getting into other potential harms, and meaning that the impact of ADDER can be greater than what is directly measured in terms of engagement and use of services specifically funded by ADDER.

Case study: enhanced harm reduction in Merseyside

In the Wirral, harm reduction activity has been significantly enhanced with local community organisations, such as hostels. This work has included naloxone distribution and training to hostel and other organisations’ staff, and needle exchange equipment distributed across the area. The operational lead for harm reduction reported that they deal with over 2,000 pieces of needle exchange equipment per month.

A new benzodiazepine group has been set up for hostel residents, in response to a significant spike in use of this drug and its associated drug harms. The ‘Benzos’ group involves outreach staff from the drug treatment service providing education to hostel residents on the drug harms from Benzos and how to reduce these harms.

Furthermore, a member of the outreach team from the drug treatment service has set up multi-disciplinary team meetings with hostel staff to work together to identify hostel residents with particularly complex needs, to try to reduce drug harms and the overdose rate among hostel residents.

Case study: enhanced harm reduction in Swansea

Naloxone was distributed to the police and to service users. The Service User Involvement Coordinator, whose role was funded by ADDER, was instrumental in developing what they called the ‘peer-to-peer’ programme, whereby people with lived experience volunteer to carry naloxone and train others on how to use it. The ‘peer’ work evolved with time, developing to also involve people with lived experience carrying out needle and syringe exchanges and dried blood spot testing for blood-borne viruses.

Pharmacological/psychological treatment

Various forms of pharmacological and psychological treatment services were funded by Project ADDER, with the aim of expanding service user access to the most appropriate forms of treatment and supporting them to live a life that is no longer dependent on drugs. This included the provision of long-acting opioid substitutions, increased rehab residential treatments, and enhanced mental health offerings.

Case study: pharmacological and psychological treatments in Bristol

Three assistant psychologist posts and one mental health nurse in the in-patient ward were created with ADDER funding. Two of the assistant psychologists worked in the community, and one worked in the in-patient setting, with all of them providing one-to-one and group-based therapy.

The community-based assistant psychologists delivered up to 12 Cognitive Behavioural Therapy-based sessions with individual service users who were referred from treatment services. They also ran group therapy with service users, such as a trauma stabilisation group, and provided psychoeducation. One of the aims of this work was to normalise and validate service users’ experiences of drug use, particularly the link between drug use and trauma.

The assistant psychologists carry out assertive outreach to engage service users. This includes visiting individuals in prison shortly before release, and visiting hostels to engage residents and encourage them to access psychological treatment.

Case study: pharmacological and psychological treatments in Merseyside

The treatment service in Knowsley has introduced attention deficit hyperactivity disorder (ADHD) screening for their service users, so that staff can understand the traits of an individual presenting with ADHD symptoms. This helps them understand how to provide treatment to that individual most effectively. For example, if the service user does not attend appointments because they feel uncomfortable sitting and talking one-to-one, the caseworker will meet them out in the community so that they can walk and talk instead.

The Accelerators team at the drug treatment service offers ADHD screening training to the core team, as well as external organisations, including the police, Youth Offending Service and probation service. Uptake of this training has been good, with staff feeding back that it has been helpful in supporting their work with service users, and encourage them to access psychological treatment.

Case study: pharmacological and psychological treatments in Wakefield

Wakefield has delivered a pilot of the buprenorphine prescription. Buprenorphine offers an alternative to methadone treatment, which gives people a monthly prescription instead of daily. This different treatment approach enables individuals to lead their daily lives without being focused on their next treatment, supporting them to enter and maintain work, and improve their overall quality of life.

Respondents noted that the trials took off very quickly, due to good word of mouth among participants and many early successes. Additional funding was sought to enable them to offer the treatment to additional participants due to the demand and positive outcomes.

“Service users felt like this was a brand new opportunity within their substance use. People who had been in services 10 years plus, really written off the fact they ever make any changes to their medication, go to the pharmacy every day, bump into people they know. The routine was entrenched in the biggest way possible with no view to it changing. Automatically had a new path to follow and a new opportunity. It broke down the routine. It takes away the daily mindset of ‘I can’t function without my medication’. …There’s a lot more time for us to put some structured interventions into place to work on other aspects of life.”

Operational, Treatment

Case study: pharmacological and psychological treatments in Middlesbrough

The heroine-assisted programme funded under ADDER was providing diamorphine treatment to opioid users; however, it was discontinued in the second year of ADDER delivery due to its limited reach. The ADDER team has also implemented smoking cessation pathways and has established a primary lung health clinic for users who smoke drugs. This includes chronic obstructive pulmonary disease testing and stop-smoking services, along with direct referrals to specialist care. The NHS specialist practice also runs a rapid access prescription programme funded under ADDER where the harm minimisation nurses provide prescriptions of methadone and other clinical services to service users.

Prior to ADDER, public health in Middlesbrough did not have the capacity to reach extremely vulnerable populations. The funding has allowed the council to deploy a transformation worker who handles a caseload of complex cases, such as individuals with high levels of drug use, polydrug use, and safeguarding issues, including rough sleepers and sex workers. The worker connects them to services such as mental health, primary care and dual diagnosis pathways supported by mental health services. They also support clients with hospital appointments for treatment and trauma-intensive services.

“It’s a case of rather than going around the roundabout, they’re having a point of contact who’s there for mental health services, who’s there for vulnerable women, to support all of that element.”

Managerial, Treatment

In terms of mental health support, non-opioid workers funded by ADDER also help service users get access to virtual appointments for mental health. The council also provides basic mental health support to young people in custody, in partnership with Barnado’s workers, who help identify people who need psychological support. Middlesbrough council has also funded a charity called Seen Heard Believed through ADDER to underwrite their trauma-informed early interventions for struggling and vulnerable families. These services help the most vulnerable people who are involved in drug or alcohol use to get access to mental health services and health practitioners, as well as a dedicated worker to provide regular support.

“The stories of recovery from people who are in rehab depict the variety of workers that they have. Quite a lot of them [people with drug issues] have been picked up by the outreach team and they have had continued conversations with them and convinced them to seek some of the services.”

Operational, Treatment

Case study: pharmacological and psychological treatments in Norwich

ADDER service users have been able to access opioid substitution treatment consisting of both a pharmacological and psychosocial element. Funding has allowed for the recruitment of a prescriber and nurse who work from a centrally located hub and in the community to get people on methadone or buprenorphine prescriptions. Via outreach work, the prescriber has been able to titrate individuals on the streets or in their homes.

Psychosocial support includes one-to-one and group sessions and activities such as yoga, walks, paddle boarding and volunteering on an allotment. These activities allow people to make positive changes to their lives and build new social networks. Stakeholders consider it important to run activities that are not about drugs and that allow service users to feel they are a part of something and to have conversations that are not formally ‘therapy’.

Case study: pharmacological and psychological treatments in Swansea

Service users have received mental health support via court-ordered MHTR. Those issued an MHTR are allocated an assistant psychologist and follow a treatment plan. They receive between 8 and 12 one-to-one sessions according to their needs (such as cognitive behaviour therapy or acceptance commitment therapy). The service is delivered by the organisation Forensic Psychology Consultancy, who employ a psychology team to provide pre-court advice, psychology assessments and treatment pathways for people in court with a link between their offences and low- to medium-level mental health difficulties. They use a hybrid model, offering both face-to-face and remote sessions. If a service user needs more than 12 sessions, they will either be offered more (if capacity) or referred on to other services, such as Mind or veterans services.

ADDER funding also covered 2 programmes aimed at improving access to prescriptions for methadone and buprenorphine:

The Rapid Access Prescribing Programme, through assertive and targeted outreach, reaches people with significant complexity and users come into service very quickly. It is not a requirement for people to be involved in the criminal justice system, instead the priority is those vulnerable to the risk of overdose and who are sex working. When treatment workers receive a referral, they do a urine test and a nurse assessment and see a doctor if needed. Before ADDER, waiting times for those coming in via the criminal justice system were 2 to 4 weeks and for others they were 12 to 18 months, whereas referrals for RAPS are usually seen on the same day as referrals come in, and the average waiting time from referral to prescribing is 6 days.

Recovery+ is a long-term prescribing programme that offers an additional 12 months of prescriptions after statutory orders have ended. Prior to ADDER, those coming off statutory orders were left without access to support. As well as giving them longer access to prescriptions, there is a focus on engaging these service users (who are further along in their recovery compared to the most vulnerable) in employment, training and education, and in addressing psychosocial problems and fostering independence.

Enhanced treatment capacity

In addition to providing pharmacological and psychological treatments, ADDER funding was used in increase capacity for treatment services. This was typically done by employing additional expert staff members across various services with specific purposes, targeted to the needs of the local area as specified under the delivery plan. Enhancing treatment capacity was intended to reduce caseloads for support staff, support key working, and increase the intensity of targeted support for service users.

Case study: enhanced treatment capacity in Bristol

Accelerator funding was used to create a criminal justice team at one of the drug treatment services in Bristol. This new team was able to provide tailored support that could better meet the needs of service users who had been through the criminal justice system.

Prior to the Accelerators project, this cohort of service users would have been supported by the general drug treatment service team, that had higher caseloads and would not have had the resources to provide such tailored, intensive and holistic support.

As referral partners became aware of the new criminal justice team at the treatment service, it encouraged them to refer individuals to the service, as they knew that there would be allocated resources to support those individuals. As an example, the probation service encouraged the judiciary to utilise DRRs more frequently as there was a higher-quality treatment resource available to support DRR than had been available pre-ADDER.

“Before Accelerators started there wasn’t a criminal justice team, and DRRs were just floating about in drug treatment, lots hadn’t been seen. So the criminal justice team have worked really well with probation to move people to the team and now we are at the point where the communication is fantastic, they are very supportive of the project. Probation have really supported them to change how the judiciary view DRRs, as in to use them more instead of short custodial sentences.”

Managerial, Diversion

Case study: enhanced treatment capacity in Merseyside

The hostels in Wirral had significant problems with residents using drugs during the COVID-19 pandemic. There were high levels of chaotic drug use and overdoses, and the treatment service lacked the capacity to support hostel residents as caseloads were high.

To address this problem, Accelerators funding was used to create new hostel outreach posts, which had much lower caseloads than treatment service staff had previously had. Caseloads per staff member were around 25, rather than the previous levels of 70 to 80.

This lower caseload per staff member allowed the outreach staff to do more intensive outreach work in hostels, working with staff and residents delivering harm reduction interventions and brief interventions to prepare residents for structured treatment, and referring them to treatment if appropriate. In this way, many hostel residents who were considered ‘hard to reach’ before Accelerators have now accessed treatment.

Case study: enhanced treatment capacity in Newcastle

The recovery worker’s role in the social work team manages the waiting list for residential rehab places. This involves working with the individual while they are on the waiting list to unpick and address any issues, signpost them to community support, and prepare them for rehab. In addition, the recovery worker engages with individuals on the waiting list to explore with them whether they are motivated to enter rehab and ensure that they are ready for it.

The recovery worker engages with individuals to build their confidence in the skills they will need for rehab to be successful, such as talking about themselves in a group setting. This ensures those who get to the top of the waiting list are prepared and can benefit from rehab.

This enhanced capacity prevents people from leaving the waiting list unnecessarily. If they do leave the waiting list, it is because they are fully informed and aware of the reasons why rehab is not suitable for them at that time. Stakeholders explained that individuals enter residential rehab voluntarily, so this engagement work is crucial in ensuring its effectiveness.

“It is definitely noticeable that those who are poor-quality referrals are coming off the waiting list, and they know there’s been a real effort to engage them and explore with them, it’s not just that they’ve not opened the letters and considered it. So we can be really confident that anyone that’s removed from the list it’s the right call for those individuals. But also those people who are referred are referred more quickly and are coming through at the right time. It’s been really good in reducing the number of people who get to the top of the waiting list then saying they don’t want it. We’re seeing more people who want it and we’re seeing them more quickly than we used to.”

Managerial, Treatment

The service is now able to refer those with an acute need for rehab more quickly, so that, for example, those with complex physical health problems who are at risk of drug-related death if they do not receive rehab support can access a rehab bed sooner.

In addition to this, staffing was increased in drug and alcohol services, including a dedicated Criminal Justice Intervention Team.

Case study: enhanced treatment capacity in Middlesbrough

Middlesbrough has historically experienced generational drug use, and drug use among the younger population has been increasing. To tackle this issue, ADDER funding was used to revamp the treatment service team so that there is a clear bifurcation of responsibilities between outreach workers and the workers handling caseloads. There has always been a presence of assertive outreach workers, but ADDER has increased their capacity as now they do not have caseloads, which increases their responsiveness on the ground to reach as many service users as possible.

The referral pathways are led by outreach workers, who are responsible for forging partnerships with mental health services, probation, housing, NHS services, primary care, IPS, and police. They conduct a host of outreach activities, from diverting youth to referring overdose cases to the hospitals, as well as informing users about treatment pathways and referring them to treatment services. These workers also train police officers to carry naloxone kits. The team works to disseminate messages about overdosing through local organisations, and supports those at risk of overdose.

The caseloads of young people are transferred to case workers, who work closely with the police to identify youth at risk, and then support them to gain treatment appointments as well as housing, employment and rehab services. Additionally, resilience workers get involved with youth who are more at risk and who have persistent issues of drug misuse, to provide them with more intensive support. Complex case or transformation workers handle caseloads for adults who are particularly vulnerable and provide them with handholding support, as well as a range of pathways like primary care, mental health, housing and employment. This approach provides more intensive support to users, along with reaching a wider population to engage people into treatment and recovery services.

“I think one of the key highlights for me is, a lot of these clients have been in services for years, and it’s only now that they get that intense support. And I think the highlight in that sense is that if these clients received that support, say 10, 15 years ago, they could have been a point of recovery right now…before it was all about come in get your prescription and off you go, now it’s more we’re supporting them with those elements what they haven’t ever received support for.”

Managerial, Treatment

Integration and improved care pathways

Integration and improved care pathways between treatment services, the criminal justice system, and liaison/diversion were also funded under ADDER, with the aim of increasing referrals into treatment, simplifying the referral process for service users, and supporting service users to live lives that are no longer dependent on drugs. This included, but was not limited to, the following:

• prison in-reach interventions
• providing continuity of care upon leaving prison
• providing continuity of care from non-criminal justice settings, such as hospital link workers, and recovery workers in domestic violence settings
• increased use of DRRs
• setting up multi-disciplinary teams to collaborate between liaison, diversion, court and probation schemes

Case study: integration and improved care pathways in Bristol

Accelerators has enabled enhanced integration and improved care pathways between prisons and the drug treatment services in Bristol. The treatment services provide an in-reach service in HMP Bristol, which involves a member of the treatment service staff based in the prison working with the substance misuse team every day. This staff member prepares prisoners for accessing treatment in the community after release and post-release planning. This can involve setting up referrals or appointments for the prisoner with various community organisations on release, including DWP, housing support, and the drug treatment service, which can provide prescriptions for substitute medication.

The treatment plan that is designed for each prisoner to follow on release includes a holistic range of support that they might need to sustain a life that is no longer dependent on drugs. For example, if appropriate, prisoners can be escorted to visit the rehabilitation centre shortly before their release date, to see if they want to access a rehabilitation bed on release.

A peer meet at the gate service is provided to meet clients coming out of prison and accompany them to their first appointment with the treatment service in the community on the day of release. Prisoners released from prisons further afield are met by a staff member off the bus on arrival in Bristol. After release from prison, individuals accessing the treatment service are offered other support if relevant, including psychological therapy from the mental healthcare provider, and the opportunity to do voluntary work, including as peer mentors to others. The treatment service reported an increase in the number of people attending their first appointment at the treatment service after release from prison since this improved care pathway has been implemented.

Case study: integration and improved care pathways in Tower Hamlets

Hospital navigators (similar to community navigators) have been used to engage individuals in hospital who are victims of violence linked to drugs, providing continuity of care pathways from the criminal justice system to healthcare settings. Equivalent pathways have also been established in prisons, with ADDER paying for probation workers who are co-located with probation services, to focus on supporting people who use drugs, and to help individuals navigate their pathway through the criminal justice system, as well as other treatment and diversion support that is available to them. These positions have also enabled core staff to be upskilled due to the co-location of these expert workers and has enabled workers to liaise with users in a way that helps to ensure that they maintain treatment as they shift from one care setting to another.

Case study: integration and improved care pathways in Merseyside

In Liverpool, the treatment services have established multiple new referral pathways into and from their treatment service. This involves integrated working between the treatment services and other services, including the police, probation, mental health and maternity units of hospitals, and the Red Umbrella project, which provides support for people involved in sex work. These services work together to support service users and vulnerable individuals by referring individuals to the most appropriate service to meet their needs.

This integrated working allows the treatment services to reach individuals who they had not been able to reach previously. As an example, a vulnerable person referral process between the police and the treatment service has been established which has greatly increased the number of vulnerable people referred to the treatment service, including individuals who are treatment naïve.

Case study: integration and improved care pathways in Norwich

The local authority have worked to improve pathways between the criminal justice system and drug treatment services. Workers from Change, Grow, Live and the youth offending teams are based in custody to engage people/children who have been arrested and to signpost them to voluntary interventions. Other teams run activities such as psychosocial interventions and Smart Recovery groups within prison and, towards the end of year 2 of ADDER, workers from Change, Grow, Live also started running weekly sessions in prison. There has been regular communication between criminal justice teams and treatment services: for example, prisons providing detailed information about individuals pre-release (including the date of release and prescription dosages) and probation and courts providing feedback on service user engagement with DRR court orders.

Case study: integration and improved care pathways in Swansea

Two treatment workers work from police custody suites to provide early intervention support to those identified via DToA as needing support. They offer brief interventions and signpost and refer on to other services as necessary.

Partnership working has meant that staff from different organisations will do outreach together: for example, treatment workers, housing officers and Police Community Support Officers. Names for targeted outreach are received from a wide range of sources, including Drug Poisoning Task Force monthly meetings, police information, the Swan project (sex worker outreach project), Barod and Adveriad (drug support agencies), and health partners (for example, homeless nurse, mental health nurse, hospital).

Annex F – Overview of evaluation activities

In the first year of the evaluation, the timeline for Accelerators and ADDER areas differed because programme implementation started later in Accelerators areas compared to ADDER areas. At the outset of the second year of the evaluation, the timelines for evaluating the programme in both ADDER and Accelerators areas were aligned.

Year 1

Table F1: Activities in Year 1 of the Evaluation

Stage of the evaluation	1. Project inception	2. Area-level immersion	3. Process evaluation	4. Impact evaluation
ADDER area year 1 dates	March 2021 – August 2021	June 2021 – July 2021	August 2021 – January 2022	January 2022 – June 2022
Accelerators areas year 1 dates	September 2021 – November 2021	November 2021 – December 2021	January 2022 – March 2022	April – June 2022

Project inception

• inception meetings and project inception document agreed with the Home Office
• document and bid review
• stakeholder mapping workshop
• development of programme-level ToC and workshops
• initial development of the evaluation framework

Area-level immersion

• in-depth interviews with strategic leads
• development of area-level ToCs and workshops
• final evaluation framework delivered

Year 1 Process evaluation

• in-depth interviews with strategic leads and area-level stakeholders
• interim descriptive analysis of MI data

Year 1 Impact evaluation

• interim quasi-experimental analysis of outcomes
• interim contribution analysis and workshops with stakeholders
• year 1 evaluation presentation and report

Year 2

Table F2: Activities in year 2 of the evaluation

Stage of the evaluation	5. Reflection	6. Process evaluation	7. Impact evaluation
Dates	July 2022	August 2022 – April 2023	May 2023 - September 2023

Reflection

• review ToCs and evaluation framework
• stakeholder mapping

Year 2 Process evaluation

• in-depth interviews with area-level stakeholders
• in-depth interviews with service users
• analysis of final MI data

Year 2 Impact evaluation

• quasi-experimental analysis of outcomes
• contribution analysis and follow-up in-depth interviews with strategic leads
• year 2 ‘impact story’ workshops with Home Office stakeholders

Annex G – Scoping phase and process evaluation methodology

Scoping and process evaluation methodology

Year 1 Project scoping and area-level immersion

The process evaluation began with a systematic review of project documentation and delivery plans. Following on from this review, 2 programme-level ToCs – one for ADDER areas and another for Accelerators areas – were developed following a co-creation workshop with Home Office stakeholders. The final ToCs are available in Annex A.

Verian then made initial contact with strategic leads for each area and conducted area-level stakeholder mapping. Typically, each area had 2 strategic leads. One was responsible for treatment and diversion interventions and was likely to be an employee of the relevant council. The other strategic lead was responsible for enforcement interventions, and was typically a high-ranking individual within the police. Strategic leads were asked to provide a list of relevant individuals responsible for the implementation of various interventions or activities in the area. Verian reviewed these lists to map out appropriate respondents for the evaluation at an area level.

In-depth interviews were then held with strategic leads in each area. The purpose of these interviews was for the evaluation team to begin developing a relationship with the strategic leads, and to gain a deeper understanding of the context of each area, the interventions they were running, emerging facilitators and barriers, and the current status of delivery.

Insights from bid documentation and interviews with strategic leads were then used in combination with the programme-level ToC to create draft area-level ToC models. These draft ToCs were then shared with strategic leads in a series of workshops to co-produce final versions.

A list of activities conducted at the local level are available in Annex B.

Year 1 stakeholder interviews

The subsequent case study research included further in-depth interviews with a range of stakeholders identified through the stakeholder mapping process, including senior local authority leads, health and social care representatives, housing and employment services, police and court personnel, and voluntary sector representatives. These stakeholders were a mixture of operational and managerial staff, and efforts were made to ensure that the final stakeholder profile allowed for all activities being run in the local area to be discussed. Strategic leads were also re-interviewed to provide more detailed information on implementation progress, update any insights from immersion interviews, and triangulate with information provided by other stakeholders.

Number of ADDER areas stakeholder and strategic lead interviews in year 1 of the evaluation:

• Blackpool: 17
• Hastings: 19
• Middlesbrough: 11
• Norwich: 20
• Swansea: 12

Number of Accelerator areas stakeholder and strategic lead interviews interviews in year 1 of the evaluation:

• Bristol: 18
• Hackney: 18
• Tower Hamlets: 18
• Merseyside: 33
• Newcastle: 17
• Wakefield: 12

These interviews focused mainly on the implementation journey, including how activities were implemented, the challenges and facilitators experienced, and what could have been improved. We also used these interactions to probe stakeholders for any anecdotal evidence about emerging outcomes and to regularly review the assumptions about change that the local-level ToC represented.

Alongside these interviews was an ongoing review of project-related MI data submitted by each area, and regular attendance at project board meetings where project representatives reported on progress. For further information about the MI data, please refer to the Project ADDER: Impact evaluation report.

Year 2 stakeholder interviews

Ahead of the year 2 stakeholder interviews, stakeholder mapping conducted in year 1 was reviewed and updated in collaboration with strategic leads in each area. As in year 1, year 2 interviews consisted of in-depth interviews with a range of stakeholders, an ongoing review of project-related MI data submitted by each area, and regular attendance at project board meetings.

Year 2 interviews focused on emerging impacts and outcomes of Project ADDER. However, they also covered updates or changes to the implementation experience, and functioned as a review of the local-level ToC. Additionally, these interviews were used to obtain contact details for relevant support workers employed within various interventions, in preparation for service user interviews.

Number of ADDER areas stakeholder and strategic lead interviews interviews in year 2 of the evaluation:

• Blackpool: 9
• Hastings: 9
• Middlesbrough: 12
• Norwich: 11
• Swansea: 10

Number of Accelerator areas stakeholder and strategic lead interviews interviews in year 2 of the evaluation:

• Bristol: 13
• Hackney: 10
• Tower Hamlets: 10
• Merseyside: 17
• Newcastle: 12
• Wakefield: 15

Year 2 service user interviews

In addition to stakeholder interviews, in-depth interviews were also conducted with ‘service users’ of the interventions. The aim of these interviews was to build a comprehensive picture of project implementation and outcomes, by understanding the interventions from a recipient perspective. Service users were asked about how they were referred into support, the nature of the support they were receiving, and how this might be improved in relation to need, access, quality or other factors. They were also asked to comment on the extent to which the support they were receiving had an impact on their lives or circumstances. The majority of the content from these interviews is not covered in this report, they are covered in the Project ADDER: Impact evaluation report.

Standardisation and analysis

All interviews and workshops across all audiences were conducted based on programme-level discussion guides, to ensure consistency across areas. However, each local area lead in the evaluation team was given the discretion to add probes to their discussion guides to address area-specific questions according to the local context. All discussion guides were designed to be used in a flexible manner to follow the cognitive flow of the participant.

Monthly MI data submissions were shared by strategic leads in each area with the Home Office, which was subsequently passed on to Verian. For the process evaluation, this data was used in the evaluation to inform area-specific probes and questions. Further analysis of the MI data was used for the impact evaluation and is available in the Project ADDER: Impact evaluation report.

All interviews and workshops were transcribed and analysed using an analysis framework to identify key themes and insights.

Annex H – Bid development activities and local project examples

Bid development

Local areas were selected by the Home Office for Project ADDER and each area was invited to prepare project proposals (or ‘bids’) which reflected their local contexts, population characteristics, models of existing service provision, existing partnership structures and preferred delivery models.

Assessing local needs and response

The strategic leads in each area drew on a range of national and local data to develop local profiles and establish the issues to be addressed by their projects. The forms of data that were analysed by areas to produce profiles of need included:

• rates of deprivation in the local area (using Indices of Multiple Deprivation)
• local health data, including life expectancies and rates of health problems
• rates of drug misuse (local needs assessments, drug treatment services databases)
• rates of mortality from drug misuse (local coroner information, Office for National Statistics data)
• drug-related offending and convictions (local police data and nationally published re-offending data)
• data on OCGs and known cuckooing locations (local police data)
• analyses of drug-related crime and offending by hotspot areas (local analyses)

Case study: assessing local needs and response in Norwich

In Norwich, a ‘profile of need’ was developed in order to assess local needs and response. This profile of need found that:

• the mortality rate from drug-related deaths in Norwich was growing and was above the England average; between 2016 and 2018 there were 152 drug-related deaths, with one-third of these being in Norwich
• it was estimated that in the year 2019/20, 45% of the opiate and crack users in treatment were in Norwich
• intelligence indicated that heroin and crack cocaine purities had increased in the previous 5 years
• Norfolk Constabulary’s response to county lines was initiated in December 2016; in Norfolk (as at July 2020) there were 52 known active lines, with 32 of these in Norwich

Within the 61 cases reviewed in the Norfolk Drug-Related Death Audit (2018), the following was found:

1. Ageing heroin users made up half (51%) of the sample. Two-thirds had more than one drug implicated in their cause of death (poly-use), and 53 had a noted mental health illness and 44 were prescribed psychoactive drugs.
2. A notable proportion had some form of social stressor, such as suffering bereavement, adverse childhood experience or family problems.
3. The majority of people lived in the most deprived neighbourhoods, with only a small number in employment (11) and 8 people were homeless or lived in sheltered accommodation.
4. Two-thirds had health conditions not directly attributable to drug use.

(Document: Project ADDER Overview. Norwich)

For many areas, collecting and analysing data on drug use, offending and mortalities had already taken place prior to developing ADDER funding proposals, which helped ensure alignment between the proposed ADDER activities and local strategic priorities. For example, in Blackpool, a detailed needs assessment had been undertaken by Public Health Consultants and Specialist Registrars to develop the Blackpool Drugs Strategy 2019 to 2022 and the Lancashire Serious Violence Strategy 2020 to 2025. In Middlesbrough, there had been a recent re-commissioning of services via a needs assessment carried out to identify ‘system blockages’ and to highlight the need for extra capacity.

Case study: assessing local needs and response in Swansea

In 2018, Swansea Bay Area Planning Board and Police and Crime Commissioner’s Office (PCC) conducted a deep-dive into drug-related deaths in the local area. The project was a collaboration between the PCC and Public Health Wales and from the outset it was based on developing a public health response to substance use and drug-related deaths. The project led to the development of a report which identified the gaps in the system.

The report set out a commitment from key partners to work together to create a whole-system approach and look at substance misuse as a health issue rather than a criminal justice one and to work together to implement more effective strategies. This work formed the basis of the design of Project ADDER in Swansea Bay and the funding provided an opportunity to pilot some of the initiatives and ways of working identified.

“You know, what we were doing before was putting sticking plasters onto a system that wasn’t working because it wasn’t a system… it was bits of provision which were patchy and allowing people to fall through the gap.”

Strategic lead, Treatment

The local projects typically also assessed existing provision, to identify local service gaps or issues, to provide a rationale for the interventions selected. Common service gaps and associated challenges that were identified by areas included the following:

• a lack of early intervention to address the root causes of drug use, such as trauma, mental health issues, emotional dysregulation, adverse childhood experiences or exploitation
• high thresholds of disruption or need for accessing support services
• long waiting lists, and a lack of timely access to treatment for those in crisis situations and for those entering/leaving the criminal justice system
• revolving doors and disengagement – where users access treatment then disengage, only to return again at a later date, which may involve reliving traumatic experiences
• complex or lengthy routes into appropriate treatment for service users
• complexity of need – even with multiple entry points, service users often struggled to remain engaged with treatment support due to the inter-related nature of the difficulties being faced, such as poly-use, dual diagnosis, and life-disrupting circumstances, such as homelessness, isolation or a lack of technological access
• siloed services, which presented challenges for service integration and led to service users repeating their stories multiple times to different services, reliving traumatic experiences

Bringing together partners

In England, the core partners receiving ADDER funding were the local police forces (receiving Home Office funding for enforcement and diversion) and local authorities (receiving Public Health England funding for treatment and recovery services). In Swansea Bay, where public health funding is issued directly from Public Health Wales to Area Planning Boards (APBs) for Substance Misuse, funding is awarded to the APB attended by South Wales Police, local authorities, and probation and substance misuse agencies.

In most areas, multi-agency stakeholder meetings were used as fora to collectively design their interventions. Prominent stakeholders included the strategic leads in police forces and local authorities, and APB partners in Swansea Bay. Other partners included local drug treatment services, adult and children’s social care, probation and youth offending teams, local authority housing teams, and housing associations.

Local areas differed in the way they approached collaborative project design, which can be broadly grouped into centralised or decentralised approaches. Centralised approaches (such as those taken by Newcastle, Hackney and Tower Hamlets) were characterised by strong influence from the strategic lead: for example, by selecting relevant partners, inviting them to contribute to design, and collating the inputs into a final delivery plan. This approach allowed for local providers to contribute to design, whilst retaining a core project ethos in the final delivery plans. As a result, this was a useful approach for areas working with large number of partners, or those establishing new partnerships. However, this approach was resource-intensive, and required a full-time project coordinator to function.

Other areas (such as Bristol, Wakefield and Merseyside) took a decentralised approach to project design, where strategic leads invited treatment providers to lead and build their own interventions to meet service user needs. This approach gave treatment providers greater flexibility and agency to contribute to discussions about design. However, it also carried the risk of splintering perspectives on the key aims of the programme, meaning that it was more commonly used where local authorities already had strong relationships with treatment providers, or where there were a smaller number of partners to engage with.

Case study: bringing together partners in Bristol

The project coordinator at Bristol City Council brought together delivery partners to discuss and plan suitable pathways. Each delivery partner carried out their own needs assessment and designed their own part of the intervention and delivery, and these were then collated and coordinated by the project coordinator.

The project coordinator also formed and chaired the ADDER steering group which included police, local treatment service providers, IPS, relevant local authority teams (such as those working on ASB), and the local mental health service provider.

Although many of these partners had pre-existing working relationships, Accelerators brought in some new partners who had not been engaged before, such as a women’s support group: The Nelson Project.

Sub-groups of providers were also formed to bring together those who would work more closely together operationally. For example, the drug treatment service set up meetings with partners such as IPS, and separate meetings with the other drug treatment service in the city to establish and maintain the pathway between services.

Case study: bringing together partners in Merseyside

In each of the 3 Merseyside Accelerators areas, the strategic leads at the local authority invited the local treatment provider to lead delivery, with oversight provided by the strategic lead.

The treatment provider in each of the 3 areas established relationships and designed referral pathways with delivery partners in their area, such as the Youth Offending Service, health services and hostels. They set up regular operational meetings between delivery partners to steer delivery of the project in their area, chaired by the project coordinator at the treatment service.

From the enforcement side, a monthly tri-meeting was set up between the enforcement strategic lead, each of the 3 local authority strategic leads, and the treatment service providers leading delivery in each of the 3 areas.

Case study: bringing together partners in Wakefield

Partners in Wakefield were brought together through round table events to discuss the gaps and deficits within the whole system, to identify how the Accelerator would be most effective and to establish its core pathways.

The round table discussions included the police, public health, and treatment and diversion providers. Partners were asked to consider different intervention options, which were then aligned with the key gaps. The costs and management requirements of these interventions were also established at this stage to support decision-making.

More widely, the different partners consulted their own staff, delivery experts and commissioners on what would be most effective.

These early meetings helped the partners integrate and improve the overall pathways and process.

Producing delivery plans

Final delivery plans were then produced by area, outlining interventions they intended to deliver and how the funding would be used. Delivery plans were guided by a ‘menu of interventions’ that was provided by the Home Office, which outlined a set of evidence-based interventions that could be proposed. These included:

• enhanced targeted outreach and harm reduction services
• increased pharmacological and psychological treatment capacity
• increased integration and improved care pathways
• enhanced recovery support
• diversionary activities, including OOCDs and DTOA
• enforcement activities
• communication campaigns
• system coordination and commissioning
• expanding drug testing capabilities

The full menu of interventions provided for ADDER and Accelerators areas, respectively, are available in Annex J.

Areas had the discretion to decide which interventions to focus on (including apportioning of funding amounts to different interventions), and the specific details of the audience, referral routes and activities within those intervention groups. Additional interventions outside of those on the menu were permitted if there was evidence to support the use of the intervention(s).

Typically, local commissioners utilised ADDER grants to rebuild local services and to complement their existing treatment and recovery provision, after a period of disinvestment, as set out in the Dame Carol Black Review (Part 1). Notable examples of this included activities in Swansea Bay and Wakefield, which sought to enhance existing services and build back strong partnerships that had fallen by the wayside.

Some areas also undertook activities that were new for the local area. In a few cases, ADDER funding allowed for interventions to continue that would otherwise have ceased. For example, in Middlesbrough, ADDER funding enabled the commissioning of new interventions in the local area, such as rapid access prescribing and police naloxone pilots, and also the continuation of the Heroin Assisted Treatment programme, which would otherwise have come to an end.

Overall, delivery plans sought to:

• enhance outreach services to be more assertive, and address the lack of proactive/early intervention services
• relax eligibility criteria and increase the flexibility of available support to lower the threshold for accessing support
• increase the intensity of treatment offers, improving the quality of support services and reducing caseloads in order to address complex needs and disengagement among service users
• utilise the WSA and embed strong partnerships to improve pathways, provide holistic support and curtail siloed support
• purchase software and technology to enable more effective intelligence and information sharing between partners
• free up specialist resources for more targeted disruption activity, and provide additional specialist resources to address gaps
• facilitate a change in management structures for greater strategic oversight

However, several pre-existing challenges were identified which final delivery plans were less able to address, including:

• the inability to support specialist, dedicated alcohol-only treatment services, and to support diversion from criminal justice system pathways to support services for those using drugs other than crack cocaine and opiates
• a lesser focus on interventions related to non-class A drugs (such as benzodiazepines and cannabis), which were also considered to be substances requiring treatment support or leading to engagement with the criminal justice system
• a limited ability to influence housing supply/access to stable accommodation – with gaps in housing supply and tenancy support services
• an inability to support users outside the ADDER/Accelerators borders, or to address crime displaced to neighbouring areas
• avoiding duplication or overlap with other activities associated with the National Drug Strategy, which was launched in December 2021 by the Conservative government,^{[footnote 10]} after the design and early implementation of Project ADDER

Lists of activities implemented at a local level are available in Annex B.

Annex I – Preparing for implementation activities and local project examples

Preparing for implementation

Once funding was approved, the local projects in England were able to prepare for implementation, with exact timings depending on local authority procurement processes and recruitment of the workforce by commissioned providers.

Common preparatory tasks included:

• establishing governance arrangements
• communicating with and between partners
• preparing for recruitment

Establishing governance arrangements

Governance arrangements refers to the reporting and accountability structures established for the implementation of Project ADDER at an area level. The precise nature of governance arrangements varied between areas and largely built on existing governance structures and partnership boards to oversee project delivery.

Case study: governance arrangements in Swansea Bay

In Swansea Bay, ADDER funding is overseen by the APB, which has strategic oversight over substance misuse services across Swansea Bay. A designated ADDER Implementation Group was established to oversee ADDER specifically, which reported to the APB on the implementation of ADDER. Comparing the Implementation Group to the APB, one interviewee said:

“Because it’s not part of the Area Planning Board’… it’s a more relaxed environment where partners are able to just talk about their experience … and ideas about things, but also then obviously we’re moving into position now where we’re looking to set up work streams with specific areas of interest.”

Strategic, Treatment

As implementation progressed, several operational ‘interest groups’ were set up to mobilise specific areas of delivery, including OOCDs and prison outreach. Key partners from different parts of the system were invited to attend the implementation and operational groups to build relationships and plan services. One interviewee described the experience of representatives from prisons joining the Implementation Group:

“We’ve got a prisons lead in Swansea Bay that comes to the implementation Board, so they’re going to look at … specific work stream that is focused on prisons but has all the partners in it … They are focused on what’s going to happen in prisons, but also how it links into the other ADDER projects … Then there’s going to be somebody leading from probation and DWP…So there’s all these kind of little offshoots of work I think [that] wouldn’t have been there before if we didn’t have the ADDER funding.”

Strategic, Treatment

Case study: governance arrangements in Merseyside

Governance arrangements were established for the treatment and diversion aspect of the Accelerators project in each of the 3 Merseyside Accelerators areas. This included reporting and accountability structures for the treatment service provider leading delivery in each area, and the strategic lead at the local authority.

Furthermore, governance arrangements between the enforcement strategic lead and each of the 3 areas’ treatment and diversion strategic leads, and their respective treatment service leads, were established, including a memorandum of understanding between enforcement and treatment and diversion leads.

The treatment service provider that was leading the operational delivery of the project in their Merseyside area took operational responsibility for the recruitment of staff to the various roles they had included in their part of the delivery plan.

Communication between partners in each of the 3 areas was facilitated by steering groups set up between the treatment strategic lead, the treatment service provider, and other key deliver partners.

Communicating with and between partners

Across the case study areas, a core component of setup and implementation was the process of communicating about Project ADDER plans within organisations, and between organisations directly or indirectly involved in ADDER delivery. This was critical for establishing strong working relationships where these were not already present.

Informal communication channels for speaking with partners across multi-disciplinary teams were set up, including online platforms such as MS Teams for instant messaging, and shared WhatsApp or messaging groups to quickly pass on information between teams.

Areas also sought to establish commissioning agreements, grants or contracts, where needed, to allocate any necessary funding. DSAs were also written and agreed where required.

Preparing for recruitment

Developing job descriptions and preparing to recruit a variety of new posts was a key component of the start-up stage for many areas. Stakeholders commonly described searching for staff with a sense of common purpose, whose values aligned with the multi-agency approach envisaged, and who were able to empathise with service users. For example, in Bristol, each delivery partner had oversight and control of recruitment for their area of delivery, where treatment providers were tasked with recruiting the roles they had included in their part of the bid. The project coordinator role at the local authority was also recruited and came into post 6 months after project inception.

Annex J – Home Office menu of interventions

Table J1: Home Office ‘menu of interventions’ for ADDER areas - Treatment/recovery

Intervention grouping	Fundable interventions
1. Enhanced targeted outreach and harm reduction services	Enhanced outreach and engagement, including targeted outreach for rough sleepers and crack and heroin users who are not in contact with treatment.
	Enhanced naloxone provision, including through peer networks.
	Police naloxone programme.
2. Increased pharmacological and psychosocial treatment capacity	Increasing the proportion of heroin users in treatment.
	Increasing the number of crack-only users in treatment.
	Increased in-patient detox provision.
	Increased residential rehabilitation capacity.
3. Increased integration and improved care pathways between the criminal justice system and drug treatment	Enhanced treatment service capacity to undertake police and court custody assessments to improve pathways into treatment.
	Improved collaboration and joint working arrangements between prison healthcare and community-based treatment services, including in-reach into prison, to improve engagement post-prison release.
4. Enhanced recovery support	Care navigators to support engagement with health (including physical and mental health) and social care.
	Intensive employment support for service users in treatment, based on IPS model.
	A tenancy sustainment/supported housing worker.
	Sponsorship of a recovery community and peer support network, including in treatment, to increase the visibility of recovery and support social integration.

Table J2: Home Office ‘menu of interventions’ for ADDER areas - Diversion

Intervention grouping	Fundable interventions
1. Diversionary activity, including through OOCDs and DToA	Motivational interviewing by a drugs worker about managing drug use.
	Repeated sessions with a drugs worker around addressing drug use.
	Other evidence-based practice.

Table J3: Home Office ‘menu of interventions’ for ADDER areas - Enforcement

Intervention grouping	Fundable interventions
1. Enforcement activity	Increase in targeted drugs warranty activity.
	Enhanced activity on financial investigations and money flows, including a focus on seizing the proceeds of crime.
	An increase in reassurance policing and visibility, including the wider use of drug and cash dogs, particularly at transport hubs.
	An increase in the use of ANPR to disrupt drug trafficking.
2. Communications	Police working with partners on evidence-based preventative activity, for example in schools.
	Targeted communications messaging to drug dealers and users designed to disrupt offending.
	Work with Crimestoppers to increase intelligence on drug-related activity.

Table J4: Home Office ‘menu of interventions’ for Accelerator areas - Treatment/recovery

Intervention grouping	Fundable interventions
1. System coordination and commissioning	Increased commissioning capacity to act as a dedicated system coordinator (a standard component in Accelerators sites) working to project manage health and care elements of the delivery plan, lead liaison with government officials and work with enforcement coordinators to embed whole-system working in practice. Some areas have suffered from a lack of commissioning resource in recent years and may need support to deliver this ambitious programme.
	Whole-system complex needs workforce training package jointly delivered to enforcement, drug treatment and other key professionals, covering drugs and alcohol, and related topics such as domestic abuse, homelessness, mental health, parental substance misuse and trauma-informed care training.
	Systems to support information sharing between enforcement and drug treatment agencies.
	Enhanced collaboration, information sharing and joint working arrangements between drug treatment and other key local agencies (depending on which local pathways into treatment for vulnerable/priority groups need strengthening).
	Enhanced local drug-related deaths and non-fatal overdose partnership investigations.
2. Enhanced harm reduction provision	Enhanced outreach (including domiciliary outreach for people with disabilities and new mothers/babies) and engagement, including targeted street outreach for rough sleepers (aligned and complementing rough sleeping grant initiatives) and crack and heroin users who are not in contact with treatment.
	Enhanced needle and syringe programmes, including more use of low dead space syringes (LDSS) and specialist as well as pharmacy-based provision.
	Enhanced naloxone provision, including through peer networks.
3. Increased pharmacological and psychosocial treatment capacity	Increased/piloted provision of novel long-acting opioid substitution treatments.
	Increased residential rehabilitation placements, including referrals from prison healthcare teams for post-prison release placements and from probation services, as part of a DRR treatment package and those in Approved Premises.
	Purchase of more in-patient beds in local authorities unable or unwilling to enter into collaborative in-patient arrangements with other local authorities in their region.
	Enhanced offer for co-occurring mental health/substance misuse (for example, specialist clinician).
	Enhanced offer for parents needing treatment, including, for example, appointments at home in children and family support services, access to regulated childcare provision and therapeutic services for children.
4. Increased integration and improved care pathways between the criminal justice and other settings, and drug treatment	Enhanced treatment service capacity to undertake police and court custody assessments to improve pathways into treatment.
	Improved collaboration and joint working arrangements with liaison and diversion schemes, courts and probation to increase the number or CSTR and support improved engagement in treatment and compliance by individuals on court-mandated orders. Areas that are already part of the CSTR programme will be expected to build on the existing enhanced provision and framework that has already been established.
	Improved performance against PHOF C20 (continuity of care post-prison release) by collaborating with probation and prison offender managers, prison healthcare teams, Approved Premises, RECONNECT and Enhanced RECONNECT provision and community treatment services to proactively support individuals through the prison gate and into community-based treatment.
	Improved continuity of care from non-criminal justice settings, ensuring treatment is seamless between community drug treatment services and other settings, especially hospitals, is important to preventing treatment dropout, morbidity and mortality.
5. Treatment capacity to respond to increased diversionary activity, including through OOCDs, liaison and diversion, and DToA	To work with police-led OOCD schemes and to respond to required assessments following testing on arrest to provide evidence-based treatment interventions, including: key working/case management; psychosocial interventions; pharmacological interventions.
6. Enhanced recovery support	One-off pump-priming payment to support development/expansion of a recovery community and peer support network, including in treatment, to increase the visibility of recovery and support social integration.
	Enhanced employment support with the aim of increasing the number of people moving from drug treatment into work, including through improved collaboration and joint working arrangements with the DWP, Jobcentre Plus and other employment support provision (such as the Work and Health Programme and locally commissioned programmes).

Table J5: Home Office ‘menu of interventions’ for Accelerator areas - Diversion

Intervention grouping	Fundable interventions
1. Out of Court Disposals/drug testing on arrest	Motivational interviewing by a drugs worker about managing drug use (can only be funded from local authority budget).
	Repeated sessions with a drugs worker around addressing drug use (can only be funded from local authority budget).
	DToA (can only be funded from the enforcement budget).

Table J6: Home Office ‘menu of interventions’ for Accelerator areas - Enforcement

Intervention grouping	Fundable interventions
1. Enforcement activity	Increase in targeted drugs warranty activity through overtime.
	Enhanced activity on financial investigations and money flows, including a focus on seizing the proceeds of crime.
	An increase in reassurance policing and visibility, including the wider use of drug and cash dogs, particularly at transport hubs.
	An increase in the use of ANPR to disrupt drug trafficking.
	Police naloxone.
	Developing drug market profiles.
2. Communications	Police working with partners on evidence-based preventative activity: for example, in schools.
	Targeted communications messaging to drug dealers and users designed to disrupt offending.
	Work with Crimestoppers to increase intelligence on drug-related activity.
10. Drug testing capability	Purchase of equipment to reduce reliance on external forensic providers.

1. For more information about cuckooing, see: Criminal exploitation of children and vulnerable adults: county lines. ↩

2. For more information about ‘trigger offences’, see: https://www.gov.uk/government/news/drug-testing-on-arrest-expanded-to-help-cut-crime. ↩

3. For more information about IPS, see: https://www.centreformentalhealth.org.uk/what-ips. ↩

4. For more information about middle market targets, see: http://eprints.lse.ac.uk/13878/1/Middle_market_drug_distribution.pdf. ↩

5. More information about organised crime groups, see: Serious Crime Act 2015. ↩

6. For the full Dame Carol Black review, see: https://www.gov.uk/government/collections/independent-review-of-drugs-by-professor-dame-carol-black. ↩

7. More information on Dame Carol Black’s recommendations in the report ‘From harm to hope: A 10-year drugs plan to cut crime and save lives’, see: https://www.gov.uk/government/publications/from-harm-to-hope-a-10-year-drugs-plan-to-cut-crime-and-save-lives. ↩

8. Formally Public Health England. ↩

9. For the full Magenta Book, see: https://www.gov.uk/government/publications/the-magenta-book and for the full Green Book, see: https://www.gov.uk/government/publications/the-green-book-appraisal-and-evaluation-in-central-governent. ↩

10. National Drug Strategy. ↩