Drowning by Numbers

When are we going to be able to do the jobs we trained for
without having to play childish numbers games, asks drug
worker ‘Beth’, in her second instalment on the reality of
working in frontline drug services.

It’s that time of the month again. I am feeling tired, irritable
and generally frustrated. It’s affecting my colleagues as well.
Unfortunately no herbal remedy or HRT will help this. It’s time
to send off the National Drug Treatment Monitoring System
report (‘NDTMS’ for those in the know).

“There are three kinds of lies: lies, damned lies, and
statistics." I am sure most people recognise these words of
Mark Twain and I suspect that other drug and alcohol workers
will groan with recognition on hearing them.We can use
statistics effectively to support any point we want to make.

I chatted with a colleague who is under great pressure to
increase the numbers of drug users on the day programme he
runs.

“That’s good, 33 per cent of the clients in this group are
drug users,” he said.

“Great,” I replied. “How many turned up for the course
then?”

“Three,” he replied. (Well done to Jim for being 33 per cent
of the clients on the course.)

So when I check I have got everything ‘right’ for the latest
NDTMS report I ponder on what is the purpose of these stats.
Actually, as anyone I work with will tell you, I don’t ponder: I
mutter and swear quite a lot.

I think about one client I have been working with, off and
on, for most of the time I have been a drug and alcohol
worker, or probably far too long in official terms.

What has our positive outcome been? Well, he is not dead
and he is not in prison and he has not attacked anyone. These
have all been very real risks over the years. At the moment
our harm reduction focus is to shift him from bingeing on
amphetamines to go back to regular cannabis use and to stay
of booze. His last brush with the law, about ten years ago, was
when he stabbed someone when he was drunk. He knows that
alcohol brings out a violent aspect to him which he does not
want to risk re-emerging. The cannabis, although he can get
rather depressed, is a better option because he eats and sleeps
on this, unlike the amphetamine binges which leave him
gaunt, exhausted and occasionally psychotic. My hope is that
he could envisage life without any substances but that is a
goal too far at the moment. Still, in terms of our NDTMs at
least he is a drug user. Tick. Very good.

I understand something of how statistics are used to
analyse social trends and experiments in social science.
People are very varied and rather unpredictable, and changes
happen for all sorts of reasons: some people even stop using
substances without any professional intervention (but don’t
spread that rumour around too much).

So if we try to establish if any particular event has an effect
we need to measure the difference between what would have
happened anyway by natural variation or chance, and what
has happened in the group affected by the event.We look for a
significant difference between the results for the group left
alone and the group being subjected to whatever we are
looking at.

Statistics can compare, for instance, the number of adults
smoking, using drugs, driving a car today to how many were
doing it, say, five years ago. These sort of figures are the ones
that often appear in the news along with speculation about
why this is and what it means for the future. They are often
accompanied by inaccurate and meaningless extrapolation,
using them to show that, possibly, by 2030, 90 per cent of us
will be watching the television for 22 hours a day while
smoking home grown skunk.

Then we have stats as a marketing tool. ‘Eight out of ten cats
prefer…’, ‘Visible wrinkles reduced by 25 per cent’, and so
forth. Any one who has a cat and /or wrinkles (I have both)
will know that cats are always a law unto themselves and if
they have a mind to turn up their noses at fresh salmon and
go and chew on a dead mouse instead, they will do so. As for
wrinkles, well you stand as much chance of stopping them
with face cream as King Canute did commanding the tide to
halt.

Which of these is the use to which our NDTMs statistics are put?

As service providers, we are set goals. I have no problem
with that. I want clients not to have to wait for appointments.
I want clients to engage and attend long enough to achieve
their goals. I want them to be discharged for positive reasons.
My work matters to me. My clients matter to me and I want to
offer them the best and most effective service I can.

So am I totally in tune with our local DAAT and the NTA?
No, because I am expected to achieve unattainable goals (100
per cent positive discharges – how is that ever going to
happen?). But more than this I am expected to provide the
statistics required, not by improving and developing the
service, but by what can best be described as ‘constructive
accounting’. I have become a ‘spin doctor’.

Perhaps I am going a bit mad at this time of the month but
I have a strange and rather wonderful dream. My dream is
that the role of the regional DAATs and DATs would be to
develop and support services. My dream is that the NTA
would use statistics not to show 8 out of 10 clients prefer
Models of Care so as to sell their product, but to collect good
quality, accurate information that would open debate and
contribute towards identifying how we can achieve
challenging goals. I mean achieve them by making changes to
services, not by learning how to give the right answer.

At school I learnt a couple of things about cheating. One
was that anyone who got 100 per cent in an exam was always
suspect, because people don’t. The other thing was about
getting the right answer in the wrong way. As I struggled with
maths I would sometimes try, when I got to the end of a
problem, adding another line of fake working out. In this way I
would turn my wrong answer of say, 8, to the right answer of
10 (taken from the answers at the back of the book) by
slipping in the line 8+2=10. It rarely worked. It could work with
teachers who were lazy markers but of course it never helped
me to work out how to get 10. What I did learn eventually,
from a better teacher, was that understanding the working
out, even if you go a bit wrong with the numbers, is a better
way to develop an understanding of maths.

Who is doing the ‘working out’ with drug and alcohol
treatment services?

We are under constant threat. I have to make 8=10 because
if I don’t, I will lose my job. My colleague is delighted at his 33
per cent drug users group because he has been told that
alcohol users ‘don’t count’.We have a regional Drug and
Alcohol Action Team but we are being threatened with
decommissioning – not because we don’t have enough clients
(we all have full case loads) but because about two thirds of
them are people with alcohol problems.Why are there more
alcohol clients? I would enjoy a meaningful discussion with
our commissioners about this, but meaningful discussions
don’t seem to be wanted, only statistics. Where does the
Alcohol Harm Reduction Strategy for England (AHRSE) fit into
this? I think Jim Royle of the Royle Family would be able to
answer that.

I have been in this business long enough to remember the
days when we provided few statistics, collected funding from
a hotchpotch of charities and grants, had sparse records and
muddled through in a way that would cause any DAAT
commissioner to spontaneously combust. (Now there’s a thought).

Despite the wrinkles and the cat, I don’t want to go back to
the good old days because I know that we often worked in a
risky way. The thing was that disasters didn’t happen and
many clients did engage and did make positive changes,
because we provided ‘an opportunity for the service user to work
towards living in a way he or she experiences as more satisfying or
resourceful’. Sometimes that happened in a week or two,
sometimes in a year or two. Sometimes it involved detailed
care plans sometimes not. Sometimes it was tier two work,
sometimes tier three, but mostly a bit of both. What we did
was that we tried to provide what the client needed, not try to
make the client fit what the service needs them to be and do.
We could have provided a much better service then and we
could provide a much better service now, but how can we get
there?

If you want to find the quote above in italics look in Models
of Care. It is the definition of counselling provided by the
British Association for Counselling and Psychotherapy, used in
Models of Care in the description of tier three, one to one work.
I am not a maverick. I do look at Models of Care. There is a lot
of thoughtful, well-researched information and guidance in
there. However, I feel I am swimming against the tide.

That ‘time of the month’ feeling is spreading and the ad in
our local paper for a trainee estate agent at a salary much the
same as mine looks very attractive. When are we going to be
able to be honest about what we do, varied and unpredictable
as its outcomes might be? Until we can we are going to carry
on ticking boxes with one eye on our expiring contracts and
struggling to find the energy to do the jobs we trained for,
with the clients we want to help.