It is widely acknowledged that some communities are underserved by substance and mental health services; however the scale of the problem remains a persistent data blindspot. The Government’s annual Substance Misuse Treatment Statistics Report, informed by the National Drug Treatment Monitoring System (NDTMS), doesn’t collect data on ethnic identity. The emergence of specialist treatment services for people who are Black, Asian, or from another minority ethnic group, such as Kikit and the Shanti Project indicates that mainstream services need to do more to meet the needs of different communities. Though there is no official data on who is not accessing services, or their ethnicity, the clues are there: in 2019-20 almost half the people in treatment for alcohol, and over half of those in treatment for crack and opiate use were living in areas ranked in the 30% most deprived areas. Most minority groups are much more likely than people in the ‘white British’ ethnic grouping to live in the most deprived areas in the UK (Gov.UK ‘People Living in Deprived Neighbourhoods’, 2020) There is no reason to believe that people from ethnic minority groups would be immune to the conditions that produce a higher prevalence of substance related harm in deprived communities, and so it is likely that mainstream substance use and family support services are missing some of the most vulnerable groups in our community.
The Covid 19 pandemic has compounded existing inequalities. ONS data shows that marginalised communities and black and mixed ethnicity people have borne the brunt of economic and physical harm during the pandemic. This is not a result of genetic predisposition but of systemic failures. As service provision and support systems are adapted to meet the needs of a nation in lockdown, practitioners up and down the country are determined to prioritise inclusivity now and ensure that it is built into post lockdown services. Adfam’s National Forum on inclusion in November 2020 saw practitioners work together to identify barriers to inclusion, as well as the changes needed at service and policy levels to help the substance use sector meet the needs of the UK’s diverse population.
The stigmatisation of drug and alcohol problems is ubiquitous in the UK, though the manifestation of stigma may differ between communities. Underrepresentation of minority groups in services for substance users and family members has often been attributed to the cultural barriers that prevent people from seeking help for themselves, or for a loved one. Cultural barriers are not erected by minority groups, neither is it their responsibility to dismantle them. It is service providers who have a duty to reach underserved communities, and this involves first identifying the factors that make some communities reluctant to self-refer to mainstream services. One practitioner attending the Adfam forum identified the fact that behavioural codes in the Traveller and Roma community can lead to families bearing substance related hardship up until the point of crisis or prohibit unsupervised contact between service users and practitioners of different genders. For communities in which alcohol, drug consumption and gambling are prohibited, social stigma is especially hard to escape. Moreover, language barriers aren’t always effectively overcome by translators, as language that may have sprung up in English speaking clinical mental health settings may not find a direct translation in some languages.
These barriers are significant, but they are not insurmountable, given the right circumstances. Unfortunately, wider social circumstances are largely pitted against greater inclusivity in services.
Many families are reluctant to engage with drug and alcohol services as they fear that service interaction could result in the removal of children by social services. The practitioners at our forum felt that the marginalisation of some communities exacerbated these fears. Refugees and asylum seekers are concerned that data collected by support services will be shared with the Home Office, jeopardising their right to stay in the UK. Asylum seekers with the most acute needs are often those who’s asylum has been rejected, leaving them without recourse to public funds. This contributes to the belief, common in marginalised communities, that substance use and family support services require payment at the point of use.
In light of social distancing measures, many services have adapted their practice to include online support. But digital services require access to phones, computers and an internet connection, and currently only 51% of households earning between £6000-10,000 had access to the internet at home, and 22% of the UK’s population lack the requisite digital skills to access online services (University of Cambridge, ‘Coronavirus Has Intensified the Digital Divide’ 2020). Stretched funding for services means that efforts to increase inclusion are often not integrated into a practitioner’s core workload, and 1 to 1 services are becoming too expensive for many services to run. On top of all of this, whatever community connections services manage to establish are undermined by common commissioning practices in which contracts are re-tendered every three years. In the face of such widespread structural barriers to access, an emphasis on ‘cultural differences’ is misleading. Pathways to inclusion must be cleared at every level of system design, from frontline service provision to commissioning practices and political initiatives to reduce racial inequality.
Adfam’s forum attendees shared some of the strategies they employ to promote inclusivity in their services. Their insights broadly fell into three categories relating to communication, forming community partnerships and dismantling physical barriers to support.
In Ealing, London, Change Grow Live employ a Punjabi speaking social worker, and they are in the process of setting up a Punjabi peer support group. In Norfolk and Suffolk, the NHS Foundation Trust is doing what it can to dispel fears held in the Traveller community around forced vaccinations or children being taken into care. This involves supporting their practitioners to become recognised and trusted figures within the community. Most of the services Adfam spoke to have found that working in partnership with pre-existing community figures and services can really help to gain access to marginalised communities where self and family referral rates are low.
Practitioners from Project 6, a drug and alcohol support charity operating in Yorkshire, are forging community connections by attending Punjabi and Bangladeshi community groups, which is helping to build trusting relationships that lead back to Project 6 services. Project 6 are adapting their services to become more flexible: practitioners are meeting service users in private homes and religious buildings, to circumvent the possible stigma associated with entering substance use services. Their practitioners are also working with Imams to illuminate the hidden harms associated with problematic substance use. Similarly, The White Ribbon Association working in the West Midlands have begun to reach out to interfaith groups, and they are now working in partnership with young carers services. GamCare is working with local services for transgender women, who have previously been underrepresented in gambling support settings. All those attending the Adfam forum testified to the immense value of practitioner networking in forging important access links.
GamCare and White Ribbon have been exploring how venues can impact inclusivity. GamCare has partnered with high street banks to provide meeting spaces in bank buildings, which helps to maintain service anonymity. Similarly, White Ribbon is working with businesses who provide them with meeting spaces, allowing service users to access support without having to enter substance specific services. Sometimes, the barriers to access can be as straightforward as not having internet access. Change Grow Live has circumvented this problem by providing service users with a £10 a month sim card allowing them to access online services.
Collaborative practices on the frontline are most effective if backed up by wider social and political initiatives to promote inclusion. This involves substantial shifts in policy. Without universal broadband and sim-internet access, or the extension of recourse to public funds to people seeking asylum, service level efforts to overcome digital and legal exclusion will be undermined. Services can’t change long-held attitudes alone. Support from trusted media sources and government bodies is needed to communicate to all service users in all communities that Social Services do not aim to take children away from families. This is a grave concern across most marginalised communities, and reassurances must come from external, trusted sources. Service users need to know exactly how their data is being used. An effort to improve data confidence in service users will require society-wide collaboration, from improvement in the regulation and transparency of government data use, to digital literacy programmes.
We may also need to see changes in the kind of data we collect. As Alcohol Change UK has pointed out in their 2019 Rapid Evidence Review on Drinking Problems and intervention in black and minority ethnic communities: ‘Clearer definitions of what is meant by ‘minority ethnicities’ and an understanding of variations within and across communities are needed. Some groups are largely missing from the research literature on alcohol support needs and experiences.’ Perhaps as a result of these data blind spots, the 2017 drug strategy doesn’t prioritise minority groups, though it does prioritise groups determined by other characteristics. Efforts are being made to diversify clinical research and practice, and there is no reason why these efforts shouldn’t be reflected in non-clinical settings. Identifying and filling gaps in data can help us to understand the factors that prevent inclusion, so long as our inquiries don’t overestimate the importance of ‘cultural differences’, and underestimate the effects of structural inequality. For example, we know that BME men are underrepresented in substance services, and we also know that a black person arrested for drug offenses is 1.4 times as likely to receive an immediate custodial sentence than a white person arrested for a comparable offense (The Guardian ‘BAME offenders “far more likely than others” to be jailed for drug offences’ 2020). The circumstances surrounding engagement with drug and alcohol services are, for many, shaped by institutional racism.
As one practitioner working with members of the Punjabi community pointed out, a major benefit of community specific services is that members can address the issues they need to address without having first to explain their culturally specific context. The more practitioners share insights and practices with one another, the less service users will have to fill in the gaps themselves. Communication between practitioners and cross-sectoral collaboration will be the driving force behind inclusivity. To ensure that hitherto marginalised communities are front and centre in drug, alcohol and gambling services, practitioners will have to work together to promote equality within and without our service doors.