9. Alcohol assertive outreach and a multi-agency team around the person
Source: gov.uk (2025-11-28)

How alcohol assertive outreach can engage and support vulnerable people with alcohol dependence who experience multiple disadvantage. This includes co-ordinating care through multi-agency teams to address complex needs and reduce health inequalities.

9.1 Main points

Assertive outreach involves a service making proactive and persistent attempts to contact a person and build a relationship with them, using a trauma-informed approach.

Assertive outreach removes some of the barriers to treatment by bringing the service to the person in settings where they feel comfortable and that they can access easily.

Commissioners and services developing assertive outreach should identify vulnerable people in their local area with alcohol dependence with high levels of need and risk and agree referral pathways into the outreach service with partner agencies. Very vulnerable people with problem alcohol use who experience multiple disadvantage are often known to several local services. They may have repeated contacts with acute and emergency services but are often not engaged in planned treatment. They are also unlikely to engage with alcohol treatment services without targeted support.

Vulnerable people with problem alcohol use who experience multiple disadvantage need integrated care that addresses their various needs in a co-ordinated way.

Assertive outreach combined with a multi-agency team around the person are ways to engage and provide care tailored to the needs of vulnerable people with problem alcohol use who experience multiple disadvantage.

This approach can also be used to engage and provide care for specific groups of people with high levels of need who are unable or unlikely to attend a service base, including:
- people who attend hospital frequently for alcohol related conditions
- people with severe alcohol related illness
- groups of people who experience marginalisation and have very poor health outcomes, such gypsies, Roma and travellers
A multi-agency team around the person involves agencies working together to share information and co-ordinate integrated care for vulnerable people with high levels of complex need. You can read more about what a multi-agency team around the person means in section 9.7.

Many local areas co-ordinate care and manage risks for vulnerable people (including those with alcohol dependence or who drink harmfully) through multi-agency forums that meet regularly.

A multi-agency team around the person should provide joint assessment and management of risk and share information based on agreed information sharing arrangements.

Assertive outreach practitioners and services should tailor interventions to the needs of vulnerable people with alcohol dependence who experience multiple disadvantage. They can do this using a harm reduction approach if the person is not ready to change their alcohol use.

9.2 Introduction

This chapter offers guidance on providing alcohol assertive outreach as part of a multi-agency team to support vulnerable people with problem alcohol use and high levels of unmet need and reduce the health inequalities they experience.

An assertive outreach approach is a way of working where practitioners offer support and deliver interventions wherever it is most appropriate, rather than asking a person to engage with treatment in a particular service or place. After a person has been referred to the assertive outreach service, practitioners make proactive and persistent (‘assertive’) attempts to contact them to help them to engage with support (see section 9.6).

A multi-agency team around the person is a way of working that involves services and organisations working together to share information and co-ordinate integrated care for vulnerable people with high levels of complex need (see section 9.7).

You should read this chapter with chapter 21 on people experiencing homelessness, which provides more extensive guidance on providing appropriate care for that group of people.

9.3 Evidence

There is evidence from a systematic review that assertive outreach for people with severe mental illness is effective (Dieterich and others, 2010).

There is also evidence that a combination of assertive outreach and a multi-agency team around the person can be effective in helping vulnerable people with alcohol dependence with harmful patterns of drinking achieve a range of positive outcomes. This evidence includes:
- a limited number of peer reviewed studies
- large scale programme evaluations
- small scale service evaluations
The studies identify positive outcomes (Drummond and others, 2017; CFE Research and the University of Sheffield, 2022; Bailey and others, 2020; Mohan and others 2022). These include:
- an increase in treatment engagement
- reduced alcohol use
- increased wellbeing
- reduced emergency service use
- fewer hospital admissions
9.4 Who assertive outreach and a team around the person can support

An assertive outreach approach combined with a multi-agency team around the person can help very vulnerable people with problem alcohol use who experience multiple disadvantage or have particularly high levels of unmet need.

In these guidelines, multiple disadvantage is defined as the co-occurrence and interaction of adverse circumstances leading to social exclusion, marginalisation and extreme inequality.

Complex, intersecting issues that can contribute to compounded disadvantage include:
- health inequalities
- poverty
- housing instability
- systemic discrimination
- family and individual history, including adverse (traumatic) childhood experiences
As well as problem alcohol use, people can experience a range of other problems, for example:
- other substance use
- mental or physical health conditions
- domestic abuse
- sexual exploitation and violence
- interaction with the criminal justice system
An approach that combines alcohol assertive outreach and a multi-agency team around the person supports people who:
- experience alcohol dependence or harmful drinking
- have very high levels of unmet need (physical and mental health, social care, safeguarding, or housing and material resources)
- have not engaged or have not benefited from alcohol treatment services
- may be at a high level of risk or pose risk to others
- lack or may lack mental capacity to make the ‘decision in question’ (see glossary), or need support to make decisions about their care
In each local area there will be a relatively low number of very vulnerable people with alcohol dependence who experience multiple disadvantage and are not engaged in ongoing treatment and support but may be known to acute and emergency services. Numbers of people will vary across regions and local areas, and are likely to be higher in areas with high levels of deprivation.

Based on local need, commissioners and services can use assertive outreach to engage local groups of people who experience marginalisation and poor health outcomes and who are underrepresented in alcohol treatment services. Groups can include, for example, sex workers, vulnerable migrants, or gypsies, Roma and travellers.

Local areas can focus on people living in areas of socioeconomic deprivation who experience health inequalities. For example, the Primary Care Alcohol Nurse Outreach Service targets people in selected GP practices that serve the 100 most deprived communities across Scotland.

Hospital based assertive outreach teams can target people who attend hospital frequently for alcohol related reasons. Community teams with medical or nursing staff can also target people with severe alcohol related health conditions, particularly alcohol related liver disease, who are too unwell to access the treatment service easily.

9.5 Developing targeted referral pathways

Commissioners and services need to identify vulnerable people experiencing multiple disadvantage with high levels of need, who are not engaging in alcohol treatment services. They should then develop targeted referral pathways into the assertive outreach service in agreement with partner agencies.

Identifying people who might benefit from assertive outreach and agreeing referral pathways will often involve emergency and acute services or the police and community safety services. This group of people is more likely to have contact with acute and emergency services than planned care. Other relevant services include:
- services for people experiencing homelessness
- primary care
- community mental health services
- criminal justice services
- services for domestic abuse or sexual violence or exploitation
- third sector community services and organisations for particular groups of people
- peer support services and organisations
Some areas have established multi-agency forums for managing care for vulnerable people with alcohol dependence or other groups of people with high levels of risk. They can use these forums to identify people who are known to member agencies but not in contact with alcohol treatment services (see section 9.7.2 on setting up multi-agency forums).

There is also evidence to suggest that community alcohol treatment services can identify people who may currently benefit from assertive outreach by looking at people with previous unsuccessful alcohol treatment episodes (Passetti and others, 2008).

You can find guidance on developing targeted pathways for groups of people who are under-represented in services in chapter 25 on developing inclusive services.

9.6 Assertive outreach

9.6.1 Making it easier to access treatment

Vulnerable people experiencing multiple disadvantage or very high levels of need often find it extremely difficult to access or remain in treatment. For example, they might fear treatment services based on previous negative experiences or have difficulty forming trusting relationships because of past trauma. They might also experience barriers that are service-related, such as stigmatising services with inflexible opening times or procedures for missed appointments.

An assertive outreach approach helps to remove these barriers by meeting people in settings that are familiar to them. This could be at their home, in a community venue or in services they already attend, such as services for people experiencing homelessness.

9.6.2 How assertive outreach works

After a person has been referred to the assertive outreach service, practitioners make proactive and persistent (‘assertive’) attempts to contact them to help them to engage with support. With the person’s consent, practitioners can contact the person at least once a week And they should continue to make supportive contact even if the person does not attend agreed meetings.

Practitioners should be flexible in the way they make contact and communicate about appointments. They can use whatever method the person prefers, including text, phone, email, letter and in-person visits, in a setting the person finds comfortable. In-person meetings are important to build a therapeutic relationship, but practitioners can use other methods to make initial contact and to support in-person meetings. Services can also support engagement in practical ways, such as providing transport costs or phone data.

Large scale service evaluations and qualitive research show that a supportive relationship between the assertive outreach practitioner and the person is central to this approach (CFE Research and others, 2021; Ward and Holmes, 2016). Hard Edges: mapping severe and multiple disadvantage in England (https://lankellychase.org.uk/publication/hard-edges/) found many people experiencing multiple disadvantage have experienced trauma as children. This often means that as adults they find it difficult to form trusting relationships. It is important that practitioners take an empathic, trauma-informed approach and focus on developing a relationship with the person at the person’s pace, which is likely to take some months, and in some cases, years.

You can read more about using a trauma-informed approach in the Office for Health Improvement and Disparities Working definition of trauma-informed practice (https://www.gov.uk/government/publications/working-definition-of-trauma-informed-practice) (for England) and A roadmap for creating trauma-informed and responsive change: guidance for organisations, systems and workforces in Scotland (https://www.traumatransformation.scot/implementation/).

9.6.3 Role of assertive outreach practitioners

The role of the assertive outreach practitioner providing in-person support is central to the assertive outreach approach, but they do not work alone. The practitioner should always be part of a multidisciplinary team or supervised by a member of a multidisciplinary team. Examples include a multidisciplinary team:
- in the alcohol treatment service
- in another relevant service, like a homelessness service, a hospital ‘frequent attenders’ service or a primary care nurse outreach service
- working specifically with people with multiple disadvantage or with specific groups of people experiencing marginalisation
Assertive outreach practitioners should also be working in a co-ordinated way with other services and systems in contact with the person, through the multi-agency team around the person.

9.6.4 Aims of assertive outreach

The aims of assertive outreach are to:
- engage people who experience barriers to accessing or completing treatment
- support the person’s motivation to make changes in their alcohol use and other areas of their life
- encourage the person’s belief in their ability to change
- reduce harm and manage risk
- support people to build on strengths and protective factors in their lives, including reconnecting with family members where appropriate
- tailor components of care and specific interventions to meet the person’s needs
- help people to access other services they need
- co-ordinate care and contribute to a co-ordinated multi-agency approach
- work with family members or friends where appropriate and with the person’s consent
- support people to access peer support
- prepare people for structured treatment and recovery where appropriate
9.6.5 Different models of assertive outreach

There are different models of alcohol assertive outreach. For example, it could be provided by:
- a community alcohol treatment service
- a hospital alcohol care team or hospital ‘frequent attenders’ service
- a multidisciplinary homeless health service that includes specialist alcohol treatment practitioners
- a primary care nurse outreach service
- an outreach service for people experiencing multiple disadvantage that includes specialist alcohol treatment practitioners
These services may be public or third sector services and some include peer led or peer-delivered outreach interventions.

This chapter does not consider specific models but provides guidance relevant to most alcohol assertive outreach services, which have several components in common.

9.6.6 Essential components of alcohol assertive outreach

A national survey of alcohol assertive outreach teams proposes the following 6 essential components of alcohol assertive outreach (Fincham-Campbell and others, 2018):
- a maximum caseload of between 10 and 20 patients per practitioner
- input from a multidisciplinary team in form of input from at least 3 different professions including nurses, medical and psychology or community support and drug workers
- regular contact between patient and practitioner (at least once a week)
- at least 50% of contacts occurring outside of the service settings, either in patients’ homes or local community settings
- a focus on both health and social care needs, including accommodation, finance, leisure, occupation, and physical and mental health
- extended care provided for a prolonged period of 12 months
Programme evaluations of projects working with people experiencing multiple disadvantage have identified that caseloads as low as 6 to 10 may be needed when working with people who experience the most severe and multiple disadvantage (CFE Research and others, 2021). Practitioners may need to contact people mostly in their homes or in the community (at least 50% of the time as noted above) for a prolonged period of time (Drummond and others, 2017).

9.7 A multi-agency team around the person

9.7.1 What a multi-agency team around the person does

Vulnerable people with problem alcohol who experience multiple disadvantage and have high levels of need are usually known to local services, but they are often not engaged in ongoing treatment and support. They are more likely to use acute or emergency services than planned health and social care. And where they are engaged with acute and emergency services, these may be only responding to one of their problems.

Vulnerable people with problem alcohol use who experience multiple disadvantage need co-ordinated and integrated care that addresses all their needs and risks. Section 21.4 in chapter 21 on people experiencing homelessness provides more guidance on integrated care (for people experiencing homelessness, but also relevant to other vulnerable people). Developing and maintaining a multi-agency team around the person is a way of providing integrated care for vulnerable people with high levels of need and risk.

A multi-agency team around the person:
- shares and records information about the person between services based on local information sharing agreements
- jointly assesses the person’s needs and risks
- co-ordinates and jointly plans the management of the person’s care and involves the person wherever possible in the planning
- co-ordinates and jointly manages risks to the person or risks they pose to others and involves the person in risk management (safety) planning wherever possible
- agrees who is the main care co-ordinator for the person
- allocates and reviews tasks to member agencies and reviews progress
- meets regularly to jointly review the person’s care
- co-ordinates, so the person can access all the care they need from the minimum number of services possible
9.7.2 Setting up multi-agency forums

A multi-agency team around the person that carries out the functions listed above can be organised in different structures.

Commissioners and service providers can work together across local systems to set up multi-agency forums that can receive referrals and co-ordinate integrated care for the most vulnerable people with problem alcohol use and high levels of unmet need. Involving clinical and strategic leadership is important to maximise the effectiveness of multi-agency forums.

Multi-agency forums bring together services that come into contact with this group of people and meet regularly to co-ordinate care for each person referred to the forum. The forums share information and professional expertise. Forum member services that are relevant to each person’s needs will form a team around the person and agree a co-ordinator for the team. They will then work together to provide care for the person outside of the regular meetings of the forum and report back to the forum regularly.

Multi-agency forums regularly review care for individuals so they will identify problems with pathways between services. They will also identify policies and procedures that make it difficult for vulnerable people with problem alcohol use and high levels of need to access appropriate care. Forum members can then work together to remove some of these barriers.

Local areas may choose to establish multi-agency forums that are solely for integrating care for vulnerable people with problem alcohol use and high needs and risks. An example of this is the Blue Light model designed by Alcohol Change UK (https://alcoholchange.org.uk/help-and-support/training/for-practitioners/blue-light-training/the-blue-light-project).

Some local areas may have established multi-agency forums to co-ordinate care for vulnerable adults. This might be, for example, a multi-agency adult safeguarding hub or forum to co-ordinate care for people experiencing multiple disadvantage. An example of the latter are forums established by some of the Fulfilling Lives project partnerships (CFE Research and others, 2021) and the Changing Futures partnerships, outlined in the Ministry of Housing, Communities and Local Government’s Evaluation of the Changing Futures programme (https://www.gov.uk/government/publications/evaluation-of-the-changing-futures-programme).

Commissioners of alcohol treatment services can propose that these types of forums include referrals and multi-agency care co-ordination for vulnerable people with problem alcohol use and high levels of need and risks.

In areas with no appropriate multi-agency forum, services in contact with very vulnerable people with high needs and high risks should have an alternative system in place. This is so the practitioner who is co-ordinating care can quickly arrange a multi-agency risk management meeting about a particular person. Services should then agree ongoing joint working arrangements that include regular multi-agency review meetings.

Various things need to be made clear when setting up a multi-agency forum, including:
- terms of reference
- membership
- referral procedures
- task allocation
- procedures for members to report information to the forum
- information sharing agreements
- escalation process if disagreements among members cannot be resolved
9.7.3 Information sharing

Information sharing is crucial to co-ordinating care and managing risk for vulnerable people with problem alcohol use experiencing multiple disadvantage. They may only have sporadic contact with several agencies and without effective information sharing, each agency might be unaware of information that another agency is holding. An analysis of adult safeguarding reviews (https://www.local.gov.uk/publications/analysis-safeguarding-adult-reviews-april-2017-march-2019) has shown that lack of information sharing is often a factor when serious incidents occur.

There should be formal information sharing agreements and mechanisms between all organisations involved in the multi-agency forum and with any organisation the person is referred to. The agreement should make clear how information will be shared at regular reviews and between regular reviews if the person’s situation or risks change. Where possible, it is helpful for partner agencies to have access to a shared electronic case record.

9.8 Care for vulnerable people experiencing multiple disadvantage

9.8.1 Overview

Alcohol services and assertive outreach practitioners should offer the same components of care that the service offers to people attending standard community alcohol treatment. But they will need to do this in a way and at a pace that is tailored to the complex needs of vulnerable people experiencing multiple disadvantage or with very high levels of need. They will need to be flexible in their approach so they can engage people effectively in support and treatment.

The following sections give some examples of tailoring care to meet the individual needs of very vulnerable people experiencing multiple disadvantage.

9.8.2 Assessing the person’s needs

The assertive outreach practitioner should aim to follow the guidance in chapter 4 on specialist assessment but will need to work very flexibly to carry out the assessment, using an informal approach.

Assertive outreach practitioners (or designated lead professional if this is someone else) should gather information from other agencies in the multi-agency team around the person as part of a joint assessment of need and risk to provide a comprehensive picture. Wherever possible, they should do this with the person’s consent. But in some situations where the person is at risk or poses risks to others, they can share information without the person’s consent.

Gathering information from partner agencies can help to reduce the number of questions about sensitive personal issues that the practitioner needs to ask the person when they first meet. This can help to reduce stress for the person.

The assertive outreach practitioner should:
- carry out the assessment in an informal and conversational way
- keep paperwork to a minimum during the appointment (although they should record their notes after the meeting)
- tailor the duration of each appointment to the needs of the person and not expect the person to engage for a full hour if this is difficult for them
Once they have gathered information on urgent needs and risks, the practitioner may need to carry out the rest of the assessment very gradually and informally over several meetings. This will allow time to build trust and help the person to feel safe before discussing sensitive personal issues.

It is important that the practitioner shows they believe in the person’s ability to make changes from the beginning and throughout their contact.

9.8.3 Assessing and managing risk

While tailoring their approach to the person, the assertive outreach practitioner should aim to follow guidance in chapter 4 on assessment and treatment and recovery planning in:
- section 4.8 on initial assessment of risks and urgent treatment or support needs
- section 4.10.4 on multidisciplinary and multi-agency treatment and recovery plans
Very vulnerable people with problem alcohol use experiencing multiple disadvantage often pose high levels of risk to themselves and sometimes pose high levels of risk to others. This means assessing and managing risk is vital. One of the main functions of the team around the person is to carry out a multi-agency risk assessment and agree a multi-agency risk management (safety) plan, involving the person in this process wherever possible. Where appropriate they should also involve family members who can offer an additional perspective and information. Services should inform partner agencies whenever there is a change in risk, in line with their local information sharing agreement and they should review the risk management plan regularly.

9.8.4 Understanding and using adult safeguarding and legislative frameworks

Assertive outreach practitioners working with vulnerable people experiencing multiple disadvantage should understand and act in line with the relevant national legal frameworks.

Practitioners should follow their organisational procedures on:
- adult safeguarding
- child safeguarding
- mental capacity
- mental health
- domestic abuse
All of these can often apply with this group of people. There is information on these frameworks in annex 1 on legislation and guidance across the UK.

Information sharing is vital where there are risks to the person or to others. While it is good practice to ask for the person’s consent to share information, practitioners can share information without consent in certain cases where:
- there are adult or child safeguarding concerns
- the person lacks mental capacity to make decisions about information sharing
- the person is in a mental health crisis and is at risk or posing risk to others
Services should have organisational procedures for managing these situations, including procedures for sharing information without consent.

9.8.5 A harm reduction approach

Taking a harm reduction approach

The alcohol practitioner and the person should consider setting alcohol use goals as part of the person’s treatment and recovery plan (sometimes called support plan). This should be based on a comprehensive multidisciplinary assessment and tailored to the person’s current situation.

A harm reduction approach will often be appropriate for very vulnerable people with problem alcohol use and experiencing multiple disadvantage who may not be ready to make changes in their alcohol use.

You can read guidance on alcohol use goals, including a harm reduction strategy, in section 4.7 in chapter 4 on assessment and treatment and recovery planning.

A harm reduction approach aims to reduce immediate and longer-term harms, risks and health inequalities that the person is experiencing. It involves actions to address a person’s:
- physical health
- mental health
- social care needs, including housing needs
The person may not be ready to reduce or stop their alcohol use initially, but meeting these needs is a positive outcome. This can encourage the person and increase their motivation to engage in alcohol treatment at a later stage.

You should read chapter 8 on a harm reduction approach for people with alcohol dependence.

Making changes in alcohol use

A focus on reducing harms may be the most useful way to work with a vulnerable person experiencing severe multiple disadvantage. But practitioners should never assume that the person is unable to make significant reductions in their alcohol use or achieve abstinence. Practitioners should regularly review a person’s goals with this in mind and adjust the goals as appropriate.

Some people may not opt for a medically assisted withdrawal but may want to make a limited reduction in their alcohol use. If the person is (or may be) alcohol dependent and they want to make a limited reduction in their alcohol use, a clinician should assess the person to assess the risks of serious complications in withdrawal. They should also advise on an appropriate plan before the person is encouraged to reduce. You should follow the detailed guidance on this in chapter 8 on:
- assessing the suitability and safety of a gradual reduction in alcohol use (section 8.5)
- supporting people with different severity of dependence levels (section 8.6)
Where the person continues to drink at harmful or dependent levels, the service should regularly review their health and take action to address any deterioration.

9.8.6 Linking people to other services

Linking people to relevant services and helping them to navigate complicated systems is often a vital part of the role of an assertive outreach practitioner.

Practitioners should be aware of local support pathways and, where relevant, assertively link the person to:
- primary and secondary healthcare services, including mental health
- social care
- the criminal justice system
- housing support
- domestic abuse services
- peer support services and mutual aid
- local community organisations
Assertively linking the person to these other services means that the practitioner:
- provides the person with information on the service tailored to their individual needs
- helps the person to talk through their anxieties
- helps the person to complete any forms required by services, or completes the forms on their behalf
- helps the person to make an appointment or makes the appointment for them
- introduces the person to the professional they will see by phone or in person
- sends text or phone reminders
- accompanies the person to the appointment
- arranges with a peer to accompany the person to the appointment where possible
- provides transport tickets where needed
Practitioners may need to advocate for the person, providing the other services with information on what might help the person to engage. They may also need to ask the services for some flexibility, for example around referral criteria or missed appointments.

9.8.7 Supporting the person over time

Vulnerable people experiencing multiple disadvantage will usually need to be in contact with alcohol treatment services for longer than average and may be in contact for more than a year.

Wherever possible, they should have a continuous relationship with one keyworker (usually the assertive outreach practitioner) to help with building a trusting relationship.

Transitions (significant changes in the person’s circumstances) are often stressful and associated with an increased risk that vulnerable people return to harmful behaviours, including more harmful alcohol use. This can be the case even if there is a positive transition, like moving into stable accommodation or leaving prison. The multi-agency team around the person should consider increasing support at times of transition. A consistent keyworker who the person trusts can help the person manage the stress involved with transitions.

Well before the assertive outreach relationship ends, practitioners should gradually introduce people to other services to help them build a support network. These might include peer support services and organisations and mutual aid.

There is guidance on facilitating access to mutual aid and peer support in section 5.5.4 in chapter 5 on psychosocial interventions.

There may be other recovery support services that are relevant for the person. There is guidance on recovery support services in chapter 6.

9.8.8 Supporting the person to engage with structured alcohol treatment

If the person’s motivation increases, the assertive outreach practitioner can help prepare them for structured treatment and accompany them to the service base.

If the person is already attending a peer support organisation, a peer could accompany them to the service. Or the assertive outreach practitioner could introduce the person to a peer supporter who had joined the treatment service after initially engaging with an assertive outreach practitioner. That peer supporter can then share their experience of the process.

Services may need to make small changes to their procedures to become accessible to vulnerable people with multiple disadvantage. This might include allowing for more missed appointments and longer periods of engagement. They will also need to allow for staff time to contribute to meetings of the multi-agency team around the person.

Assertive outreach can continue while the person engages with the treatment service to help the person make the transition to structured treatment at the service base. For example, the assertive outreach practitioner might schedule some meetings with the person away from the service base and some at the service base for a period to support their transition. It is important that the person has adequate support during this time.

9.9 Staff competencies and governance

9.9.1 Staff competencies

Assertive outreach and multi-agency working is highly skilled work and practitioners need to have a range of advanced competencies and specialist knowledge.

You can find information on staff competencies in manuals and programme evaluations in the resources section at the end of the chapter.

Important skills that practitioners should have include:
- building and maintaining relationships with very vulnerable people
- communicating with vulnerable people and with professionals
- trauma-informed practice
- assessment of vulnerable people
- risk assessment and risk management
- advocacy
- multi-agency working
- using a friendly, informal approach while maintaining professional boundaries
- crisis management and conflict resolution
- management of challenging behaviour
- resilience under pressure
Important knowledge that practitioners should have for assertive outreach includes:
- alcohol dependence and associated health harms
- flexible engagement processes
- harm reduction approaches and information
- strengths based approaches
- evidence-based alcohol interventions
- mental health conditions
- the impact of trauma
- adult safeguarding legislation and procedures
- mental capacity and mental health legislation and procedures
9.9.2 Staff support and governance

Assertive outreach practitioners should receive regular input from a multidisciplinary team, including medical, nursing and alcohol and drug treatment specialists.

There should be clear lines of accountability in their organisation for:
- reporting and escalating risks and clinical concerns
- regular clinical supervision
- training
Caseloads for assertive outreach need to be much smaller than the average caseload in alcohol services. This is because people experiencing multiple disadvantage who are not engaged with services usually have high levels of need and risk and require more intensive interventions. Caseload size will depend on how the caseload is made up but can range between a maximum of 6 and 20 (see section 9.6.6 for more information).

Risks can be higher when staff are working away from the service base. This means services should have comprehensive policies and procedures for assessing and managing risks to staff.

Services should provide appropriate support to outreach staff to help them manage the impact of their work on their wellbeing. Outreach staff are normally working closely with people with the highest levels of need, who can be in distressing circumstances. People on their caseload experience high risks and are often more likely to die than people in the general service, so support and supervision for these staff are essential.

9.10 Resources

9.10.1 Alcohol Change UK

Alcohol Change UK ‘s Blue Light Project (https://alcoholchange.org.uk/help-and-support/training/for-practitioners/blue-light-training/the-blue-light-project) develops alternative approaches and pathways for people with problem alcohol use who are not in contact with treatment services but have complex needs. Resources include a manual and evaluations of services using a Blue Light model.

Alcohol Change UK has also published a manual on assertive outreach (https://alcoholchange.org.uk/publication/alcohol-assertive-outreach-a-handbook).

9.10.2 Changing Futures (and Fulfilling Lives) programme

Changing Futures (https://www.tnlcommunityfund.org.uk/funding/funding-programmes/changing-futures) is a £91.8 million initiative between the UK government and the National Lottery Community Fund. It seeks to test innovative approaches to improving outcomes for people experiencing multiple disadvantage, including:
- homelessness
- drug and alcohol problems
- mental ill health
- domestic abuse
- contact with the criminal justice system
The funding builds on the Fulfilling Lives programme. It is running in 15 areas, covering 34 council areas across England from 2021 to 2026.

The Evaluation of the Changing Futures programme (https://www.gov.uk/government/publications/evaluation-of-the-changing-futures-programme) evaluated the impact of the Changing Futures programme on people experiencing multiple disadvantage. It also looked at how changes at a wider system level affected the way services were delivered.

9.10.3 Making Every Adult Matter

The Making Every Adult Matter (MEAM) approach network helps local areas design and deliver better co-ordinated services for people experiencing multiple disadvantage. The MEAM website (http://meam.org.uk/publications/meam-approach-evaluation-final-report/) describes their approach and includes a 5-year (2017 to 2022) evaluation of the programme.

9.10.4 Primary Care Alcohol Nurse Outreach Service

In 2019, the Primary Care Alcohol Nurse Outreach Service (PCANOS) was implemented in selected ‘deep end’ GP practices in Glasgow. These are the practices that serve the 100 most deprived communities across Scotland. This involved specialist addiction nurses working closely with GP practices to help engage and provide care for patients with alcohol problems who had not previously engaged, or had not engaged well, with community alcohol services. They also aimed to eventually link patients to mainstream services after discharge.

The report Alcohol management in deep end practices (https://www.shaap.org.uk/publication/alcohol-management-in-deep-end-practices/) presents the findings of a qualitative study to gather stakeholders’ experiences and perspectives on PCANOS and the wider community alcohol services.

A qualitative study of the views of alcohol frequent attenders at Royal Alexandra Hospital, Renfrewshire (https://shaap.org.uk/downloads/reports/518-a-qualitative-study-of-the-views-of-alcohol-frequent-attenders-at-royal-alexandra-hospital-renfrewshire.html) was conducted in the West of Scotland where the impact of alcohol consumption and the level of health inequalities is significant and the population is distinct compared to other similar studies.

9.11 References

Bailey M, Ward M and Steele A. Sandwell Blue Light: an approach to support treatment-resistant drinkers (https://journals.sagepub.com/doi/10.1177/1757913919899694). Perspectives in Public Health 2020: volume 140, issue 2 (registration and subscription required for full article).

CFE Research and the University of Sheffield. A summary of programme achievements, evaluation findings, learning and resources (PDF, 697KB) (https://www.tnlcommunityfund.org.uk/media/insights/documents/Summary-of-programme-achievements-evaluation-findings-learning-and-resources-2022.pdf), 2022.

CFE Research and the University of Sheffield, with the Systems Change Action Network. What makes an effective multiple disadvantage navigator? Workforce development and multiple disadvantage (PDF, 251KB) (https://www.tnlcommunityfund.org.uk/media/insights/documents/What-makes-an-effective-multiple-disadvantage-navigator-2020.pdf), 2021.

Dieterich M, Irving CB, Park B and Marshall M. Intensive case management for severe mental illness (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007906.pub2/full). Cochrane Database of Systematic Reviews, 2010.

Drummond C, Gilburt H, Burns T, Copello A, Crawford M, Day E, Deluca P, Godfrey C, Parrott S, Rose A, Sinclair J and Coulton S. Assertive community treatment for people with alcohol dependence: a pilot randomized controlled trial (https://academic.oup.com/alcalc/article/52/2/234/2660942). Alcohol and Alcoholism 2017: volume 52, issue 2, pages 234 to 241.

Fincham-Campbell S, Kimergård A, Wolstenholme A, Blackwood R, Patton R, Dunne J, Deluca P and Drummond C. A national survey of assertive outreach treatment services for people who frequently attend hospital due to alcohol-related reasons in England (https://academic.oup.com/alcalc/article/53/3/277/4644521). Alcohol and Alcoholism 2018: volume 53, issue 3, pages 277 to 281 (registration and subscription required for full article).

Passetti F, Jones G, Chawla K, Boland B and Drummond C. Pilot study of assertive community treatment methods to engage alcohol-dependent individuals (https://academic.oup.com/alcalc/article/43/4/451/128612?login=false). Alcohol and Alcoholism 2008: volume 43, issue 4, pages 451 to 455 (registration and subscription required for full article).

Ward M and Holmes M. Working with change resistant drinkers: the project manual (‘the Blue Light manual’) (https://alcoholchange.org.uk/help-and-support/training/for-practitioners/blue-light-training/the-blue-light-project). Alcohol Concern, 2014.