Guidance

The alcohol CLeaR approach to system improvement

Updated 12 June 2020

1. About alcohol CLeaR

1.1 Introducing CLeaR

The alcohol CLeaR (Challenge services, Leadership and Results) is an evidence-based approach that local alcohol partnerships can use to think about how effective their local system and services are at preventing and reducing alcohol-related harm.

This approach helps partnerships to develop action plans for improvement through its focus on 3 main areas:

1. Challenge for the services that deliver interventions to prevent or reduce alcohol-related harm.
2. Leadership for the alcohol agenda, which involves considering how local structures and governance arrangements can support collaborative action to reduce alcohol harm.
3. Results achieved through recent activity to reduce alcohol harm, evidenced by national and local data sources.

The CLeaR approach asks partnerships to review progress against their priority alcohol objectives within the context of other plans to improve people’s health in the local area. CLeaR will have more impact if the partnership sees alcohol as part of the bigger local picture and understands how reducing alcohol harm can help to meet other local objectives. This can also help make the case for continued investment in alcohol harm reduction.

The alcohol CLeaR approach offers:

• a self-assessment tool to measure the success of local action to address alcohol harm and identify opportunities for improvement
• optional opportunities for external validation to independently challenge or confirm the findings of the self-assessment

The approach encourages local partners to come together to discuss what they are doing to reduce alcohol-related harm and the effect it is having in their area.

1.2 Local alcohol partnerships

Local alcohol partnerships are generally, but not only, based around a local authority area. Membership can include:

• local politicians and senior decision-makers
• directors of public health
• local authority alcohol commissioners
• other local government officers from public health, trading standards, housing, children’s services and social care
• health commissioners in NHS clinical commissioning groups or NHS England local area teams
• NHS providers of primary, secondary and mental health care
• police and other organisations involved in community safety, offender management and crime reduction
• Jobcentre Plus staff and representatives from local housing services
• local voluntary and community sector services
• service user and carer representatives

2. Why use the alcohol CLeaR?

The CLeaR approach provides an opportunity for local partnerships to:

• showcase good and innovative local practice
• identify opportunities for improving practice
• bring local partners together to discuss the range of local interventions and to decide on priorities for future action
• compare local alcohol harm reduction work over time and against other local areas

CLeaR helps local partnerships to assess their arrangements and delivery plans and to develop a collective view of their strengths and weaknesses. It can give them the assurance that their resources are being invested in a range of effective services. It can also help show if the interventions their services are delivering meet local need and support their local vision and ambition for reducing alcohol-related harm.

CLeaR also helps to identify opportunities for development within the system which partnerships can use to inform local improvement planning.

The approach can reinvigorate partnership working, promote more active engagement from a variety of local agencies and help areas reach a consensus about their strategic vision for alcohol.

CLeaR is not a formal inspection regime nor a framework for external audit. Any results and findings from this process belong to the partnership and only exist to help partners identify strengths, opportunities for development and priorities for further action.

3. The alcohol CLeaR approach

3.1 CLeaR self-assessment

Partnerships can start using the alcohol CLeaR approach to improvement straight away by completing the self-assessment tool.

This self-assessment tool will help the partnership to:

• evaluate local activity to prevent and reduce alcohol-related harm
• make sure that current activity reflects identified need and follows the latest evidence-based practice
• identify priority areas for development
• plan effectively for improvement
• check progress and improvements to services and oversight arrangements

Since local systems change over time, it’s best to re-do the self-assessment every 2 years or so. This will help partnerships track any changes and reinvigorate local activity.

3.2 CLeaR enhanced offer

PHE has an ‘enhanced offer’ to support partnerships that are interested in using the CLeaR self-assessment tool but are not sure how to start the process.

This offer is tailored to meet local need. It can include online support answering queries about the CLeaR process or to access extra materials such as briefings or presentations. These can help the accountable board and designated local CLeaR lead promote the approach and engage partners. These extra materials are available on request.

PHE can also help to run workshops for decision-makers in local partnerships to learn more about the CLeaR approach and to start completing the self-assessment. This extra support can help local agencies get the most out of the CLeaR experience.

For more information about the enhanced offer, contact the alcohol lead in the local PHE centre in the first instance or email [email protected].

3.3 External validation of the CLeaR findings

Local alcohol partnerships might want some validation of their CLeaR findings. If they do, look at options for further scrutiny of their self-assessment before developing a local improvement plan.

Further advice about this is available by emailing [email protected].

4. Using the CLeaR approach to system improvement

4.1 Understand the principles of CLeaR self-assessment

CLeaR is based around completing a simple self-assessment tool. The tool contains statements (criteria) that show attributes or practices partnerships are asked to assess themselves against and provide evidence for their rating.

Partnerships can appoint a CLeaR lead to plan and coordinate the local process. This CLeaR lead can then encourage partners to join in the process and identify the evidence needed to complete the self-assessment tool.

The principles of CLeaR self-assessment are:

1. Simplicity: it should be a quick and easy exercise to find evidence that shows if partnerships are meeting the criteria.
2. Collaboration: the self-assessment is best completed jointly through discussion between local partners and stakeholders.
3. Evidence-based responses: partners should be able to prove their evidence of achievement against each criterion and compare what they’ve achieved locally with the national evidence base.
4. Honesty: partners should be open and transparent when rating their evidence to develop an accurate and shared understanding of what is working locally and the opportunities for development. The focus should be on existing arrangements and the services and interventions the partnership is currently delivering, not on aspirations and future plans.

4.2 Get the right people involved in the self-assessment

To get the best out of the CLeaR approach, all the organisations in the partnership need to understand the local policies and approaches used to reduce alcohol-related harm. So, to make sure responses reflect all local activity and relevant evidence, it’s important for representatives of any local organisations that contribute to this work to complete the self-assessment together, rather than allowing the criteria to be scored by one or 2 individuals.

This kind of open discussion between local partners and across organisational boundaries should result in a collective understanding of what is working and a shared vision about the need for further development.

Alcohol partnerships are likely to include public health and other local government departments, the NHS (commissioners and providers), organisations involved in community safety and offender management such as the police and third sector agencies. See the local alcohol partnerships section for more information about who could be involved.

But there may be other local agencies in the area that could contribute to the local CLeaR discussions. PHE encourages partnerships to be inclusive when deciding who could be involved in the CLeaR process.

It’s important that a range of local partners contribute to completing the self-assessment because this will:

• reflect the full extent of local activity to reduce alcohol-related harm
• help partners to see how well all this work is integrated
• identify barriers to agencies working together
• help to develop or refine local referral pathways

Partners who are involved in CLeaR may need to encourage other local organisations and people to get involved, if they do not see the benefit of completing CLeaR at first.

Partnerships that have already used the CLeaR tool have found it useful when the local senior leaders responsible for alcohol harm reduction actively promote CLeaR at strategic meetings (such as the health and wellbeing board). This can create opportunities to encourage other leaders to get their organisations actively involved in the local CLeaR process.

4.3 Gather the right local knowledge

To complete the self-assessment, local areas will need to involve partners who together have the right knowledge and experience to respond to all the CLeaR criteria. This includes:

• a good understanding of the local approach to alcohol harm reduction at a strategic and operational level
• being aware of all the local and regional level activities and different partnerships that focus on reducing alcohol harm
• an understanding of the local policies and initiatives which affect alcohol harm reduction work
• knowing how the governance and accountability arrangements work between the health and wellbeing board, the community safety partnership and NHS clinical commissioning groups
• detailed evidence about the local partnership’s performance against its priority targets

4.4 Set the partnership’s alcohol-related activity in its local context

The first section of the CLeaR self-assessment tool asks partnerships to put their actions to prevent and reduce alcohol harm into the wider local context. It asks partnerships about their local vision and shared ambition. This helps identify:

• the highest level strategic priorities jointly agreed by system leaders across the area (as opposed to individual organisations’ priorities)
• the main local strategies and action plans that alcohol harm reduction work contributes to
• what outcomes the area wants to achieve for its residents

These priorities might not be health-specific. They may include wider goals such as helping children and young people to achieve their potential, increasing economic prosperity, or reducing unemployment or re-offending rates.

Linking the 3 most important objectives from the alcohol strategy or action plan to these high-level local strategies and priorities will help make the case for continued investment in work to reduce alcohol harm.

4.5 Complete the questionnaire

Getting started

The self-assessment tool is an Excel workbook. It uses macros that automatically add up the scores and can generate charts. Whoever is leading on completing the questionnaire:

• should ‘enable content’ when asked, so the tool can work properly
• might need to save the blank template onto their system and make the alcohol CLeaR a ‘trusted’ document, to change the macro settings

Good practice and meeting the criteria

The 3 main areas in the CLeaR self-assessment are broken down into related themes (such as vision and governance, children and young people, and achieving positive outcomes). Each of these themes contains criteria that show a specific attribute or practice. Partnerships are asked to provide evidence to show how these criteria are being met locally.

There are separate ‘good practice pointers’ worksheets which can be accessed from the respective individual topic worksheet. These contain advice about what good practice looks like for each criterion in the alcohol CLeaR self-assessment tool.

These good practice pointers will help partnerships see if there is good practice across their local system, including in their services. However, the good practice pointers are not exhaustive.

PHE can make a Word version of the good practice pointers available on request. Please email: [email protected].

How to calculate the partnership’s score

When completing the self-assessment, partnerships will need to consider whether they can show they are meeting the criteria in each section. There are 3 possible options for selection in the drop-down menu.

1. If the partnership is not meeting the criterion, select ‘no evidence of achievement’.
2. If the partnership has some evidence of meeting it, but there is room for improvement or development, select ‘some evidence of achievement’.
3. If the partnership can show it is fully meeting the criterion and that the practice is well-established select ‘strong evidence of achievement’.

To rate itself as having ‘strong evidence of achievement’, a partnership should be able to show evidence for all the component parts of each criterion.

Where possible, partners should agree the response collectively, because different organisations might be able to identify different sources of evidence to demonstrate these attributes and practices.

Where the partnership rates itself as having ‘some’ or ‘strong evidence’ of achievement, it will need to make a brief note about the evidence used to show this. This will support internal approval of the findings, action planning and any external validation processes. The best place to record this evidence is the ‘brief comments and references’ column in the CLeaR self-assessment.

Advice from local areas which have already used CLeaR

There’s no one right way to complete the self-assessment tool. Partnerships that have already done the self-assessment had different ways of doing it. These included:

• completing the tool as a partnership in a workshop
• using smaller groups to look at specific topics
• discussing responses at partnership board meetings
• having a single author complete the tool after carrying out a series of 30-minute interviews with relevant staff

Partnerships who have already carried out a self-assessment thought it was best to get people together to talk through the issues while they were completing the tool, rather than relying on email and other virtual responses. This allowed partners to engage better, share more information and helped everyone be clear about what they were doing.

They found that open questioning worked best, for example asking, “what do you do?” and “what evidence do we have to show that this has worked?”, as this gave clearer and more honest responses.

Partnerships also found it useful to hold a follow-up workshop at the end of the self-assessment process. This gave partners an opportunity to come together to make sure they were happy with what had been recorded in the completed tool. They were also able to look at how the evidence had been scored, discuss exceptions and check that it made sense.

4.6 Locate evidence of achievement

To produce a good, well-evidenced self-assessment, partnerships will need to refer to a range of local policies, plans, reports and specifications to show what they are achieving.

The partnership will also need to assess the impact of these policies and plans by reviewing local and national data as well as using surveys and feedback from service users and partner agencies.

The evidence could include:

• high-level local plans and strategies, such as the joint health and wellbeing strategy or community safety partnership plan, being clear about where these documents focus on reducing alcohol harm
• the local alcohol strategy and delivery plan
• needs assessments including the joint strategic needs assessment where it addresses alcohol harm
• the statement of licensing policy
• local service specifications or contracts
• local protocols and service level agreements
• reports or reviews of your alcohol programmes and services
• terms of reference or minutes of relevant meetings
• results from local surveys
• service user feedback
• relevant overview and scrutiny reports
• public health data like National Drug Treatment Monitoring System (NDTMS) activity data, Public Health Profiles and the Local Alcohol Profiles for England or locally collected data measuring outputs and outcomes related to reducing alcohol harm

4.7 Manage the partnership’s evidence

Partnerships need to show the reason for their self-assessment score but should try not to show too many documents as evidence. Be careful not to burden local stakeholders with too much detailed information and make sure everything included is good quality and relevant.

Partnerships should also make sure all the evidence is well-referenced, so anyone reviewing the self-assessment can easily match the evidence to the criteria it relates to. It may help to include hyperlinks and page references in the ‘comments and references’ column.

There’s a column in the alcohol CLeaR spreadsheet, labelled ‘action planning’. Partnerships can use this to identify internal priorities for future action or to record comments made during the local discussion.

Advice from local areas which have already used CLeaR

People who have been through the process and already gathered their evidence found it helpful to compile a portfolio of evidence to show how they had met the criteria. This might include:

• storing electronic copies of relevant documents in one place
• saving documents in a format which is easy to share with others if you decide to have an external validation process
• agreeing a systematic method of referencing the evidence, so it’s easy for readers to find it all and to be clear about which criteria each piece of evidence demonstrates

4.8 Calculate the score

The tool automatically scores the rating of evidence for each criterion. It calculates the scores for each section and presents them as a number and as a percentage of the maximum achievable score. These can be found in the ‘scoring and CLeaR profile’ worksheet.

Another automated column in the spreadsheet (labelled as ‘peer review scores’) is for use by the peer assessment team, if the partnership chooses to follow up the self-assessment with some sort of external validation event.

This allows external reviewers to compare their rating of the evidence with the scores awarded by the partnership in the final report. Partnerships will need to have strong evidence to show that they are achieving what they say they are, because the 2 scores could be compared on the spider-graph in the ‘scoring and CLeaR profile’ worksheet.

The score provides a rough overview of where the partnership is against each area and theme covered by the CLeaR approach, which will help inform discussions about priorities for action and improvement planning. Partners will be able to see where the local area is achieving good outcomes and where further work is needed to improve.

Although the scoring scale is only a pointer, it should give enough detail to start a conversation about what further action the partnership could take to improve in each of the 3 main CLeaR areas. Partners will want to pay attention to areas where the partnership has not scored as highly as expected.

Partners will need to reflect on their findings to determine what practice could be improved, think about what’s stopping the delivery of better services and outcomes and agree what needs to be further developed. This will form the basis of the local improvement plan.

5. Action planning for improvement

Once the CLeaR process is completed the partnership will need to draw up an action plan based on what they have learned from assessing their local arrangements and practice.

The plan will reflect the partnership’s local priorities and targets for improvement. Partners will also need to agree governance and monitoring arrangements for the action plan, so they can track their progress.