A dual dilemma
People with mental health and drug and/or alcohol needs are still being neglected.
That’s the conclusion of a recent (3 August 2016) report from Turning Point entitled: Dual Dilemma: the impact of living with mental health issues combined with drug and alcohol misuse.
Facts and figures
It’s a long time since people disputed the scale of the problem (historically known as dual diagnosis, more recently termed people with complex needs) but the figures remain startling:
- Research suggests that up to 70% of people in drug services and 86% of alcohol services users experienced mental health problems.
- Between 22 and 44% of adult psychiatric inpatients in England also have a substance misuse problem.
- Co-existing alcohol and drug misuse and mental health issues are the norm rather than the exception among most offenders.
- Mental health and substance misuse issues are high among the homeless population. 12% have both a mental health and substance misuse problem, while 41% of homeless people surveyed by Homeless Link said that they used alcohol or drugs to cope with their mental health issues.
Critically, a 2015 Drugscope state of the sector report found that 22% of 189 drug treatment services in England reported that access to mental health services deteriorated over the 12 months to September 2014.
There have been numerous policy and practice initiatives over the last 15 years to try to ensure that the large numbers of people living with mental health and substance misuse problems received a co-ordinated service rather than being shuttled back and forth by clinicians who told them they needed to sort out their “other problem” before being able to access the service they were actually standing in.
The Health and Social Care Act (2012) brought in changes to how services are commissioned proposing greater integration between local authorities, clinical commissioning groups (CCGs) and NHS England. Responsibility for public health moved to local authorities with the result that the gap between substance misuse and mental health commissioning widened.
Turning Point reports that despite the many initiatives introduced and guidance published, joint commissioning across addiction support and adult psychiatry, remains rare with many service users continuing to fall through the gaps in service provision.
Making things better
The report argues that improving service can only come from responsible for funding and commissioning services working together to develop solutions. Two critical priorities are to skill the workforce and replicate services that have proven to be effective. The report sets out eight goals for effective support:
1: Collaboration – services working together to develop effective responses
This requires mental health and substance misuse services to communicate and share information so individuals get the support they need, when and where they need it. Collaboration means having data sharing protocols in place; agreed outcome measures; and staff working with each other as well as the individual and their families where appropriate, to achieve sustained recovery.
2: Responding to change – support that remains relevant
A person’s use of drugs and /or alcohol and their mental health needs change over time. Therefore support has to remain relevant and be based on a recovery approach that supports individuals on their journey. This can include supporting people to gain living skills, confidence, independence and education, training and employment opportunities, all of which improve peoples’ quality of life.
3: Partnership working – staff supporting each other
This is a complex and challenging area of work that requires many agencies to come together around the needs of the individual. This can be supported through access to training and development; joint working protocols; and information sharing agreements to improve partnership working.
4: Training – a set of national standards and education
Mental health staff should receive drug and alcohol awareness training and vice versa, including the opportunity to shadow colleagues on shift. This way staff gain confidence in how to refer and how to work together to provide multi- agency support. Advice sessions provided by counsellors and psychologists can also benefit staff along with forums to discuss challenges and opportunities around clients. Well trained staff able to recognise and support people with co- existing mental health and substance misuse issues with inevitably help to improve outcomes and efficiency across the system.
5: Translating strategy into practice – embedding change
National policy and guidance has been clear on the merits of integration for this client group. Multiple strategies have encouraged practice that is joined up and working around the needs of the individual. In many areas there are locally driven strategies that have aligned thinking at a strategic level, however this is often not translated on the ground into the day to day work of practitioners. A paradigm shift is required that delivers a ‘no wrong door approach’ and provides support around the person. This requires investment and leadership in changing processes, cultures and providing on-going intelligent monitoring to ensure that outcomes and people’s experience is improved.
6: Flexible services – responding to people along a spectrum of need
Some individuals are dependent on alcohol, others use intermittently. A flexible service means individuals are not forced to go from place to place for help, or have to explain their situation too many times. Those most in need of support often find it hardest to engage; therefore services should be provided flexibly so that individuals are able to build trust over significant periods of time and have accessible routes in and clear pathways out.
7: Managing risk and providing appropriate support – tailoring services to fit
People with co-existing mental health and substance misuse issues are at higher risk of relapse, hospital readmission and suicide. Therefore successful services are non-judgmental and tailor support to the different stages of the person’s recovery. Care should focus on the whole person. People need real- life support around real-life difficulties such as housing and debt. Local areas benefit from a range of provision, including outreach, residential services and good quality crisis provision.
8: Early intervention – identifying individuals early who are at risk
Recognising issues early on prevents their needs escalating. Otherwise it can mean people not getting the support they need and leading more chaotic lives which can lead to lost working days, poor physical health, homelessness and even offending behaviour.