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MIND THE GAPS
Meeting the needs of people with co-occurring substance misuse and mental health problems
CHAPTER 2: EXECUTIVE SUMMARY AND RECOMMENDATIONS
EXECUTIVE SUMMARY
Introduction (
Chapter 1)
2.1 '
Mind the Gaps' is a report for people with deep-seated and multiple problems which often have complex and multiple causes. They have co-occurring mental health and substance misuse problems and often occupy the margins of our society. Most can benefit from help and support of many types. But there are shortcomings and gaps in the help that is available. This report seeks to address them. The Working Group has taken account of the following policy initiatives, which already exist or are being developed; and all seek to narrow or close gaps in advice and support:
towards social inclusion;
towards a successful and sustainable economy, with good employment prospects, training experience and opportunities;
towards reducing homelessness;
towards targeted provision of housing support services; and
towards creating equitable access to a range of care services, regardless of boundaries, and designed to meet the needs of people as clients or patients.
2.2 The report serves to underline the importance of sustained implementation of social, health and economic policy and delivery of effective public services which promote inclusion. The main challenges ahead are to create the climate of public and service attitudes, and the culture of good practice, which promote the well-being of this group of people.
2.3 Many people with co-occurring substance misuse and mental health problems have had bad early life experiences and grown up to lead troubled young adult lives. Therefore this report focuses on the need for continuing effective endeavours to ensure:
education on the problems that drugs and alcohol can cause and greater understanding of mental health;
firm but fair means of crime prevention, management and justice;
earlier detection of abusive experiences, by facilitating disclosure and acceptable intervention;
early intervention and support; and
the right conditions to enable participation in the community, including positive education experience and peer support.
The Nature and Extent of the Problem (
Chapter 3)
2.4 The nature of co-occurring substance misuse and mental health problems is complex with a number of interacting continuums such as severity; type of mental health problem; type and amount of substance misused as well as change over time.
2.5 It is a major and growing problem. The evidence in this report comes from a variety of sources with Scottish data supplemented by information from other parts of the UK and elsewhere.
2.6 In summary the evidence shows that:
up to 3 in 4 drug using clients have been reported as having mental health problems;
up to 1 in 2 patients with alcohol problems may also have a mental health problem;
up to 2 in 5 people with mental health problems may have a drug and/or alcohol problems; and
co-morbidity in general practice in England has risen by 62% between 1993 and 1998.
2.7 The evidence also shows that people who experience co-occurring substance misuse and mental health problems also often experience other complex social problems, such as unemployment, homelessness, violence and childhood trauma which can occur over long periods of time.
2.8 Clients are also likely to present to services with combinations of needs other then just solely substance misuse or mental problems or combinations of these two.
Existing Service Provision in Scotland (
Chapter 4)
2.9 There have been a number of recent policy developments in the field of mental health service provision. As yet these have not led to a consistent improvement across the country in the collaborative planning, delivery and accountability of services for people with co-morbidity, including those with mild to moderate mental ill health.
2.10 The separation of the planning processes for services for those with co-occurring substance misuse and mental health problems, through Drug and Alcohol Action Teams (DAATs) and Joint Mental Health Commissioning Groups at local level can inhibit joint service provision for this client group.
2.11 The Joint Future Agenda for health and social care services offers the prospect of better outcomes for those with co-occurring mental and substance misuse problems, through an integrated approach to the management, financing and day to day running of services. The drive towards integrated care for drug users, based on the principles of Joint Future, is now gathering momentum following the publication of
Integrated Care for Drug Users: Principles and Practice published by the Effective Interventions Unit (EIU).
2.12 The
National Programme for Improving Mental Health and Well-Being in Scotland, further endorsed within
Partnership for Care, aims to undertake a number of measures to promote mental well-being, preventing mental health problems and ensuring early identification and action when problems occur. The findings of our research confirms the need for this action.
2.13 There is a lack of professional consensus on the role of secondary mental health services in the treatment of personality disorder in Scotland. Apart from policy initiatives for mentally disordered offenders, there is no Scottish guidance. With only a few exceptions, service provision is rudimentary, despite a growing evidence base for effective practice, intervention/management and the solid evidence of the likelihood that such individuals are at high risk of becoming dependant on substances.
2.14 There is a lack of systematic service provision for people who have survived earlier traumatic experiences. Research studies and anecdotal evidence suggest that many NHSScotland staff are uncomfortable with their level of skills in handling disclosure of this type. The range of necessary services which should be provided is currently being examined by the Scottish Executive Health Department.
2.15 There are currently variations in the provision of services for those suffering from mental health and substance misuse problems. Issues include:
some mental health services working on too narrow a model of assessment and care;
general lack of communication at both operational and planning levels between addiction and mental health services;
lack of clarity in defining clients with co-occurring mental and substance misuse problems ('multi-problematic', as opposed to 'dual diagnosis'), with poor assessment by generic workers and primary diagnosis often reflecting source of referral rather than causation;
lack of specified core competencies, and thus training for staff in generic and front-line services;
lack of willingness to work with this client group, and stigmatisation associated with their problem; this sometimes results in treatment not being offered and inappropriate and rapid referrals on to other services when their significance is not clear;
the need for aftercare support to be planned as an integral part of treatment to prevent recurrence; and
the need for better partnership with the voluntary sector in delivering services to this client group.
Assessment, Intervention and Support (
Chapter 5)
2.16 There has been a history of separation in NHSScotland at operational and planning levels between mental health and substance misuse services, with the result that services are at risk of failing to provide fully joined up care for those who have co-occurring problems. If an experience of effective services is to be achieved for the service user, not only must the providers share a broadly similar understanding of what types and sequences of care are appropriate, they must also be able to apply these flexibly and jointly across both professional and organisational boundaries.
2.17 These issues need to be addressed and resolved by better joint service planning, systems of care and delivery, workforce planning and governance, before there can be any opportunity of developing truly integrated pathways of care. As before, mechanisms now exist, deriving from the Joint Future Agenda and
Partnership for Care, which facilitate this process.
2.18 What this report is seeking to achieve is a service that:
has a sufficiently diverse skill mix to allow ready access to both specialist and generic services as a client's needs become apparent;
is populated by workers confident enough of their own abilities to construct practical care plans in the face of complex problems;
is well enough understood by generic workers to allow them to contribute to tackling the less complex issues, partnering the specialist service; and
is understood and accepted by other potential providers, as well as care funders and commissioners.
2.19 Proper assessment is the key to establishing with the individual as complete a picture as possible of all their needs - health, physical and mental; social needs; housing; employment and their state of readiness to change - in order to be involved in the care most likely to promote a positive outcome.
2.20 There is robust evidence that different interventions can work for this client group. These should be as broadly based as possible and include social, education and employment elements. They are:
engagement - simple listening skills, courtesy and respect are the foundation of this;
meeting basic needs - such as safety, accommodation and food;
persuasion - the point at which the person's perceptions about their problems can be discussed and better understood;
active intervention - mostly carried out collaboratively in the community; and
early intervention - this should be the basis of the treatment system of known effectiveness, tied into broader prevention work.
Planning and delivery of services (
Chapter 6)
2.21 People with co-occurring substance misuse and mental health problems present an extreme challenge, but nevertheless deserve access to the most appropriate and timely services.
2.22 Treatment and care can and does work for this client group, although there is no UK evidence on what model of care is most effective.
2.23 NHS Boards and partner local authorities should consider the needs of this care group in their entirety, and a programme budget allocated to be managed as a whole, whether or not there is a defined severe or enduring mental health illness present.
2.24 Planners and commissioners of services need to be aware of the nature and scale of the problem for this population, so that resources are targeted appropriately. Service commissioners should concentrate on looking to see how gaps in current service provision, its profile, culture and flexibility to respond, might best be met. They should look to do this, where possible, through mainstream generic services, with easy referral to meet more specialised needs. The voluntary sector should play a key role in both planning and delivery care to this client group, being resourced accordingly.
2.25 The following should be key features of service provision:
early intervention, which is likely to be cost-effective, avoiding inappropriate referrals to more expensive specialist services;
broadly based interventions, to include social, education, and employment elements;
person-centred interventions, not based on existing service availability;
advocacy, with key workers helping service users through treatment and care services and;
positive expectations of what can be achieved through treatment and intervention being emphasised to client and to service providers alike.
2.26 Staff, whether in mental or substance misuse services, need to develop the skills necessary to identify and understand clients with co-occurring problems, to develop the confidence to deal with them, and to be given the capacity to cope. Training and continuous professional development should include:
development of assessment skills based upon substance misuse and mental health assessment frameworks;
integration of knowledge of drug and alcohol trends for individuals with mental health problems, into practice; and
effective working with a range of mental health interventions and treatment modalities.
2.27 Effective staff supervision, both clinical and managerial, is equally important. Support mechanisms should also be in place for staff at all levels to help them cope with this particularly challenging client group.
RECOMMENDATIONS
Prevention
1. The Scottish Executive should continue its social justice approach and social inclusion policies to further reduce the impact for those with adverse life experiences to allow them to fully participate in community life.
2. Bullying, detection and management of abuse and other trauma are key measures for early intervention to avoid manifestation of problems of vulnerable children in later life. The Scottish Executive should implement in full the Scottish Needs Assessment Programme/Public Health Institute for Scotland (SNAP/PHIS):
A Review of Child and Adolescent Mental Health Services. A Short Life Working Group has been set up by the Scottish Executive Health Department to review services which should be available to those adults who have earlier experience of trauma. This is due to report at the end of 2003.
3. The Scottish Executive and local decision-makers, including Drug and Alcohol Action Teams, should give priority to evidenced-based education and prevention work to reduce substance misuse and to address the treatment and care needs of those with substance misuse problems.
4. The Scottish Executive should continue to address the need for greater awareness and understanding of mental health and mental illness, and maintain the work to eliminate the stigma and discrimination associated with mental ill-health, as part of the
National Programme for Improving Mental Health and Well-Being.
Standards and strategic planning
5. NHS Quality Improvement Scotland, together with the Care Commission for Scotland, should consider the development of standards for integrated services for people with co-occurring substance misuse and mental health problems, ensuring the application of best practice and holistic and integrated care across services. As far as possible, clients should be involved in developing such standards.
6. A joint approach, involving the Scottish Executive Health Department Mental Health Division, the relevant professional organisations, and NHS Education Scotland should produce specific Scottish guidance on the identification, assessment, workforce training and treatment of people with personality disorder.
7. Drug and Alcohol Action Teams, Mental Health Commissioners and other statutory and voluntary caring agencies should work jointly and across boundaries to ensure adequate and integrated service provision locally for those with co-occurring mental health and substance misuse problems, including clients with personality disorder. The establishment of Community Health Partnerships should help to facilitate this joint working.
8. Planners and commissioners should develop tiered treatment and care services for this client group within the principles of Joint Future and
Integrated Care for Drug Users to ensure greater communication and more effective joint working between substance misuse, mental health and other relevant services (statutory and voluntary).
9. Planners and commissioners should work to ensure flexible and seamless services with appropriate links to the criminal justice system and to wider social interventions, including housing support, provision of accommodation, life long learning opportunities, employment and other measures to assist with the social integration of service users.
10. Planners and commissioners should make better use of existing points of contact with the client group who may present in crisis through the criminal justice system and attendance at Accident and Emergency (A & E) departments. Rapid referral to
appropriate services will provide a useful start to lasting engagement with the client
11. Drug and Alcohol Action Teams should include action on service provision for this client group within their annual Corporate Action Plans, and within local Alcohol Action Plans.
12. Planners and commissioners should expand the role of the voluntary sector in the planning and delivery of services in recognition of its particular skills, experience and expertise in dealing with this challenging client group.
Delivering better services
13. Service providers should raise expectations among staff as to the positive treatment outcomes which can be achieved for those suffering from co-occurring substance misuse and mental health problems through staff training, education, and application of management principles of continuous improvement and positive feedback.
14. Service providers should raise awareness among users of the possibility of positive treatment outcomes and involve them in the development of plans for their own treatment and care in a meaningful way.
15. Service providers should ensure that information on local services is more readily available in suitable format, accessible to users and referring agencies.
16. Service providers should ensure that advocacy services are integral to the care plans for this client group.
17. Service providers in generic mental health services should re-examine their attitudes to those clients using substances to develop more positive and holistic/integrated responses to their care.
18. Service providers should ensure that staff working with this group, whether in the NHS, local authorities or the voluntary sector, receive continuing support and encouragement.
Training
19. Service providers should ensure that staff in both substance misuse and mental health services are trained to develop the skills and confidence necessary to identify and understand clients with co-occurring problems.
20. STRADA (Scottish Training on Alcohol and Drug Abuse) and other training providers should develop further training provision covering staff attitudes and service re-design in order to reduce stigma and encourage user participation in services.
21. Training and service providers should ensure that there is greater emphasis on joint training between the medical profession and other professionals and staff of voluntary agencies who also have a role to play in providing care and support for this client group.
Research and information
22. The Effective Interventions Unit (EIU) should ensure that its research findings on the nature and extent of health and social services provided to people with dual diagnosis are widely disseminated and that its report identifies the need for further work and evidence of implementation which may, for example, include evaluating promising examples of practice.
23. Information and Statistics Division (ISD Scotland) should consult with service commissioners and providers to improve information for management, epidemiology, and future planning within the context of integrated care.
24. ISD Scotland and relevant health, social and voluntary care, addiction and mental health services should consider the development of national data standards for mental health and substance misuse information to support local data collection and monitor implementation of other recommendations in this report.
25. The research community should work with all stakeholders to improve the evidence, information and skills base to support services for this client group.
Implementation
26. The Scottish Executive should draw up an Implementation Plan to ensure that the above recommendations are carried out.
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