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MIND THE GAPS
Meeting the needs of people with co-occurring substance misuse and mental health problems

CHAPTER 4: EXISTING SERVICE PROVISION IN SCOTLAND

This Chapter:

• outlines the policy context within which mental health and addiction services in Scotland are provided;

• describes mental health services in Scotland, including services for people with additional care needs;

• describes a number of service approaches in different parts of Scotland and in different service setting;

• refers to the findings of recent research into the experiences of service users with co-occurring mental health and substance misuse problems; and

• identifies gaps in current service provision.

4.1 The Chapter highlights that there has been much progress in recent years in devising policy and guidance which seeks to address the health and wider social needs of our most vulnerable members of society, including those with substance misuse and mental health problems. Despite this progress, however, the negative experiences of some of those with co-occurring problems, expressed during our research into users views ( see Annex E), highlights that much work has still to be done to bridge the gap between aspiration and practice in many areas.

THE POLICY CONTEXT

Mental Health Services

4.2 The current policy on the organisation of mental health services is set out in A Framework for Mental Health Services in Scotland (1997), Our National Health, (2000) and Partnership for Care, (2003). Taken together these documents describe how the Scottish Executive, working with the statutory agencies, the voluntary sector and others, has introduced and developed a number of policies and initiatives to improve the planning, delivery, quality and accountability of mental health services.

4.3 Partnership for Care continues these objectives for mental health services, not least by the plans for mental health to be a client group for the Joint Future initiative by April 2004. Care networks for the organisation of seamless care for users of mental health services will be actively promoted. Partnership for Care also confirms steps to be taken to address a variety of workforce issues and recognises the important role for primary care in the seamless organisation of mental health care. Each initiative underlines further the need and benefit of joint working for better services.

4.4 Achieving the goal of improving Scotland's health involves addressing not just physical health, but also the mental health and well being of people and the communities within which they live. Commitments to health improvement made in Our National Health saw the beginning of an ambitious National Programme aimed at improving mental health in Scotland. The National Programme, further endorsed within Partnership for Care aims to:

• raise awareness of mental health issues;

• promote positive mental health and well-being;

• promote effective prevention of mental health problems;

• encourage and support action for early identification, and intervention when mental health problems occur; and

• support recovery from mental ill health.

4.5 Local progress toward improved services has been examined since 2000 by the Mental Health and Well-Being Support Group, using the Framework objectives as a template for local progress. Two rounds of visits to the relevant agencies and users of services in all 15 Health Board areas have been completed to date. The Support Group's findings can be found at www.show.scot.nhs.uk.mhwbsg.

4.6 Good quality, credible information accepted by all parties is essential to make national and local progress to better services. Four linked sources aim to make improvements. These are as follows:

• Improving Mental Health Information Project (working across partner organisational boundaries to agree on data sets and processes in order to provide essential care management and outcome planning information);

• NHS Quality Improvement Scotland;

• Mental Health and Well-Being Support Group reports ; and

• Mental Health Services Improvement Network (comprising national bodies with broadly similar aims).

Alcohol Services

4.7 The Plan for Action on Alcohol Problems, published in January 2002, sets out measures to reduce alcohol-related harm in Scotland. Local co-ordination of activity in support of the plan is the responsibility of Alcohol Action Teams (AATs) or DAATs.

4.8 A Framework for Alcohol Problems Support and Treatment Services (Sept 2002) has subsequently been published and all local AATs have drawn up 3-year local strategies on how they plan to meet identified need for support and treatment within their areas. These include action in support of services for people with alcohol problems who also have significant mental health or drug problems.

Drug Misuse Services

4.9 Current policy on tackling drug misuse, including the provision of treatment and care, is set out in the national strategy Tackling Drugs in Scotland: Action in Partnership (1999) and in the Scottish Executive's Drug Action Plan Protecting Our Future (2000). Local co-ordination and delivery of services is the responsibility of Drug Action Teams (DATs) or DAATs, in partnership with agencies with responsibility for drug issues at local level. These include health, social work, education, police, prisons and the voluntary sector.

4.10 In 1999, the UK Department of Health published Drug Misuse and Dependence: Guidelines on Clinical Management. More recently in October 2002, the EIU within the Substance Misuse Division of the Scottish Executive Health Department published 'Integrated Care for Drug Users: Principles and Practice This sets out the evidence base for integrated care and offers a framework for the development of the key elements of integrated care including assessment, information sharing and planning and delivery of care.

Joint Future Agenda/Integrated Care for Drug Users

4.11 The Joint Future Agenda seeks better outcomes through an integrated approach to the management, financing and day to day running of services ( www.scotland.gov.uk/health/jointfutureunit). In particular, it improves partnership working through joint resourcing and joint management, improves access to services through single shared assessment and improves results through its drive to joint services.

4.12 The Joint Future Implementation and Advisory Group has agreed that full implementation across all community care groups should be achieved by 1 April 2004. Amongst those services which have been identified as being well placed to make an early transition to the joint arrangements are drug misuse services and mental health services.

4.13 The aim of Integrated Care for Drug Users is to support the planning, design and delivery of services for drug users who, in most cases, have multiple needs eg employment, housing, offending behaviour, family and social relationships etc. The development of Integrated Care for Drug Users is now being taken forward by DATs. The key elements are: accessibility of services, including action on needs assessment and waiting times; assessment of the individual, based on the principles of single shared assessment; planning and delivery of care, with the emphasis on co-ordination of care designed to meet the assessed needs of the individual; information sharing across the range of services; and monitoring and evaluation.

Services for homeless people

4.14 Current policy on the health of homeless people is outlined in Our National Health (2000) and in the Health and Homelessness Guidance (2001). The guidance sets out the framework for the activity required of NHS Scotland to improve the health of homeless people. All NHS Boards were required to produce and implement Health and Homelessness Action Plans, which were based on an assessment of the health needs of homeless people in each NHS Board area. With high numbers of homeless people experiencing co-occurring substance misuse and mental health problems, structural and attitudinal barriers have made addressing such issues very challenging. As a result this is currently a focus within local Health and Homelessness Action Plans.

4.15 In addition, in its final report, the Scottish Executive Homelessness Task Force, set up in 1999 made a specific recommendation regarding access to mental health services for those with substance misuse problems. Recommendation 46 states that 'NHS Boards should address the provision of mental health services to homeless people to minimise the barriers to access. Being free from substance misuse should not be an automatic pre-condition for access to services.' This recommendation, along with the other 58 made by the Task Force has been accepted in full by Cabinet and endorsed by the Scottish Parliament.

HEALTH SERVICES IN SCOTLAND FOR PEOPLE WITH PARTICULAR DIFFICULTIES

Survivors of trauma

4.16 WHO estimates that 20% of females have experienced some sort of abusive sexual experience by the time they reach the age of 16 years. The figure for males appears to be lower, but this may be due to greater reticence to report on their part. There is no information about what the Scottish figures might be, but also little reason to suppose that they would show major differences. Abusive experiences in childhood relate not only to sexual matters, but also to bullying and violence - direct experience, threats of it, and witnessing it within the family or care group, and the experience of care breakdown. The so-called 'looked after' children and young people, with fostering and care home experience, are particularly at risk of having had such experience. Such abusive experiences lie behind the presentation of many mental health problems - drug and alcohol misuse, eating disorders, depressive experiences, violent outbursts, suicidal feelings and suicidal behaviour, as well as incessant anxiety and a lack of well-being.

4.17 There is a growing body of evidence from neurobiological research in the USA about women with a history of abusive experiences (the work has not been done on men as yet), particularly those who have continued to experience symptoms of post-traumatic stress disorder. The research shows consistent persisting abnormalities in hormonal stress responses, the relative size of certain brain nuclei, and under function of the parts of the brain concerned with new learning and social adaptation. As yet, it is not clear to what extent specific treatment or therapies can make a significant difference, but it does begin to clarify the nature of a link between early experience, and subsequent behaviour, so often distressing and harmful to the individual herself as well as to others.

4.18 All of these constitute mental health problems, but people do not necessarily come to the attention of services, whether statutory or voluntary. This may be through fear of stigmatisation or through not knowing that the problems resulting from past experiences can be helped. Services are available in a patchy distribution throughout Scotland, provided by voluntary organisations, social care or health services. Although there is an increasing evidence base for the benefits of intervention, particularly by directive counselling or psychological therapies, provision is not systematic.

4.19 Beyond Trauma (2001) is the report of a qualitative research study which explored the views and experiences of survivors of trauma and staff working in the statutory and voluntary sectors in Edinburgh. Survivors of abuse found mental health services to be operating on too narrow a model of assessment and care. Survivors welcomed the opportunity for disclosure of troublesome information. Often they had not spoken about these matters for many years. However, staff seemed to believe that speaking about such matters would 'open a can of worms' which would ultimately be more damaging to the individual. The user view was that intervention had to be decided upon jointly - this was not an area where professionals could decide unilaterally what action was appropriate and when it should be undertaken. Finally, the report showed that there was mutual misunderstanding about the roles of the statutory and voluntary sectors.

4.20 Similar issues were raised in two small-scale surveys undertaken in Glasgow in 2001 to inform the work of the Homelessness Planning & Implementation Group. The first survey asked about homelessness workers' perceptions of the effect of trauma on homeless people, and the other asked for information from homeless people with mild to moderate mental health problems on how these problems affect their lives and what service responses might be helpful to them.

4.21 The surveys found that many, if not most, homeless people experience some mild to moderate mental health problems which manifest in a range of symptoms, which can be exacerbated by addiction. Many of these problems are likely to be linked to experience of trauma, often rooted in childhood experience of abuse. It was found that for many vulnerable people, substance use operates as a type of self-medication which dulls emotional pain. The co-existence of mental health and addiction problems makes it even harder to access support and help.

4.22 The surveys concluded that rather than receiving purely medical interventions a homeless person with mild to moderate mental health problems requires broad-based support across the full range of the individual's needs - emotional, psychological, social and accommodation-related. Services need to work more closely together to achieve this. Many services already offer support around mild to moderate mental health problems as part of generic support. However, a lack of understanding, confidence, skills and resources often means that workers are reluctant to get too involved, and that responses may be at best limited in effectiveness, and at worst potentially harmful.

4.23 There is no reason to believe that these issues are isolated to the study areas in Scotland. The Health Minister gave a commitment in 2002 to the Cross Party Parliamentary Group on Survivors of Sexual Abuse that the range of necessary services which should be provided would be examined by the Health Department. A Short Life Working Group, including service users and both statutory and voluntary service providers, will report later in 2003.

Suicide among young men

4.24 The suicide rate among men in Scotland has shown an upward trend and plateau over the past 30 years. The male suicide rate is now about 75 per cent higher than it was at the start of the 1970s. Over the past 30 years the greatest increase in suicide incidence has been found in the 15-34 year age groups. The risk of suicide is now highest among 25-54 year olds. Among men, over one in six deaths in the 15-24 age group, over one in four of deaths in the 25-34 age group and one in eight deaths in the 35-44 age group are by suicide. Similar trends have been noted for women, although the proportion of deaths attributable to suicide is lower. In addition over 7000 people are treated in hospital following episodes of self-harm each year.

4.25 Substance misuse (both drug and alcohol) is a known risk factor for suicide and suicidal thoughts. In a recent survey (2002), carried out by the Office for National Statistics, 4% of people who were not alcohol dependent had at one time thought about suicide. This proportion increased to 9% among those moderately dependent on alcohol and rose to 27% of the severely alcohol dependent group. Those who were dependent on drugs (other than cannabis) were around five times more likely than the non-dependent group to have ever attempted suicide, 20% compared with 4%. Of 382 drug-related deaths in Scotland in 2002, 30 (8%) were as a result of intentional self-poisoning: in a further 55 deaths (14%), it was not clear if the death was accidental or suicide.

4.26 While 25% of people who commit suicide have been in touch with services in respect of a mental health problem the majority have not sought this form of help before taking their own lives.

4.27 Taking action to prevent suicide will involve a combination of efforts across many aspects of Scottish life: eradicating poverty, addressing social exclusion, tackling inequalities, improving educational opportunities, improving health. Action must involve people from a range of organisations, professions and groups, with sustained effort required over a long period of time.

4.28 To support and encourage this action, in December 2002, the Scottish Executive launched Choose Life: a National Strategy and Action Plan aimed at addressing the rising rate of suicide in Scotland. The strategy looks for both national and local actions to address the risks and to provide better responses to people who are at risk of suicide and those affected by suicidal behaviour. The priority groups for whom the strategy recommends appropriate actions and investments be addressed include young people (especially young men), and people who abuse substances. Guidance was recently issued to local community planning partners will look for plans for implementing the strategy in local areas to be developed by December 2003.

4.29 This strategy and the actions to be taken form a key part of the work of the National Programme. From this Programme, 12m of new money will be invested from 2003 - 2006 on supporting the implementation of this National Strategy and Action Plan.

4.30 Two other initiatives within the National Programme are also of particular relevance:

• ' see me': campaign to address the stigma which can be associated with mental ill-health; and

• ' Breathing Space': an advice line for young men with low mood or depression.

These are outlined in detail in Annex B.

Drug-induced psychosis

4.31 This term refers to those psychotic symptoms which arise specifically as a result of intoxication with a drug but which continue beyond the point at which the drug is fully eliminated from the body. Symptoms will only recur if there is re-exposure to the drug and will have a demonstrably different course, outcome and prognosis, compared to other psychoses.

4.32 There are three possibilities to explain why psychotic symptoms may be present in the context of drug use:

• the symptoms may be induced by drug use in the absence of an independent psychotic disorder (usually as part of an intoxication or withdrawal state);

• the symptoms may be induced by drug use in the presence of an independent psychotic disorder; or

• the symptoms of psychosis may be aggravated by drug use in pre-existing independent psychotic disorder.

4.33 The first point of contact with psychiatric services is usually an out-of-hours emergency admission from a crisis situation to an acute adult psychiatric ward. Despite meeting the existing criteria for detention, (of mental disorder, risk to self or others, and no alternative management being possible), often an assumption is made that the Mental Health Act (1984) cannot be used in such circumstances. A valuable opportunity to engage with the patient may be lost as a result of unwillingness by ward staff to tolerate the different kinds of confrontational behaviour that are often seen. Client contact should be made with whatever substance misuse and mental health agencies (if any) have been dealing with the client before discharge. This will avoid damaging any mutually agreed treatment plan which is already in place.

People with schizophrenia and a substance misuse problem

4.34 In 2000, the then Clinical Standards Board (now part of NHS Quality Improvement Scotland) published its Standards for Schizophrenia. The statement for Standard 11 - Misuse of Alcohol and Illicit Drugs - sets down that 'every person who has a diagnosis of schizophrenia has their use of alcohol and illicit drugs reviewed whenever their needs are assessed by a multi-disciplinary mental health team. A person who misuses alcohol and/or illicit drugs has access, where appropriate, to the specialist addiction services'.

4.35 The National Report (2002) published by Clinical Standards Board for Scotland (CSBS) on the implementation of the first tranche of the Schizophrenia Standards noted that the use of alcohol and illicit drugs by most patients with schizophrenia is reviewed regularly. Also, in most Primary Care Trusts, users have access to specialist addiction services. However, the report noted challenges, including the variation that exists in approaches to the provision of specialist addiction services throughout the country. The report said there was no systematic audit of these services anywhere in Scotland. Systematic and proactive approaches to the provision of information about alcohol and illicit drug use for users and carers was also noted for its absence. There are few local health promotion programmes that specifically address the use of alcohol and illicit drugs by people who have a diagnosis of schizophrenia.

4.36 It was found that, generally, staff are not currently given specific training in caring for people with schizophrenia who also misuse alcohol and/or illicit drugs. The CSBS Report recommends that the role of specialist addiction services in caring for people with schizophrenia is reviewed to enable models of best practice to be identified. In addition, training in caring for people with schizophrenia who also misuse alcohol and/or illicit drugs should be included in staff learning plans. In 2000, no Trust met this criterion, and only 4 out of 18 Trusts partially met it.

4.37 The Standards recommend that there is a policy regarding the use of alcohol and illicit drugs on all Trust premises (hospital and community based) and that guidelines detailing the procedure to be followed when a user or carer is found in the possession of alcohol and/or illicit drugs on Trust premises are followed. Again in 2000, only 9 out of the 18 Trusts had such guidelines. Co-incidentally with the publication by CSBS of the National Report, the Scottish Executive Health Department released NHS Health Department Letter (HDL) (2002) 41 Managing Incidental Drug Misuse and Alcohol Problems in Mental Health Care Settings, which promotes safe care, prevention and considered approaches. That guidance links also to the Support Group report on Risk Management (2000), available from www.show.scot.nhs.uk/mhwbsg. The measures suggested have broad application to most community care settings.

Personality disorder

4.38 The National Institute for Mental Health in England has recently published Personality disorders - no longer a diagnosis of exclusion (2003). This gives guidance on the identification, assessment and treatment of people with personality disorders and aims to ensure that people who are in significant difficulty or with significant distress are seen as being part of the legitimate business of mental health services. It estimates that the prevalence of personality disorders in the general population is between 10 and 13% . People with personality disorders are at a much higher risk of developing substance misuse problems.

4.39 Secondary NHS Scotland mental health service workers have grown to believe, wrongly, that there is little therapeutic care that can be provided for people with personality disorders. The processes of assessment and categorisation are not well developed in day to day clinical practice. As a result there are only rudimentary services currently available for those diagnosed as having personality disorders in Scotland. These are mainly located within forensic settings, where approaches tend to be short-term and too focussed to meet the needs of the client group. This often results in premature self-discharge, with no follow up, unfairly leaving partner agencies, who have little expertise, to provide support. There is a need for a triple approach which changes staff attitudes, demonstrates the evidence base, and provides training in the necessary competencies.

4.40 Often the assumption is made that disordered behaviour seen in the present is indicative of a pattern going back to early adulthood, thus making the individual 'untreatable'. This contradicts knowledge about the vulnerability of some people to particular stresses and the effect of illicit substance use, which can lead to behaviour called 'borderline' personality disorder. The condition is containable given the right approach, over time, by knowledgeable people working in a committed service. The knowledge and skills are teachable and can be acquired. Unfortunately, there is no current guidance available on treating the condition in Scotland. The Executive is however looking at its response to the guidance recently issued south of the border Personality Disorder: No Longer a Diagnoses of Exclusion.

EXISTING MODELS OF CARE FOR THOSE WITH CO-OCCURRING SUBSTANCE MISUSE AND MENTAL HEALTH PROBLEMS

4.41 There are a number of different models of care operating in Scotland for those with co-occurring substance misuse and mental health problems. It is likely that current provision will have had as much to do with how services have evolved over the years in particular areas, however, rather than as a result of services being developed and adapted to meet the continuing assessment of needs of this client group. We also recognise that the key to successful services may also not necessarily be about the structure of those services, but the people involved, their skills, approach and commitment.

4.42 Services are provided in a range of care settings, from community settings, through primary care to specialist mental health services. In terms of specialist services, we outline below different models operating in Ayrshire & Arran and Glasgow, with a brief informal look at specialist services elsewhere. The EIU of the Scottish Executive Health Department is currently undertaking more detailed work into current service provision for co-occurring mental health and substance misuse problems, which will report at the end of 2003.

Ayrshire and Arran

4.43 A service has been developed in Ayrshire & Arran (population 390,000), following recognition that a large patient group consisting of those suffering from co-occurring mental health and substance related problems were not accessing the range of services that met their needs. A small, skilled and willing staff group were brought together to provide a direct service to this client group, including advocacy, liaison and shared care with both addiction and mental health workers. Training and personal development were key aspects of the development of the service. The team now comprises consultant psychiatrists, 5 community psychiatric nurses, an occupational therapist and a social worker.

4.44 Care programmes are planned in full consultation with the client, not in terms of primary or secondary diagnoses, but based on a pragmatic analysis of presenting problems, along with a thorough assessment of attendant risk. Care is rarely provided solely by the dual diagnosis team, but in liaison with mainstream services. In addition to the local addiction services and community mental health teams, there is also continuing and constructive dialogue with other organisations relevant to the client's care, including Local Health Care Co-operatives (LHCCs), the courts, the local A & E department and the local prison.

4.45 A residential support unit for people with dual diagnosis problems has now been established locally. It too has liaison and shared care roles.

4.46 A full description of the current service operating in Ayrshire and Arran, how it has evolved and indicative costings are outlined in Annex C.

Glasgow: Co-morbidity Evaluation and Treatment Team (CoMET)

4.47 An Addiction Psychiatry Service for Substance Misusers (non-alcoholic) was identified as a priority by the Greater Glasgow DAT in its Strategy Getting to Grips with Drugs in Greater Glasgow, following research by a DAT sub-group. The service, which deals with those with severe and enduring mental illness, combined with opiate use, became fully operational in October 2000 and now has designated staff for clients from each of the four local mental health sectors.

4.48 The team comprises a consultant psychiatrist, community psychiatric nurses (CPNs), social workers, psychologists and administrative staff. The CoMET team accepts referrals from a wide range of agencies, including the Glasgow Drug Problems Service, the Drug Crisis Centre, GPs, social work services and voluntary organisations. There is a simple referral form and the team has its own comprehensive assessment tool. A case management approach is adopted with particular emphasis on risk assessment.

4.49 Although the team has a wide range of skills due to its multi-disciplinary nature, there is a commitment to joint working and close relationships have been established with other agencies. Successful liaison and shared care is now the norm, resulting in fewer inappropriate referrals and more professionals being willing to share in the care of patients. The team has several prescribing clinics which operate in health and resource centres throughout Glasgow. Advice clinics have also been established in the Drug Crisis Centre and the Drug Problem Service. Assertive outreach and motivational interviewing in these settings have proved to be successful in preventing clients falling through gaps in care.

4.50 The co-morbidity service has undoubtedly met needs which were not previously satisfied, although it is acknowledged at local level that there is a need for dedicated inpatient beds and for more support and training to non-specialist staff, who have to treat mild to moderate mental illness.

Glasgow: Community Addiction Teams

4.51 Glasgow is currently developing service provision through proposals for Community Addiction Teams (CATs), piloting of which commenced in two areas in June 2003, before roll-out across the whole of Glasgow.

4.52 The CATs target those with primary drug and alcohol problems, who may also have co-occurring 'mild to moderate' mental health problems. The CATs assess, care plan and manage people into specialist health services - in-patient and partial hospitalisation and into purchased independent sector services. CATs also offer a range of specialist psycho-social interventions around addiction and mental health problems. They are staffed by addiction workers and mental health and physical health nurses.

4.53 For many people with severe or enduring mental illness, care management will normally be undertaken by mental health services, but CATs offer specific addiction related interventions.

4.54 The key features of the model are:

• direct access for clients to CATs and primary care services;

• CATs linked to psychiatric team and Community Mental Health team at defined stages;

• training and support to providers, including GPs;

• identified referral routes through a tiered structure of services to meet complex needs;

• care management into, through, and out of services; and

• residential services purchased from the independent sector.

Elsewhere in Scotland

4.55 Elsewhere, the picture across Scotland is one of patchy service provision. In Grampian, Forth Valley and Fife there is little specific provision and individual patient care is dependent upon the working relationship between addiction and mental health services and varies according to time and person. NHSLothian has recently appointed a director of its prescribing service which notionally will allow the 2 consultant psychiatrists currently providing this service to spend most of their time working with clients with co-occurring problems. Services in NHSBorders, and in the NHSWestern Isles have traditionally provided a completely generic service in which mental health workers are also expected to provide a service for drug and alcohol users. In NHSTayside the recent appointment to the post of senior lecturer in addiction psychiatry is expected to develop a service. NHSHighland has recently funded a number of community worker and CPN posts to work specifically in this area.

Primary Care Services

4.56 Primary care services undertake a wide range of work with this client group and their carers, often in conjunction with local authority services and voluntary agencies. Joint working is an area where primary care, through Local Health Care Co-operatives (LHCCs), has made good progress, with particular emphasis on the provision of services to socially excluded people through flexible funding and contractual arrangements such as Local Development Schemes and Personal Medical Services. This includes early brief interventions to tackle alcohol and drug use; on-going shared care of drug users; the screening for, and the management of, mild to moderate anxiety and depressive illness in those with substance misuse problems; and referral to psychiatric and psychosocial services. Primary care services also provide a 'safety net' for people who do not otherwise fit defined models of service provision - and it is for primary care to ensure that the complexity of their situation is appropriately managed.

4.57 The Primary Care Modernisation Group has highlighted the management of mild to moderate mental health as a priority; and the Centre for Change and Innovation is leading a project 'Doing Well by People with Depressive Disorders' which seeks to facilitate change and service redesign in the management of people with depressive disorders.

4.58 LHCCs are regarded as the key building blocks for primary care services and have made good progress in developing into responsive and inclusive organisations which are now a principal focus for the planning and development of community based services. LHCCs will evolve into Community Health Partnerships to reflect a new and enhanced role in service planning and delivery, within the community planning structure, so that innovation and service improvement is led by people working in the frontline in the NHS.

4.59 Opportunities exist, as never before, for primary care teams to work collaboratively with the rest of the NHS and partner agencies to ensure that the necessary skills, time and support - including that provided by specialists is available to deal with people with multiple problems. These developments are only possible by enabling professional staff to develop their roles, extend their skills and work more flexibly through training and development. Extended professional roles and skillmix changes place a greater emphasis on teamworking and many NHS services will be provided locally by an increasingly wide range of skilled staff working together as a team. Such teams will not be confined to particular buildings, but will work across communities and care settings so that patients can access services at a range of locations from a range of professional staff. This multi-disciplinary, and increasingly multi-agency approach is essential to support people with co-occurring problems through sustainable, integrated services and a seamless journey of care regardless of where, or how, they access it.

Services provided within a prison setting

4.60 The Scottish Prison Service (SPS) aims to provide an extensive range of services for offenders with co-occurring substance misuse and mental health problems. The main focus of their needs are being addressed by those working within the field of Rehabilitation and Care, namely Health and Inclusion Teams at both a local and national level.

4.61 SPS Policy initiatives, which exist or are being developed to address the needs of prisoners with this complex problem, are:

• Inclusion Policy which will incorporate the Addictions Policy, Social Care Policy and Learning, Skills and Employability Policy (2003)

• Short Term Assessment Process (2003)

• Sentence Management Manual (2002)

• Suicide Risk Management and Custodial Care (2002)

• Making a Difference (2002)

• Positive Mental Health (2002)

• Health Care Standards for Prisoners (1996) and

• Mental Health Care Nursing Practice Strategy (1995).

4.62 These documents are available from the Rehabilitation and Care Directorate, Scottish Prison Service, Calton House, 5 Redheughs Rigg, Edinburgh, EH12 9HW.

4.63 Positive Mental Health aims to provide a setting which encourages positive mental health in all aspects of prisoner management and care, responding to mental health and individualised care needs, including addictions.

4.64 Currently all addictions services in the Scottish Prison Service follow a recognised care pathway, called the Addictions Integrated Treatment Care Process. A number of key individuals from establishments are involved in this process (addictions, health and social care staff, officers, psychologists, caseworkers and transitional care workers).

4.65 Where a prisoner presents with a mental health and substance misuse issue the Addictions Co-ordinator will represent the addiction team on the Multidisciplinary Mental Health Team. Joint care planning and prioritisation of the issues (i.e. addictions and/or mental health) with as much information being shared as possible will prevent fragmentation of care, aiming to improve the treatment outcome for the individual. Community partners are crucial to this integrated care process. The three phases of this process are assessment, action and transitional care.

4.66 Currently every prison in Scotland has a degree of mental health resource. These include first level mental health nurses (RMN, RNMH), consultant psychiatrists, social workers, psychology services, chaplaincy, GPs, addictions nurses and in some prisons, forensic mental health outreach services. However, the distribution of many of these resources is not consistent across Scottish prisons and, as a result the quality of mental health services differs from prison to prison. In terms of psychiatric services few prisons have contractual arrangements in place and this is currently being resolved.

4.68 A standardised Multidisciplinary Mental Health Team (MDMHT) working approach has been devised and will be piloted in four SPS establishments between June and September 2003. Lessons learned will be incorporated and help to clarify the resources required for adoption of this corporate approach. This standardisation will provide the foundation for all mental health activity in the SPS. Improvements will be made to the process of linking prisoners to external community mental health services. The Addictions Advisor and Mental Health Co-ordinator are currently developing protocols and guidance for those with a mental health and substance misuse problem.

4.69 Inclusion is a process whereby, having assessed and addressed needs and risk SPS puts 'offenders back into society better equipped, and more able to be part of a community, than when they came into prison.' Historically, prisons have been seen as places of isolation and exclusion. This does not sit easily with concepts of inclusion and reintegration. The SPS is undergoing a culture shift, which accepts the need to work with others if it is to maximise the opportunities for prisoners to be successfully re-integrated back into the community. The SPS intends to develop the role of integrated care pathways and to adopt a cross-agency multidisciplinary approach involving key stakeholders.

4.70 At the present time SPS establishments are introducing 'LINKS Centres '. The purpose of LINKS Centres are to provide physical settings where prisoners can be assisted with their re-integration back into their community and quite literally be 'linked' to a range of services and partners to assist with reintegration, resettlement and inclusion. The aim is that every prisoner, on liberation, has an individual Community Integration Plan (CIP). The CIP identifies needs and actions which will assist the work being undertaken with prisoners to make a difference in their lives, thereby reducing reoffending and enhancing inclusion.

Services provided by the voluntary sector

4.71 Both the generic and specialist voluntary sector drug services have been working with people with co-occurring mental health and substance misuse problems for a considerable time in many parts of the country, delivering a range of treatment and rehabilitation services at all points along the care continuum. They also provide social, primary health and mental health care services and may manage specialist resources including crisis units, day and housing support services, and training and employment projects. Increasingly the sector is working with those people unilaterally excluded from mainstream provision because of their complex and challenging needs. This includes extensive experience of working with people labelled as having personality disorders or as sociopaths. Flexible and inclusive working approaches have been developed to assist retention in service, despite managing severe challenging behaviour. As a result of the style of working and the relationships built up with service users, such organisations are more likely to encounter disclosures of childhood sexual abuse, violence or trauma and reports of self-harming.

4.72 As voluntary sector agencies are often the first point of contact, they may carry out the first assessment. This first assessment is crucial in developing support plans and onward referrals for partnership working, including treatment for people with co-occurring mental health and substance misuse problems. Agency workers report that, on occasion, they have received less than helpful responses from both general and mental health providers.

4.73 There is also a vast network of support provided by voluntary agencies not funded by statutory resources which offer respite and support. An example of a voluntary sector project which deals with those with co-occurring mental and substance misuse can be found in Annex D.

Recent Research: Exploring the Experiences and Views of People with Drug/Alcohol Problems and Mental Health Difficulties

4.74 In order to inform the content of this report, the Working Group agreed to commission a limited study of users views by the Mental Health Foundation and Turning Point Scotland. This involved consulting people with drug and/or alcohol problems and mental health difficulties and exploring their views about their problems, their experiences of services and their views about how services could be improved. An Executive Summary of the research is at Annex E.

4.75 The findings substantiate other work which indicates that people with co-occurring mental health and substance use problems are likely to have a wide range of needs to be addressed, and this should be reflected in the kind of support that they are given. A person-centred and holistic approach, covering mental health, physical health and social needs, should be taken when designing, commissioning and delivering services. Access to services and therapies such as counselling, peer support, creative and alternative therapies is required. Access to support and advice on housing, employment and childcare is also important. Services also need to be more accessible and flexible, and it is important that service users are provided with the information they need about what services may be available to them.

CONCLUSIONS AND GAPS IN SERVICE PROVISION

4.76 Recent policy developments in the field of primary care and mental health service provision should lead to an improvement in the planning, delivery and accountability of mental health services, including those with mild to moderate mental ill health.

4.77 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. Applying the principles of Integrated Care for Drug Users should ensure that the multiple needs of this client groups are taken care of through better co-ordinated and integrated services, including housing, employment, treatment, criminal justice and other forms of support. A number of areas are already applying these concepts to services for people with mental health and addiction problems, but practice is not universal.

4.78 The National Programme, further endorsed within Partnership for Care, aims to undertake a number of measures to promote mental well-being, the prevention of mental health problems and the early identification and action when problems occur. The findings of our research confirms the need for this action.

4.79 The separation of the planning processes for services for those with co-occurring substance misuse and mental health problems, through DAATs and Joint Mental Health Commissioning Groups at local level, is not helpful to encourage joint service provision for this client group.

4.80 There is a lack of guidance in the treatment of personality disorder in Scotland, with only rudimentary service provision. A three pronged approach, changing staff attitudes, demonstrating the evidence, and training in the requisite skills, will be necessary.

4.81 There is a lack of the varied service provision that survivors of abuse require. The range which should be provided is currently the subject of other work led by the Scottish Executive Health Department.

4.82 There are 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;

• a lack of effective joint working between addiction and mental health services prevailing in some parts of Scotland;

• a 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;

• a lack of the necessary core competencies of staff in generic and front-line services;

• a lack of willingness to work with this client group, and a stigmatisation associated with their problem; this sometimes results in treatment not being offered and inappropriate referrals to specialist services;

• the need for aftercare support to be planned as an integral part of treatment to prevent recurrence; and

• the need for better use of the voluntary sector in planning and delivering services to this client group.

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