MIND THE GAPS
Meeting the needs of people with co-occurring substance misuse and mental health problems
CHAPTER 6: PLANNING AND DELIVERY OF SERVICES
looks at how services might be structured locally to meet the needs of those with co-occurring mental health and substance misuse;
advises commissioners on key elements of service provision which should be available locally; and
considers the wider needs of the client group.
Models of care
6.1 There is no UK evidence on what model of care is most effective in the treatment of those with co-occurring mental health and substance misuse problems. Whilst this document sets out what the essential considerations must be, it cannot recommend any particular model of service delivery. Those involved at a local level must agree on how they can meet the needs of service users in the light of their knowledge of the prevailing conditions. Matters such as workforce training and service redesign can be set in motion to allow the services to evolve. As indicated earlier, Partnership for Care, the Joint Future Agenda and Integrated Care for Drug Users are the key drivers for change to the way that services are planned and delivered. This should ensure a broad-based approach to service delivery. Just as important, is the style and culture of service delivery.
6.2 NHS Boards and partner local authorities should consider the needs of this group as one entity. A programme budget for the group should be allocated and managed as a whole, whether or not there is a defined severe or enduring mental illness present. Both NHS Boards and local authorities have continuing responsibilities under the Community Care Act 2002 to expand local joint working including the pooling of budgets.
6.3 Chapter 4 provides detail on two different models currently operating in Glasgow and in Ayrshire & Arran. What can be achieved for this client group will depend on local joint agreements on service re-design, which will inevitably be based on the existing service make up and demographic and geographical factors. The following framework offers a suggested approach to the grading of care which might be worthy of consideration for those planning and commissioning services. The framework is one within which Joint Future principles can apply.
Grading of care
6.4 The following diagram attempts to match increasing severity of need to increasing levels of specialism and conceptualises care in 4 or 5 steps, the availability of which forms a pyramid of specialisms. However, it is important to understand that this way of looking at individual need and the way services might respond is useful for analysis, but does not provide any kind of blueprint for the design of a local service. It is quite likely that an individual who has complex needs in one area of life will have simple requirements in others, but which are just as important to be met for the overall outcome.
The steps which might be considered as part of this kind of graded system are outlined below.
6.5 This might be the degree to which information about services and possible assistance is visible in the client's community. It might include family, friends, social clubs, football teams, fellow pub clientele, churches - anyone who knows of the person, is aware of at least some of his or her difficulty and wishes to try and help. Although often 'unskilled' in service terms, this step has the advantage of being the most readily accessible, least stigmatising and most acceptable, based on a close knowledge of the individual. It is a level of care that can be very powerful and which is often undervalued, if not overlooked, by professional carers. Without doubt there are issues arising from the entitlement to confidentiality, and the risk of stigmatisation. However, the services can ill afford to neglect sources of continuing support for an individual, if arranged sensitively.
6.6 Generic services, which might include schools, police, general practitioners, social workers, A & E staff and community workers. They are providing care and support in some form. Although there may be no substance misuse or mental health related specialist function, these workers will have some skills in the detection of difficulty. At present such workers may not feel confident to embark on exploration of difficulties, partly because of not wishing to precipitate a crisis, partly because of an unawareness of local services. There also needs to be continued contact and liaison for productive working.
6.7 Generic services with some specialist function, for instance workers from the voluntary or statutory sector who specialise in either mental health or substance misuse services. These are people who may feel proficient or skilled to work in some arena and not another, although they will very often have some expertise by virtue of a degree of overlap in training.
6.8 Specialist services, which intervene for people with co-occurring problems can be derived from the voluntary or statutory sector and have special expertise. While some are trained, many often gain expertise in the absence of adequate training in the particular difficulties brought by this group. They may or may not form a discrete service, one alternative being the dispersal of suitably qualified individuals into the teams providing the Step 3 service, thus producing a 'virtual' team. The advantages of such a model would include the onsite, gradual and fluid upskilling of generic workers. The disadvantage would be relative isolation and difficulty in accessing peer support.
6.9 Those services offering a highly specialised treatment resource. This might include, as an example, an inpatient unit specialising in the long-term treatment specifically of those people with co-morbid difficulty and personality disorder. Whilst the other 4 steps could be seen as being appropriate within one NHS Board area or one local authority, Step 5 is much more likely to be appropriately placed regionally or supra-regionally. Mapping this intervention sequence requires some delineation of the level of need within the population of those with co-morbid needs. 'Severity boxing' might produce the following:
Severe mental illness/severe substance misuse (Steps 4 & 5)
6.10 This would comprise the core client group of Step 4 and would be those whose illness and misuse have become so intertwined as to render causal explanation irrelevant. It is with this group that the most pragmatic responses to need will be made, often irrespective of formal diagnosis but rather responding to expressions of need. This group will be the most chaotic, least able to keep appointments, most likely to demonstrate a variety of risky behaviours and least likely to be able to keep up with the demands that society makes on them. They will require careful, well-communicated client-centred care planning with frequent intense input over very long periods of time and will usually benefit most from the input of a wide range of professions. Diagnoses might include severe and schizophrenia, severe and refractive affective psychosis and severe post traumatic disorder, including childhood trauma, with polydrug abuse, reported self-harm etc. Models of care for this vulnerable group who pose a number of risks need to be developed. The Low Threshold Methadone Project in Lothian, which deals with 30 to 40 individuals at any time, gradually engages people in treatment and staff relationships, as an essential preliminary to a move onto other services. This is one way of attending to the needs of a care group which otherwise can easily be overlooked.
Severe mental illness/some substance misuse (Steps 3 and 4)
6.11 Those whose needs might best be met by input from mental health services with support, advice and occasional episodes of shared care from Step 3. The Step 3 services may need to be helped in adjusting their expectations of their client group who may on occasion behave in ways that are difficult to accept. It would include those who misuse substances as a way of 'self-medicating'.
Non severe mental illness/severe substance misuse (Steps 3 & 4)
6.12 Those whose needs might best be met by input from the substance misuse services with support, advice and occasional episodes of shared care from Step 4. The Step 3 services may need to be helped in adjusting their expectations of their client group, who may on occasion be unwilling to accept personal responsibility for themselves to the degree that would normally be expected. It would include those who have milder forms of those being seen by Step 4 as well as those suffering the dysphoria implicit in severe substance misuse.
Non severe mental illness/substance use/misuse (Steps 2 & 3)
6.13 Those whose needs would be best met at the level of Step 2 with support, advice and shared care from Step 3, as appropriate.
6.14 The needs of these 4 groups can be met in a number of ways. The functions implicit in the structure above are more important than the structures themselves. The way in which they are achieved will often have their roots in the way that services are already structured. There may, however, be real tensions locally between:
the exclusivity and expense, but potentially more effective outcomes, of having a Step 4 service;
the potential burnout and de-skilling of an allocated specialist worker to Step 3 services to provide much needed support and advice for generic workers; and
the more equitable, but potentially less effective service, of partially upskilling all generic workers.
6.15 These can only be resolved at a local level. It is important that the functions previously outlined are met. However, service standards setting for those in this client group would be helpful to underpin coverage and quality of services.
Needs assessment/service mapping
6.16 Planners and commissioners of services need to be aware of the nature and scale of the problem, so that resources are targeted appropriately. Evidence outlined in Chapter 3, however, shows the extent of co-occurring substance misuse and mental health problems already known throughout Scotland. Further extensive needs assessment work using epidemiological techniques at local level is probably not, therefore, required at this time. Service commissioners should concentrate on looking to see how gaps in current service provision, its profile, culture and flexibility to respond as highlighted within this report, might best be met.
6.17 This would be highlighted by service mapping and looking at the links and referral patterns between them in line with the Joint Future and Integrated Care Agenda. Within that, the following issues need to be taken into account.
This client group is extremely challenging, but nevertheless deserves access to the most appropriate and timely services.
These services should be available where there are existing facilities where this client population is likely to be found.
Expectations of what can be achieved through treatment and intervention need to be emphasised to client and to service providers alike.
Interventions should be as broadly based as possible, and include social, education, and employment elements.
Commissioners should consider how best to pursue service re-design in order to address the needs of this client group within mainstream, generic services with easy referral to meet more specialised needs.
Voluntary sector services should play a key role in planning and delivering treatment and care to this client group and should be resourced accordingly.
Early intervention is likely to be cost-effective, avoiding inappropriate referrals to more expensive specialist services.
Interventions need to be person-centred and not based on existing service availability. Services should aim to give the client as much involvement in decision making, partnership in care and sense of control as is appropriate in the circumstances.
The 'take this letter and go and see this person I have decided you need to see' approach is highly unlikely to be helpful; successful service collaborations are likely to involve link workers who 'stay with' the client, especially the more chaotic individuals, in their early contacts with the service. This should reduce missed appointments and help to reassure clients of a genuine commitment from service providers. There are successful alcohol liaison nurse models, particularly in Edinburgh, which could be adapted.
Independent Advocacy should be a key feature of service provision, with workers helping service users through treatment and care services.
Liaison with service users and those who care for them is an essential part of the process of staying in focus and making sure what is done is as fit for purpose as possible. Who better than the users of the service to let those providing and those commissioning the service know how it was for them?
Training and support
6.18 The need for proper support and training for all staff has been emphasised throughout this document. 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:
the development of assessment skills based upon substance misuse and mental health assessment frameworks;
the facilitation and handling of disclosure about previous traumatic experiences;
the 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.
6.19 It is recommended that STRADA should take account of the detail of this report in a review of its material.
6.20 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.
'If it wisnae for him, ah widnae be here right now.'
Mental Health Foundation Research 2003