Substance Misuse Research: Co-morbid Mental Health and Substance Misuse in Scotland

Chapter 3: Regional Variations in Experiences of Co-morbid Mental Health and Substance Misuse

Introduction

The structure and resources of current mental health and substance misuse services is a consequence of historic service configurations, funding patterns and past planning approaches by local health and social care commissioners working with other partners. The effectiveness of commissioners' decisions relies on their awareness of clinical realities, their capacity to predict future needs and demands and their ability to integrate these demands with Government policy. Understanding local commissioners' perspectives on co-morbidity is a vital part of predicting how local services are likely to develop or need to change.

The first part of this chapter summarises service commissioners' observations on co-morbidity service provision in their respective areas. Factors common to all localities are covered in subsequent sections. These cover the debate on providing integrated and specialist services to those with co-morbid mental health and substance misuse issues, service user consultation and involvement in decision-making and planning and views on what might constitute an ideal service for this cohort of people.

Commissioner profiles

A total of 26 commissioners were invited for interview. Six were interviewed during the pilot stage and 20 during the main phase. In total 29 people were interviewed with some interviews involving more than one interviewee.

The commissioners in the pilot phase included representatives of Local Authorities and NHS services. In the main phase, the range of commissioners was expanded to include Directors of Social Services (or equivalent), Public Health Physicians, Drug and Alcohol Team ( DAAT) Co-ordinators and Lead Officers for Mental Health across the identified regions.

The professional histories of the commissioners were reflective of their respective posts and included a mixture of social work, nursing, medicine, psychiatry, psychology, sociology and criminology. Commissioners' current remits varied across research localities, inter- and intra-professionally, with considerable overlaps at the inter-professional level. The nature of direct experience of co-morbid mental health and substance use also varied between commissioners. Many had informal experience either working with co-morbid individuals or working at a more strategic level, with some indicating no direct experience. Few referred to any formal training in the theoretical frameworks of co-morbidity.

Summary findings from interviews with Commissioners

Table 1 Tayside

Tayside: Dundee
Co-morbidity Service Provision	No specific services were in place. Those with co-morbid mental health and substance misuse problems might find it difficult to establish which service (addiction or mental health) had primary responsibility for care and treatment. There were no plans for specific service provision in the Corporate Action Plans from the three Drug and Alcohol Teams ( DAATs) and the Health Plan.
Key Issues	Patients with addictions had difficulty in accessing mental health services. General Adult Psychiatry ( GAP) was reluctant to deal with patients who had drug or alcohol issues and might discharge them from their caseloads, even when an on-going and severe mental health problem existed. Specific psychological services were essentially non-existent for patients with addictions. GAP did not display a consistent approach in dealing with co-morbidity and there was a lack of uniformity in terms of service response and procedures. For example, there were few case conferences and these patients were often not included in the Care Programme Approach ( CPA). There was little attention paid to the care pathways of patients with co-morbidity. Although the NHS general psychiatry service and substance misuse services were nominally part of the same directorate, they had traditionally been run as separate services.
Planned Developments and Changes	In response to the Clinical Standards Board for Scotland, Standards for Schizophrenia, (Standard 11), NHS Tayside had initiated work on co-morbidity through the Primary Care Division. GAP and substance use service managers together with the independent sector had started work to address issues of liaison and joint working.

Tayside: Dundee

Co-morbidity Service Provision

No specific services were in place. Those with co-morbid mental health and substance misuse problems might find it difficult to establish which service (addiction or mental health) had primary responsibility for care and treatment.

There were no plans for specific service provision in the Corporate Action Plans from the three Drug and Alcohol Teams ( DAATs) and the Health Plan.

Key Issues

Patients with addictions had difficulty in accessing mental health services. General Adult Psychiatry ( GAP) was reluctant to deal with patients who had drug or alcohol issues and might discharge them from their caseloads, even when an on-going and severe mental health problem existed.

Specific psychological services were essentially non-existent for patients with addictions. GAP did not display a consistent approach in dealing with co-morbidity and there was a lack of uniformity in terms of service response and procedures. For example, there were few case conferences and these patients were often not included in the Care Programme Approach ( CPA).

There was little attention paid to the care pathways of patients with co-morbidity. Although the NHS general psychiatry service and substance misuse services were nominally part of the same directorate, they had traditionally been run as separate services.

Planned Developments and Changes

In response to the Clinical Standards Board for Scotland, Standards for Schizophrenia, (Standard 11), NHS Tayside had initiated work on co-morbidity through the Primary Care Division.

GAP and substance use service managers together with the independent sector had started work to address issues of liaison and joint working.

Table 2 Fife

Fife, Levenmouth Area
Co-morbidity Service Provision	The Fife Intensive Outreach Team was a specialist resource working with people with co-morbid conditions. The team carried an active caseload of 60+ clients and provided support to all 'sectorised' mental health teams in Fife. Finding information on the existence of services and how to access them was difficult. Existing care pathways between services were informal and depended on the working relationships of the professionals involved.
Key Issues	All services were perceived as being overstretched and community care and addiction services were under-funded. No focused attention was paid to the care pathways of co-morbid patients. General psychiatry and addiction services were traditionally viewed as distinct and separate services. Agencies viewed each other as competitors for finite resources and were reluctant to 'lose' their clients by referring them on. Although co-morbidity issues were well recognised, there was no focused attention on care pathways for co-morbid individuals. The main perceived problem was keeping people in treatment.
Planned Developments and Changes	Co-morbidity was expected to become part of the mainstream within service provision. The establishment of locality mental health teams was expected to address co-morbid issues more specifically. Work had already begun on increasing integration between drug treatment agencies in the region and between general psychiatric services and the addiction services. The Health Service-based treatment services dealing with drug and alcohol problems in Fife, Tayside and Forth Valley had been supporting one another informally for some years with the aim of improving services to patients. Lead clinicians and managers from Tayside, Fife and Forth Valley (East Central Scotland Addiction Services - ECSAS) had begun formally to develop a Managed Care Network ( MCN) in addictions.

Fife, Levenmouth Area

Co-morbidity Service Provision

The Fife Intensive Outreach Team was a specialist resource working with people with co-morbid conditions. The team carried an active caseload of 60+ clients and provided support to all 'sectorised' mental health teams in Fife.

Finding information on the existence of services and how to access them was difficult. Existing care pathways between services were informal and depended on the working relationships of the professionals involved.

Key Issues

All services were perceived as being overstretched and community care and addiction services were under-funded. No focused attention was paid to the care pathways of co-morbid patients.

General psychiatry and addiction services were traditionally viewed as distinct and separate services.

Agencies viewed each other as competitors for finite resources and were reluctant to 'lose' their clients by referring them on. Although co-morbidity issues were well recognised, there was no focused attention on care pathways for co-morbid individuals. The main perceived problem was keeping people in treatment.

Planned Developments and Changes

Co-morbidity was expected to become part of the mainstream within service provision. The establishment of locality mental health teams was expected to address co-morbid issues more specifically.

Work had already begun on increasing integration between drug treatment agencies in the region and between general psychiatric services and the addiction services.

The Health Service-based treatment services dealing with drug and alcohol problems in Fife, Tayside and Forth Valley had been supporting one another informally for some years with the aim of improving services to patients. Lead clinicians and managers from Tayside, Fife and Forth Valley (East Central Scotland Addiction Services - ECSAS) had begun formally to develop a Managed Care Network ( MCN) in addictions.

Table 3 Borders

Borders
Co-morbidity Service Provision	There was no specific integrated care pathway for co-morbid service users and situations arose where neither substance misuse nor mental health sectors took responsibility for these service users. Since inpatient services were limited and access unpredictable, co-morbid service users were often referred via extra-contractual arrangements to residential services outside the region, most notably Edinburgh. This had forced providers in the Borders to consider a wide variety of treatment options such as services available within a primary care setting, in the voluntary sector and in generic social services. Some progress had been made in terms of co-referral where generic mental health teams liaised with the Borders Community Addictions Team to decide on the most appropriate action, and vice versa. This had sometimes resulted in joint working. The adapted DAAT structure with its new commissioning group was thought to be linked to improvements in collaborative efforts.
Key Issues	There was a perceived discrepancy between National directives and recommendations, such as the use of a joint assessment tool, and local need and ability to implement these changes. Differences in practice criteria and professional cultures, especially between mental health and substance misuse services, required to be overcome. Attention needed to be paid to the wider health and psych-social needs of the individual, the need for increased training for staff and the further development of voluntary services. There was a dearth of diploma-qualified social workers, particularly in the core substance misuse and mental health teams. Limited resources and new responsibilities and initiatives, such as adherence to the Agenda for Change and out-of-hours services, had forced the prioritisation of essential services and slowed down the achievement of national priorities and objectives.
Planned Developments and Changes	Some of the recent developments across the Borders included addressing joint services, joint management of services and joint resourcing, the introduction of a new IT system for information sharing about service users and investment in advocacy services for people with mental health problems.

Borders

Co-morbidity Service Provision

There was no specific integrated care pathway for co-morbid service users and situations arose where neither substance misuse nor mental health sectors took responsibility for these service users.

Since inpatient services were limited and access unpredictable, co-morbid service users were often referred via extra-contractual arrangements to residential services outside the region, most notably Edinburgh. This had forced providers in the Borders to consider a wide variety of treatment options such as services available within a primary care setting, in the voluntary sector and in generic social services.

Some progress had been made in terms of co-referral where generic mental health teams liaised with the Borders Community Addictions Team to decide on the most appropriate action, and vice versa. This had sometimes resulted in joint working.

The adapted DAAT structure with its new commissioning group was thought to be linked to improvements in collaborative efforts.

Key Issues

There was a perceived discrepancy between National directives and recommendations, such as the use of a joint assessment tool, and local need and ability to implement these changes.

Differences in practice criteria and professional cultures, especially between mental health and substance misuse services, required to be overcome.

Attention needed to be paid to the wider health and psych-social needs of the individual, the need for increased training for staff and the further development of voluntary services. There was a dearth of diploma-qualified social workers, particularly in the core substance misuse and mental health teams.

Limited resources and new responsibilities and initiatives, such as adherence to the Agenda for Change and out-of-hours services, had forced the prioritisation of essential services and slowed down the achievement of national priorities and objectives.

Planned Developments and Changes

Some of the recent developments across the Borders included addressing joint services, joint management of services and joint resourcing, the introduction of a new IT system for information sharing about service users and investment in advocacy services for people with mental health problems.

Table 4 South West Edinburgh

South West Edinburgh
Co-morbidity Service Provision	There were no specific services or provisions in existence for the co-morbid service user. The Community Drugs Problems Service in Edinburgh and the Lothians, in light of the Joint Futures agenda, were beginning to prioritise people who had co-morbid mental health and substance misuse issues. A medical training position had been developed to provide some provision for co-morbid people who were also homeless. The development of direct links between psychology provisions and homeless services had helped to reduce waiting times and service bottlenecks. Locality clinics, led by community mental health services, provided a one-stop shop for multi-professional advice, assessment and referral. These were helping to reduce waiting times and provide access to appropriate support and treatment interventions. The locality teams were able to maximise economies of scale and scarce professional resources including clinical psychology services. The additional cognitive behavioural therapy training provided for nursing and occupational therapy staff meant that psychologists' time could be freed up for more complex issues.
Key Issues	More resources needed to be assigned to catering for those with less severe needs. The law was seen as interfering with the flexibility needed to deal with complex co-morbid problems. Substance misuse often prevented people from gaining access to mental health provision, especially residential or inpatient facilities. The voluntary sector had limited capacity to cope with alcohol-related problems. Different statutory services tended to concentrate on uniform problems which had led to an inefficient and disparate way of dealing with service users. Investment in the non-statutory sector was considered to be essential for the development of specific projects and services that the statutory sector was not able to provide on its own.
Planned Developments and Changes	Although it was recognised that services needed to adapt and provide more appropriate support and interventions, the real issue was that of meeting current structural and organisational requirements and recommendations. It was proposed that growth and change should be organic and emergent rather than being superimposed. Co-terminous partnerships between health, social care and the non-statutory sectors were helping to deliver more integrated working. Although this development was welcome, doubt was expressed on the extent to which specialist services catering across local authority boundaries could interface with localised general services.

South West Edinburgh

Co-morbidity Service Provision

There were no specific services or provisions in existence for the co-morbid service user. The Community Drugs Problems Service in Edinburgh and the Lothians, in light of the Joint Futures agenda, were beginning to prioritise people who had co-morbid mental health and substance misuse issues.

A medical training position had been developed to provide some provision for co-morbid people who were also homeless. The development of direct links between psychology provisions and homeless services had helped to reduce waiting times and service bottlenecks.

Locality clinics, led by community mental health services, provided a one-stop shop for multi-professional advice, assessment and referral. These were helping to reduce waiting times and provide access to appropriate support and treatment interventions.

The locality teams were able to maximise economies of scale and scarce professional resources including clinical psychology services. The additional cognitive behavioural therapy training provided for nursing and occupational therapy staff meant that psychologists' time could be freed up for more complex issues.

Key Issues

More resources needed to be assigned to catering for those with less severe needs.

The law was seen as interfering with the flexibility needed to deal with complex co-morbid problems. Substance misuse often prevented people from gaining access to mental health provision, especially residential or inpatient facilities.

The voluntary sector had limited capacity to cope with alcohol-related problems. Different statutory services tended to concentrate on uniform problems which had led to an inefficient and disparate way of dealing with service users. Investment in the non-statutory sector was considered to be essential for the development of specific projects and services that the statutory sector was not able to provide on its own.

Planned Developments and Changes

Although it was recognised that services needed to adapt and provide more appropriate support and interventions, the real issue was that of meeting current structural and organisational requirements and recommendations. It was proposed that growth and change should be organic and emergent rather than being superimposed.

Co-terminous partnerships between health, social care and the non-statutory sectors were helping to deliver more integrated working. Although this development was welcome, doubt was expressed on the extent to which specialist services catering across local authority boundaries could interface with localised general services.

Table 5 North East Glasgow

North East Glasgow
Co-morbidity Service Provision	Frontline service provision was provided by: Community Addiction Teams ( CATs), 9 new specialist teams bringing health and social work staff together and linking with education and employment services. They assessed the needs of patients with drug and alcohol problems and provided a range of individualised managed system of care and treatment programmes. They acted as the principal referrers to residential and hospital services and operated a single shared assessment scheme ensuring that both mental health and substance misuse issues were dealt with appropriately. The Homeless Addiction Team ( HAT) was a specialist team for homeless service users. The Drug Crisis Centre consulted and involved the service user and worked in partnership with the Social Work Department, the Housing Department, Greater Glasgow Health Board and with the voluntary sector housing and drug services. The independent sector largely addressed the needs of those presenting with less severe problems and those who found themselves in a crisis situation. It was substantially involved with the statutory sector in providing services to those with mental health and substance misuse issues and the homeless.
Key Issues	Service users tended to be passed between services and inter-agency working did not always function efficiently. The current Tier four service in Glasgow was not well enough developed to handle complex problems. There was an urgent requirement for liaison psychiatry for patients with drug and alcohol addictions to be provided on all acute hospital sites. The independent sector needed to be more actively involved in strategic planning and activities. Financial constraints were seen as a potential barrier to appropriate service provision.
Planned Developments and Changes	A complete medical service review was being undertaken to provide a comprehensive needs assessment for Greater Glasgow. A key priority for Glasgow was to increase skills training and employability for everyone, particularly for the socially disadvantaged and the unemployed. Equal Access Teams were based in all 9 of the local authority's sectors to offer direct support and guidance. These initiatives would benefit co-morbid service users.

North East Glasgow

Co-morbidity Service Provision

Frontline service provision was provided by:

Community Addiction Teams ( CATs), 9 new specialist teams bringing health and social work staff together and linking with education and employment services. They assessed the needs of patients with drug and alcohol problems and provided a range of individualised managed system of care and treatment programmes. They acted as the principal referrers to residential and hospital services and operated a single shared assessment scheme ensuring that both mental health and substance misuse issues were dealt with appropriately.

The Homeless Addiction Team ( HAT) was a specialist team for homeless service users.

The Drug Crisis Centre consulted and involved the service user and worked in partnership with the Social Work Department, the Housing Department, Greater Glasgow Health Board and with the voluntary sector housing and drug services.

The independent sector largely addressed the needs of those presenting with less severe problems and those who found themselves in a crisis situation. It was substantially involved with the statutory sector in providing services to those with mental health and substance misuse issues and the homeless.

Key Issues

Service users tended to be passed between services and inter-agency working did not always function efficiently.

The current Tier four service in Glasgow was not well enough developed to handle complex problems.

There was an urgent requirement for liaison psychiatry for patients with drug and alcohol addictions to be provided on all acute hospital sites.

The independent sector needed to be more actively involved in strategic planning and activities.

Financial constraints were seen as a potential barrier to appropriate service provision.

Planned Developments and Changes

A complete medical service review was being undertaken to provide a comprehensive needs assessment for Greater Glasgow.

A key priority for Glasgow was to increase skills training and employability for everyone, particularly for the socially disadvantaged and the unemployed. Equal Access Teams were based in all 9 of the local authority's sectors to offer direct support and guidance. These initiatives would benefit co-morbid service users.

Table 6 Aberdeen

Aberdeen
Co-morbidity Service Provision	Care pathways in Aberdeen were often designed and managed by community psychiatric nurses ( CPNs) who drew on other providers, including the voluntary sector, to complete a comprehensive care package with relevancy over time. Receiving funding for a care package was dependent on a certain level of inter-agency co-operation. Mental health services were the primary providers for complex problems involving psychological and psychiatric difficulties. This had resulted in mental health leading on addiction provision. Aberdeen's Joint Alcohol and Addiction Team had made the development of integration of services to drug users a strategic priority. This service combined the expertise of key voluntary sector organisations to provide a comprehensive package of support to drug users. There were some perceived inconsistencies between proposed strategy and reality on the ground because the service was funded by the Scottish Executive's New Opportunities Fund. The challenge was to join up services horizontally as well as implement corporate plans from above.
Key Issues	Grampian's rural nature made the delivery and integration of certain services demanding, particularly services to prison inmates. Carer support was identified as a gap in service provision. Specific examples included children who informally care for one or both of their parents with either a substance misuse or mental health problem(s) or both. Inpatient facilities were viewed in need of revision with specific reference to the co-morbid service user. There was a perceived over-concentration on the diagnosed mental health issue to the exclusion of addressing other needs, including issues associated with the person's substance misuse.
Planned Developments and Changes	Work to increase user involvement was on-going, though still in need of attention. The current focus was on substance misusers rather than on individuals with mental health problems or a combination of the former and latter.

Aberdeen

Co-morbidity Service Provision

Care pathways in Aberdeen were often designed and managed by community psychiatric nurses ( CPNs) who drew on other providers, including the voluntary sector, to complete a comprehensive care package with relevancy over time. Receiving funding for a care package was dependent on a certain level of inter-agency co-operation.

Mental health services were the primary providers for complex problems involving psychological and psychiatric difficulties. This had resulted in mental health leading on addiction provision.

Aberdeen's Joint Alcohol and Addiction Team had made the development of integration of services to drug users a strategic priority. This service combined the expertise of key voluntary sector organisations to provide a comprehensive package of support to drug users. There were some perceived inconsistencies between proposed strategy and reality on the ground because the service was funded by the Scottish Executive's New Opportunities Fund. The challenge was to join up services horizontally as well as implement corporate plans from above.

Key Issues

Grampian's rural nature made the delivery and integration of certain services demanding, particularly services to prison inmates.

Carer support was identified as a gap in service provision. Specific examples included children who informally care for one or both of their parents with either a substance misuse or mental health problem(s) or both.

Inpatient facilities were viewed in need of revision with specific reference to the co-morbid service user. There was a perceived over-concentration on the diagnosed mental health issue to the exclusion of addressing other needs, including issues associated with the person's substance misuse.

Planned Developments and Changes

Work to increase user involvement was on-going, though still in need of attention. The current focus was on substance misusers rather than on individuals with mental health problems or a combination of the former and latter.

Table 7 Forth Valley

Forth Valley
Co-morbidity Service Provision	Despite the existence of new referral protocols and the collation of epidemiological and demographic data, current collaborative and integrative efforts remained inadequate to deal effectively with co-morbid individuals. There was an expressed need for service role clarity regarding responsibilities and boundaries. Coterminous access points were seen to give proximity between services and provided a starting block for them to work together more effectively. Key providers from the independent sector, particularly in substance misuse, had helped to develop partnership working between the statutory and non-statutory sectors. The non-statutory sector was able to offer a more flexible approach, provide a more holistic care package and address more generic issues since they were less constrained by professional boundaries.
Key Issues	Although partnership working was viewed positively, there were still outstanding cultural and attitudinal barriers, which were not helped by current financial strictures on health budgets. Prioritisation had resulted in the diminution of substance misuse and mental health services, because these services were not ranked highly among service providers. Traditional ways of working coupled with a lack of knowledge regarding co-morbid mental health and substance misuse issues further constrained the degree to which people receive or are referred to appropriate services. The statutory and non-statutory sectors found working together challenging, especially when it involved sharing of budgets or contributions from different budgets. This was highlighted as a significant barrier to working out an appropriate strategy that actually targeted people's needs.
Planned Developments and Changes	Commissioners in Forth Valley had explored the idea of developing a specialist service for co-morbid service users but concluded that such a service might be too restrictive in its eligibility criteria to provide effectively for this group of people. Ineffective management was cited as a potential barrier to providing appropriate and consistent service delivery. Utilising the Unified NHS Board with people from the local authority on board along with the Joint Futures agenda was suggested as a possible pathway to dealing with co-morbidity in a pragmatic and systematic fashion.

Forth Valley

Co-morbidity Service Provision

Despite the existence of new referral protocols and the collation of epidemiological and demographic data, current collaborative and integrative efforts remained inadequate to deal effectively with co-morbid individuals.

There was an expressed need for service role clarity regarding responsibilities and boundaries. Coterminous access points were seen to give proximity between services and provided a starting block for them to work together more effectively.

Key providers from the independent sector, particularly in substance misuse, had helped to develop partnership working between the statutory and non-statutory sectors. The non-statutory sector was able to offer a more flexible approach, provide a more holistic care package and address more generic issues since they were less constrained by professional boundaries.

Key Issues

Although partnership working was viewed positively, there were still outstanding cultural and attitudinal barriers, which were not helped by current financial strictures on health budgets.

Prioritisation had resulted in the diminution of substance misuse and mental health services, because these services were not ranked highly among service providers.

Traditional ways of working coupled with a lack of knowledge regarding co-morbid mental health and substance misuse issues further constrained the degree to which people receive or are referred to appropriate services.

The statutory and non-statutory sectors found working together challenging, especially when it involved sharing of budgets or contributions from different budgets. This was highlighted as a significant barrier to working out an appropriate strategy that actually targeted people's needs.

Planned Developments and Changes

Commissioners in Forth Valley had explored the idea of developing a specialist service for co-morbid service users but concluded that such a service might be too restrictive in its eligibility criteria to provide effectively for this group of people. Ineffective management was cited as a potential barrier to providing appropriate and consistent service delivery.

Utilising the Unified NHS Board with people from the local authority on board along with the Joint Futures agenda was suggested as a possible pathway to dealing with co-morbidity in a pragmatic and systematic fashion.

Common views on issues relating to co-morbid mental health and substance misuse

Commissioners were in broad agreement on a number of topics relating to:

the management of co-morbid service users
user consultation and involvement
ways of improving integration of services and delivery of care.

Integrated versus specialist service provision

This section discusses the relative merits of integrated care and specialist service provision, outlining commissioners' views on their respective usefulness and feasibility.

Partnership working has been described in several ways:

Partnership work: organisations with "differing goals and traditions, linking to work together" (Home Office, 1992)
Joint working: [drug] services developing working relationships with other drug-related organisations or services to "help establish the broadest range of seamless service delivery" ( NTA, 2002)
Shared care: the joint participation of specialists and primary care, especially GPs and pharmacists, in the planned delivery of care for patients with a drug misuse problem, "informed by an enhanced information exchange beyond routine discharge and referral letters" (Department of Health, 1995)
Integrated care: an approach that "seeks to combine and co-ordinate all the services required to meet the assessed needs of the individual" (Effective Interventions Unit, 2002).

Drake et al. (2000) support integrated treatment or integrated care pathways as set out in Dual Diagnosis Good Practice Guide (Department of Health, 2002) rather than parallel or consecutive approaches. Integrated treatments are based on the notion that a single tailored programme caters for both mental health and substance misuse issues by the same specialist clinicians.

Supporting integration

Integration as a concept, at the very least at a structural level, was viewed by the majority of commissioners as essential to effective and efficient service delivery, not only to co-morbid service users but to all service users with complex needs. Some commissioners spoke of the difficulty in overcoming the unintentional barriers, titles and terms created when attempting to develop sound team work.

Others explored the idea that sharing budgets on a needs-led and consumer-focused basis might lead to lowered conflict between services that currently have very different remits and might ring-fence resources to satisfy those responsibilities.

Interviews also highlighted the lack of an evidence-base relating to how a joined-up multi-disciplinary work force might be created. Current guidance was not viewed as sufficiently informative to answer this question adequately. Several commissioners seemed unsure about what an integrated service might look like. The expressed opinion was that the outcome of any service configuration should result in a complete package of care and support at the user's level and that it might not be necessary to have a truly integrated service to enable that to happen.

Although there were examples of effective collaboration and good partnership working between different service sectors and agencies, the arrangements could be much improved. The commissioners felt that integrated services would be admirable as long as the service user and his or her main needs remained the focus but queried how this might be achieved. This aspiration reflected the principles set out in Our National Health and Partnership for Care of putting the patient at the centre. They sought a better understanding of the underlying antecedents that brought co-morbid service users to the point where specialist service involvement was necessary.

Querying integration

A note of caution was expressed by commissioners who understood 'integrated' as 'holistic' care with all services coming together to address pertinent and wider needs. One commissioner raised the possibility that such an approach might have the unintended consequence of service users falling through the net because of a perceived threat to their daily life, such as the fear of child protection involvement. This showed a lack of awareness of the availability of published guidance and advice on Integrated Care Pathways and Managed Care Networks.

Other views centred on the notion that a 'one size fits all' approach would be unlikely to favour all service users and might be unsuitable in certain areas, resulting in either limited benefits or no benefits at all. Commissioners with a wide remit of services were concerned about the complexity of integrated service provision and the potential for chaos and confusion as opposed to smooth and seamless functioning.

Supporting specialist provision

Only one commissioner viewed a specialist service positively. Most commissioners preferred to focus on developing current services rather than create new ones and risk further divisions across the services. Funding restrictions were likely to be a significant barrier in creating effective care pathways and joined-up planning and practice.

Querying specialist provision

The majority of commissioners were not in favour of a specialist co-morbidity service for a variety of reasons. Those in rural localities felt there was no demand for a specialist service, in spite of the need for service improvement and possible reconfiguration. Their preferred approach was to address need via existing services by enhancing levels of inter-agency working.

Many commissioners felt that the creation of a specialist service was potentially risky. It could become remote from more mainstream services, resulting in a 'dumping ground' for 'difficult' service users and creating an overall less skilled and knowledgeable staff base. This view was also expressed by providers in Chapter 4 of this report.

The isolation could also result in little movement between services and service sectors and create lengthier waiting lists due to case overload.

The consensus was that co-morbid service users would be better served by increased joint planning and working rather than by specialist services focusing on co-morbidity.

User consultation and involvement

The NHS in Scotland has a statutory duty to involve service users, but users and professionals have experienced problems in interpreting this and putting it into practice. In recognition of this NHS Boards are therefore required to have a Designated Director for Patient Focus and Public Involvement ( PFPI) with responsibility for supporting and co-ordinating this work across the organisation. Boards are expected to develop a variety of approaches to meet the requirements of specific groups of service users. In this context it is worth noting that in 2004 the National Institute for Mental Health in England ( NIMHE) commissioned the Health and Social Care Advisory Service to consult with service users, carers and other stakeholders to establish what the main issues were and how service user involvement might be improved. Their conclusions centred on the importance of reaching out to diverse communities and groups, involving users more informally rather than formally at meetings, making routes to involvement more equitable, and monitoring and evaluating these strategies in terms of good practice.

Advocating involvement

"User and carer involvement undoubtedly changes the dynamic and makes you think about much more about what you're saying, what the impact is of what you're saying, having to explain it in ways that are not jargonistic and also isn't tokenistic or patronising."

The majority of commissioners and service providers in both the statutory and non-statutory sectors agreed that routine consultation with service users (and carers) was important, even if some of that consultation was tokenistic in gesture.

Issues highlighted by those with experience of widening the scope of consultation and involvement included how to approach service users linguistically at a level comprehensible to them without being condescending or demeaning.

Perceived challenges

The commissioners emphasised the importance of mutual respect and understanding. Some questioned the belief that the views of service users were inevitably sacrosanct and better-qualified than those of providers.

During the interviews, it became clear that a key factor in involving users was the need to ensure that this involvement was real, meaningful and representative. The overriding concern was that user consultation and involvement was not adequately supported. There was little or no training given on how to approach users, no clear brief on their roles and little thought given to incentives for their involvement.

The ideal and the reality of user involvement were thus frequently viewed to be at odds. Rising expectations among users, an inability of many organisations to understand user involvement and tokenistic implementation of user consultation was viewed by many to lead to frustration, mistrust and a questioning of the basis of its foundation.

Despite an overall consensus regarding the challenges of engaging service users there was also overarching agreement that their experiences and perceptions were as important as those emanating from the service sector.

In an ideal world

Toward the end of the interviews, all commissioners were asked to imagine an ideal world in the context of co-morbid mental health and substance misuse. Many responses centred on current recommendations (e.g. Models of care,NTA 2002) and emphasised the importance of providing treatment through integrated care pathways across all four treatment tiers that were as seamless as possible. Joint commissioning and robust service level agreements were viewed as essential to enhance seamlessness and counter unnecessary duplication of services.

Commissioners essentially concentrated on three core areas for improvement to allow integrated care pathways to come to fruition. These included a holistic or person-centred approach to treatment, improved access and the need for wholesale change in cultural values and attitudes toward mental health and substance misuse.

The Care Programme Approach, advocated here, promotes a level of integrated practice and takes a holistic approach to treatment, care and support. A key element of this 'whole system' approach is effective care co-ordination for individuals with complex needs. Links need to be made across social work or care services, health, education and employment, housing, criminal justice and voluntary agencies to facilitate access for individuals to the range of services required to meet their needs.

Accessibility of services is a key element of integrated care. Improved pathways to access also mean that service users should be able to engage with a range of services depending on need and different services over time as their needs change. The responses of commissioners suggested that this was not currently happening but that that it was an ideal to strive for.

A cultural shift in attitudes toward people with mental health and substance misuse issues presented possibly the greatest problem. Unhelpful and pessimistic attitudes towards substance misusers were noted elsewhere in the Effective Intervention Unit publication Rural and Remote Areas: Effective Approaches to Delivering Integrated Care for Drug Users (2004). Increased joint-training was advocated as a possible solution in overcoming these barriers.

Person-centred and needs-led

The complexity of co-morbid mental health and substance misuse made it difficult to treat. This was compounded by the continued debate surrounding the aetiology of co-morbid manifestations. One of the commissioners' main aspirations was to align need and provision. This would need a much better knowledge and understanding of the causes of different co-morbidities.

Interviewed commissioners from rural areas particularly emphasised the need for improved localised interventions and support structures so that people could reside in and benefit from their own known environment and cultural norms rather than having to travel to the major towns and cities.

Simplified and easy access

I think it's really a question of having such a range of services you can tap into that are appropriate for their needs at that particular time because we know this is a group of people whose needs change quite dramatically over periods of time, and indeed within 24 hours depending on what they're using. This is an incredible opportunity that we must take to shift services for dual diagnosis and other people with acute and enduring mental health problems to a different way of working, different area, different timescales, different times of the day.

Commissioners were unanimous in advocating easier and simpler access to treatment and support provisions. This ideally would involve the removal of barriers such as opening times as these were seen to lead to a lack of engagement and non-attendance. In addition commissioners felt that organisational arrangements should be flexible enough to offer a service that was as person-centred as possible.

The view was that traditional cultures continued to prevent individuals with dual mental health and substance misuse problems from accessing psychiatric care.

Although it was acknowledged that there were ongoing debates about who should take ownership of co-morbid individuals, this was not necessarily seen as affecting the service user's right to support and treatment.

The overall observation regarding points of access was that engagement should occur proactively at varying levels. GP-led services, for example, tended to focus on early intervention and prevention. By the time services were accessed via the criminal justice system, the problems were more complex and corresponding needs were greater, making engagement more difficult. Commissioners highlighted the advantages of a single point of entry with all the necessary staffing to meet the service user's requirements,

In rural locations, geography, poor transport links, planning and awkward appointment times were all thought to militate against timely access. Service users with complex problems needed additional support to attend appointments and this had to be made as straightforward and realistic as possible.

The nature of co-morbid mental health and substance misuse issues could also create barriers to access. Co-morbid service users often displayed fractious behaviours that were difficult to manage, leading to services or individual staff members being reluctant and apprehensive to deal with them.

The needs of many service users could be met at the primary care stage. The new General Medical Service contract, however, has given GPs the possibility of opting out of dealing with substance misusers. This had resulted in certain specialist services being over-stretched. The lack of a specialist prescribing service discouraged many service users from seeking treatment, as they had to rely on these same GPs.

Access to care and treatment was often only gained at crisis point, leaving a gap in service provision for those service users with less severe or mild to moderate problems.

Cultural and attitudinal change

The issue of stigma was another phenomenon frequently alluded to during interviews with commissioners. Either imagined or real prejudice might have the effect of turning people away from seeking advice, support and treatment. An equitable and respectful approach was needed to encourage engagement and disclosure.

"I wouldn't have any stigma or discrimination against people. We need to ensure that people are treated fairly and respected well."

There was also a call for more acceptance and understanding of co-morbid issues and a realisation that these complex needs required team working across agencies and sectors.

Information sharing and cross-fertilisation of ideas across Scotland were viewed as important to avoid duplication of effort, helping to discover what actually worked and contributing to an evidence base.

All commissioners stressed that wholesale changes in the way providers and society in general viewed co-morbid mental health and substance misuse issues were essential to create an ideal world for service users and their families.

Summary

The commissioners taking part in the research study were drawn from locations with a wide range of demographic profiles, demands and needs. Although there was considerable overlap between the types of services offered in these areas, the nature of the services and working styles differed considerably. It was not clear to what extent this reflected local service user needs, other requirements or historically grounded ways of working.

There were few co-morbidity-specific provisions in any of the locations; the one that did exist was viewed by the relevant commissioners to be effective only to a minority of service users, because of the strict access criteria, staffing and lack of sound interagency working. It was noteworthy that this view was not echoed either by participating providers or by service users.

Ownership

Commissioner views differed about who should have majority ownership of co-morbid service users. To ensure consistency in care, many commissioners supported the current stipulation that generic mental health should maintain key worker responsibility for an episode of care for clients with co-morbidity or a primary diagnosis of a mental health problem. It was also felt that this arrangement should be complemented by facilitated access to specialist services. This would support generic mental health services more effectively.

Others were sceptical about the value of maintaining consistency where this hindered appropriate service provision. The expressed view was that ideally key responsibility should be dependent on the service user's needs and should be aligned accordingly. Ownership would then become a collective issue and would help change entrenched cultures and barriers and engender an alternative culture and more positive attitudes toward co-morbid service users.

Clear pathways for co-morbid individuals

Joint policies and shared assessment protocols were widespread although not practised in all the localities. Gaps between national directives and local need and ability to implement the recommendations were highlighted by a number of commissioners.

The support for interagency and joint working was moderated by a degree of scepticism and concern that a policy preoccupation with a 'quick fix' had driven the debate. The gap between policy recommendations and local reality was viewed as difficult. It was recognised that assisting recovery for people with co-morbid mental health and substance misuse issues would be a long and often frustrating experience for the service user and their families and for service providers.

Most commissioners did not support a new or separate service for co-morbid service users but did accept the existence of staff with specialist knowledge based within provider services. In rural areas, this lack of support could be attributed to low demand and limited resources. In other areas, it was thought that vast numbers of people with complex needs might present and this would be difficult to manage efficiently. The knowledge and ability to deal with this service group should be available from all services as a matter of course.

Increased involvement of non-statutory sector

Commissioners expressed concern about the underdevelopment of the non-statutory sector. They felt that increased and effective engagement with the non-statutory services would help to ease some of the pressures experienced in the statutory sector. This issue was compounded by the lack of comprehensive lists of services available and limited awareness of the nature and scope of those services.

Increased emphasis on prevention and early intervention

With notable exceptions, the study found that most research locations did not have established protocols and practices addressing prevention, early intervention or focus on recovery. This had implications for training and education of staff, especially staff in generic services that were most likely to come into contact with people when problems were still emerging.

Crisis and out of hours access

The service mapping exercise pointed to inadequate out-of-hours access in crisis situations. Coupled with this, commissioners suggested a need for all services within the respective localities to explain what they do, why they work in a particular way, their referral criteria and what to expect from their involvement. This would offer service users and providers a wider choice when support from the mainstream services was not available. It would also help identify service gaps and indicate the best ways to provide crisis support.

Consultation versus involvement

The barriers to effective consultation and involvement were thought to be underpinned by historic views resistant to the inclusion of substance misusers as stakeholders. These barriers were intrinsic to the nature of many services and centred around professionalism and power imbalances. One school of thought adopted a tokenistic response, and adhered to the philosophy of filing returns. Another tried to make a real difference in relationships by learning how to engage and empower service users effectively and equitably.

Professional training

Commissioners felt that training for mainstream service staff should be introduced to produce specialist co-morbidity workers and increased awareness among all practitioners working with combined aspects of mental health and substance misuse. This included staff in the statutory and non-statutory sectors. The identification of core competencies needed to be clarified in order to develop the right quality of training for the right level of practitioners.

Potential challenges

Analysis of the collective views of commissioners has shown where service provision could potentially fail. The list below identifies stages and service gap points where there is a risk that service users could fall by the wayside.

Generic services appeared to be ill-equipped to identify at risk or vulnerable people. This could prevent them from applying preventative measures or referring these people appropriately at an early stage to prevent escalation of any presenting problems. A lack of focus on prevention and timely intervention could lead to minor problems going undetected and service users falling through the gaps.
Varied assessment time frames and lengthy waiting times following the recognition of a service user in need could contribute to prolonged distress and the potential for drop-out.
At the point of assessment, many mainstream mental health and substance misuse services had continued to screen out on the basis of substance misuse in mental health and mental health in substance misuse. Such territorialism was felt to fail the person-centred approach currently advocated.
While some localities had systems in place to pick up those with less severe problems, others relied informally on the non-statutory sector. An over-concentration on severe and enduring problems was seen to highlight the need for preventative actions and timely intervention.
The non-statutory sector was seen as under-developed in many regions and was unable to fill service gaps or cope with unmet needs.
At the point when service providers were assessed and provided with intervention and support options, individual care plans - the ideal option - were often not put in place.
With some exceptions, crisis services and out of hours services were restricted across all localities, with service users having nowhere to turn. As service users often only came to the attention of providers during crisis situations, this had significant service planning implications.
Support for informal carers was not well developed in many areas and this compounded the stressors associated with co-morbid problems.

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