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Chapter 7: Main Findings and Recommendations

Introduction

This qualitative research project has explored the experiences of 26 commissioners of services spanning mental health, social work and substance misuse, 90 staff members across a variety of primary and secondary health and social care services and 38 service users living with severe mental health problems and substance use issues. The interview narratives were analysed to address:

• participants' understanding of co-morbidity
• the impact of living with co-morbidity
• experiences of support provided through statutory and non-statutory sector services
• the 'gaps and problems' that individuals identified which significantly affected their ability to manage complex dual health issues.

Service user and provider responses were compared. The focus of each group differed but there was substantial agreement about the impact of co-morbidity on peoples' lives and how ideally these complex problems might be tackled.

Accessibility and availability

Signposting: The degree to which services were advertised and the level of knowledge regarding the nature, remit and limitations of services were insufficient to guide the service user either to or through the service maze. Booklets and pamphlets went out of date quickly and often appeared or were available only in a limited number of facilities, most notably in general health facilities. In the absence of a 'live' and regularly updated directory of service remit and availability, providers were likely to continue to rely on historical links to services rather than on what was actually available.

Structural obstacles: The structure of existing services and their service philosophies were considered by many as creating barriers for co-morbid service users who might need input from a number of different service providers. Reports suggested that traditional trajectories rather than client-centred thinking often influenced decision-making about approaches to service users. As a result, there were debates between services as to who should take responsibility for service users with different presenting problems.

Management of mild to moderate mental health problems in substance misusers: Individuals with substance misuse-related issues often did not have sufficiently severe mental health problems to be eligible for attention from community mental health teams which prioritised severe and enduring mental illness. The majority with mild to moderate mental health issues were then sometimes inappropriately managed by substance misuse agencies or by primary care services.

Management of mild to moderate substance misuse problems in those with mental health problems: Similarly, individuals who used substances such as cannabis that were commonly thought to be relatively innocuous often did not qualify for eligibility to substance misuse services. These concentrated largely on opiates and other injectable drugs. This service configuration created obvious gaps in provision for people who needed help for both substance use and mental health issues.

Particular tensions:

Accommodation: Positive experiences were reported in relation to supported accommodation, though the availability of such living arrangements was scarce and often restricted to those who did not use substances.

Contentions between drugs misuse and alcohol: Many of the respondents, commissioners and providers included expressed dismay and frustration over the ways in which generally more money and other resources were made available for drug misuse compared to alcohol.

Specialist provision: Frustrations were expressed at the difficulty experienced in accessing specialist help in a crisis. The responsiveness of the 'system' to the needs of a group of people with multiple needs was challenging for all concerned.

Service characteristics

The need for flexibility and consistency: The research highlighted the contrast between the inflexibility of services and the chaotic characteristics of co-morbid service users' lives. The narratives described how people living with mental health and substance use problems had ordinary life goals such as obtaining work, forming meaningful relationships, and generally improving the quality of their lives. The services set up to support their recovery, however, were heavily medicalised and not sufficiently flexible or appropriate to their needs, concentrating largely on 'diagnosis' and ignoring the wider picture.

The need for responsiveness and continuity: Providers and users alike reported that when service users asked for help they needed it immediately. They did not want to be placed on a waiting list and told to come back later. Equally, throughout the research project, it was generally felt that service users were often isolated and cut off from appropriate services after formal treatment had ended. A particular example cited was of a service user leaving a hospital environment, where no-one appeared to be 'in charge' of that person to help them access further support services to address their total need. There was a clear need for case managers or co-ordinators.

The need for strengthening psychotherapeutic approaches: Participants agreed that the most effective interventions took the form of warm, friendly, empowering services usually provided by one individual on a continuous basis. Concern was expressed at the relative lack of psychotherapeutic interventions available and the consequent lack of opportunity to develop trusting, therapeutic relationships with one person.

The need for holistic care: While there were examples of good practice and many positive experiences of different therapeutic relations, service users, commissioners and providers alike commented with regret that several services did not treat problems holistically and in a joined-up manner. They continued to consider mental health and substance misuse issues in relative isolation from one another and deal with them sequentially.

Service organisation

The need for specialists: There was a lack of dedicated co-morbidity specialists who appreciated the interaction of substance misuse and mental health problems and had the expertise and the resources to undertake this work. Both service users and providers identified the potential benefits of such specialists, either embedded within mainstream substance misuse or mental health teams or in specialist units.

The need for training to underpin provision: Service providers stated that they needed specific training and support that would help them deal with the complexities co-morbid individuals brought to the services. A minimum requirement would be to have access to workers who did have the knowledge and expertise of supporting people with co-morbid issues.

Multi-agency partnerships: In many parts of Scotland, health services and local authorities were working together and shared funds, yet evidence of joint working remained patchy. Where it did exist, experiences were positive. There was evidence to suggest that putting joint working into operation was envisaged differently across the researched localities. Although multiple engagements were considered to be inevitable, limits to the number and complexity of arrangements needed to be put in place. For some, more informal intersectoral agreements remained a realistic option. For others, change in infrastructure, in terms of coterminous partnerships between health, social and non-statutory sectors, was viewed more favourably than implementing service change per se.

Shared assessment protocols and development of care pathways: As a result of patchy joint working arrangements, shared assessments and the creation of care pathways for co-morbid individuals were lacking or under-developed in several locations. Again, there was some controversy regarding the usefulness of uniform integrated care pathways for such a heterogeneous group of people with quickly changing but ongoing needs. Discussions with commissioners indicated that the requirement for joint-funding approval in creating a care package could help to bring about closer collaborative efforts between health and social care.

Bureaucratic quagmire: Providers and commissioners voiced concern over the expediency of policy and directional changes and associated changes in remit. These structural and procedural modifications were believed to act as barriers to developing functional and successful collaborative efforts and providing consistency in care and support. The volume of information and guidelines to wade through were also a cause of concern and their relevance to local contexts was questioned, especially in relation to rural areas.

Exclusion: Service users felt excluded from decisions about their care and wanted greater involvement and empowerment. Many providers and commissioners thought that only lip service was paid to service users during formal meetings. Their opinions were not taken into account and were not followed through by action at the planning level. Although user involvement was acknowledged by some to be important, others considered that service users were not necessarily best placed or informed to direct and advise on service provision and practice. Service users interviewed also stressed their need for peer support groups.

Stigma and inclusion: All participants spoke of aspects of wider cultural and social problems that needed addressing. Stigma was an enduring feature of mental health and substance misuse problems alike. Since the New Labour Government of the late 1990s, a marked policy shift towards recognising the importance of social inclusion had taken place. Although the structures within which care and support is provided had changed for many, the language of the various professional silos and the theory that underpinned them frequently remained the same.

Concerns about the medicalisation of co-morbid issues and neglect of social factors did not imply that providers and commissioners were ignorant of their professional limitations or the need for a holistic outlook. Most practitioners appeared to value their relationships with users as individuals with wider needs. Nonetheless, tension continued to exist between the real needs of co-morbid service users and the resources to provide 'holistic care' and the treatment interventions currently available and administered. As social and health care workers operated as members of a wider collective social culture, understanding this culture offered insights into some of the social forces that shaped their work and in turn could allow attitudinal change to take place at the societal, professional and individual level.

Recommendations

The recommendations in this report are categorised into 6 main components, with some overlap:

• Strategic
• Operational
• Clinical
• Training
• Workforce considerations
• Research suggestions.

Overall strategic plan

• A national strategy: National organisations (e.g. Scottish Drugs Forum and Scottish Recovery Network) for service users need to have a joint approach to co-morbidity to help develop national priorities, including increased resources and funding opportunities, best practice models and the identification of research gaps. Such an approach would also benefit organisations, such as Drug and Alcohol Action Teams ( DAATs) and Mental Health groupings across Scotland.
  There is also a clear need for commissioners to take increased responsibility for developing a national strategy and encourage joined-up working.
• Agreed definitions and overall model of care: Within the strategic plan described above there is a need to describe and define the use of the term co-morbidity. The model of care should acknowledge that co-morbidity is a complex, chronic and relapsing condition that needs focused and flexible responses at different service levels/tiers in the health and social care system. A chronic care model such as those in the field of diabetes and coronary care might be a viable policy approach to target this needy population more effectively. The definitions and model of care should be agreed by all key service providers and commissioners and made widely available via agreed channels in order to facilitate communication between services.
• Joined up provision: The Scottish Executive Departments responsible for the provision of health and social care need to have a more joined-up approach to co-morbidity. Mind the Gaps should act as the catalyst to this end.
• Greater integration of mental health and substance misuse services: Overall, mainstream mental health services, both statutory and non-statutory, need to pay greater attention to the issue of co-morbidity when planning and delivering services. Equally substance misuse services need to pay greater attention to mental health. Mainstream mental health and substance misuse services need to work more closely together in order to maximise resources, expertise and skill mix. Effective inter-agency working and better communication are essential to provide an integrated response to the needs of people with co-morbid mental health and substance misuse issues. There should be improved networking and better interagency protocols between different organisations. Information-sharing protocols outlining how information should be shared with different agencies and with providers must be developed. Communication agreements between service users, providers and commissioners should also be explicitly addressed, with effective communication being evidenced horizontally as well as vertically.
• Development of policies, protocols and procedures: Organisations should develop specific co-morbidity policies, together with appropriate protocols and guidelines for responding to clients who have these complex problems. Protocols should include practical toolkits for the identification of co-morbid conditions and provision for data collection and the recording of evidence and later evaluation.
• Commissioning: Clear identification and responsibilities of service commissioners in relation to their role in the field of co-morbidity are needed. Adequate training for commissioners and managers is also recommended.

Operational

• Stigma and prejudice: Information about mental health problems and substance use should be available to inform service users, providers and the public in order to attempt to reduce the stigma attached to these problems.
• Health promotion: Health promotion activities should be increased to address the negative impact of substance use on mental health. This is consistent with prevention and early intervention strategies to prevent issues escalating with disabling health and social care consequences.
• Means and mechanisms: Better information resources should be provided to increase the knowledge-base around co-morbidity and the services available locally and nationally offering help and support. Resources should signpost service users and providers to services including helplines, self-help groups, support groups, NHS facilities, local authority facilities and local non-statutory sector provision.
• Accessibility: Greater provision of access to out of office hours and drop-in facilities are required to support service users who are having difficulties with substance use or mental health problems, both on a day-to-day basis and in a crisis. Staggered and co-ordinated opening times might also be a consideration in certain localities.
• Education, training, employment: There is a need for provision of information and advice on vocational training and employment opportunities, and support in obtaining and retaining work, where possible. Establishing links between employers and employability services and developing local agreements may go some way to removing the multiple barriers co-morbid individuals face when trying to access employment.
• Ethnic minorities: Since there is insufficient knowledge about the nature and extent of the needs of minority groups, consideration needs to be given as to how best to address these needs. It is clear that a culturally sensitive approach is recommended.
• Carer support: There should be further development of services for carers supporting people with co-morbidity problems and specific support groups for carers and users living with combined mental health problems and substance use. Children and adolescents living with family members with co-morbid issues in particular need increased support.

Training and education

• Defining the objective: All those working within mental health and substance misuse organisations should receive training in relation to the complexities of co-morbid mental health and substance misuse to support this group and their families. A range of training opportunities are required.
• Training needs analysis: Appropriate and different levels of training are required to skill providers and support staff. In recognition that there will be providers with high-level skills and experience of working with co-morbid service users, a training needs analysis of providers should be undertaken.
• Education: There is a need to address co-morbidity as part of an educational component at undergraduate, post graduate, CPD levels in medicine, nursing, social work, psychology, pharmacy, etc. Drugs and Alcohol National Occupational Standards ( DANOS) courses may be appropriate for other workers.
• Training resources: New methods of training delivery and knowledge building need to be developed to maximise access and increase skill-mix. New methods may include the use of DVDs, CDs, e-learning, manuals and toolkits.
• Face-to-face: New opportunities are needed for staff to experience alternate ways of working with this complex group of co-morbid people. The possibility of in-house training, access to accredited courses, shadowing and secondments should be enhanced.
• Special groups: Advanced training and educational requirements are likely to be necessary for tailored provisions for special groups of service users, including for example adolescents, older people and learning disabled.
• Childhood trauma: Specialist co-morbidity services should have one or more workers trained in sexual abuse and childhood trauma. Increased resources should be allocated to provide opportunities for service users to access validated and effective psychological therapies in the field of co-morbidity.
• Other relevant organisations: Where specialist training is not deemed sufficiently necessary, guides ( Mind the Gaps, not yet widely circulated or read) or toolkits (such as the Rethink and Turning Point toolkit for dual diagnosis) should be available. A dedicated worker or 'champion' may help to communicate and publicise the most significant messages.

Clinical

• Inclusivity rather than exclusivity: The research team noted the importance of adopting an inclusive approach to supporting people in distress. Service users report the benefit of providing approaches that are non-judgemental and supportive for dealing with their mental health and substance misuse issues (also supported by NTORS⁴ research findings).
• Philosophy: Harm reduction and intermediate goals should be aimed for rather than concentration on abstention and full recovery.
• Needs-led rather than service-led: There are dangers of labelling service users as having a co-morbidity in the long term because substance misuse and mental health problems are transitional and the severity of the problem often fluctuates. Specialist service provision that concentrates on a narrow definition of co-morbidity may not be appropriate in certain instances. Any provision should be needs-led rather than service-led.
• Assessment framework: A comprehensive assessment and information sharing framework should be established to eliminate duplication of effort when conducting interviews.
• Development of a user-friendly screening and assessment tool: When developing a screening and assessment tool to be used in routine practice by staff from a wide range of backgrounds, preliminary research should be carried out into the services available for co-morbid problems
• Working with childhood trauma: Childhood trauma is highly prevalent amongst the co-morbid population and screening for this should be implicit and routine. Where they exist, links to appropriate services should be made. Further development of provisions for this subgroup should also be addressed, in particular provisions for minority groups and men.
• Care planning: Collaborative working between mental health and substance misuse services (perhaps facilitated by the Joint Futures agenda), led by mental health teams needs to be in line with Models of Care or Integrated Care approaches. Every co-morbid service user should also have a care plan in place.
• Provision of the range of psychological and pharmacological interventions: Increased provision of alternatives to medication including effective psychological interventions should be available, to allow service users to address their problems through the development of trusting, therapeutic relationships with providers.

Workforce considerations

• Learning environments: There should be opportunities to make traditional health and social care environments therapeutic and learning environments for both service users and providers. This should have the effect of reducing burnout within the workforce as a result of dealing with potentially stressful experiences.

Further research

Information on co-morbid treatment and service delivery in Scotland is scarce. The following areas of research are suggested as part of a national research strategy, underpinned by funding:

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