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13. Service Planning
Mind the Gaps and A Fuller Life both make recommendations to planners and commissioners to ensure that services are co-ordinated between a wide range of potential agencies. The responsibilities of services must be made explicit and monitored.
The needs of those who substance misuse and require interventions should be met through a consultative and co-working arrangement between substance misuse and mental health services with agreement reached on the allocation of responsibilities between services which addresses all stages and transitions.
A shared protocol on the arrangements in place, including monitoring and review of performance and outcomes, should be agreed and published.
NHS boards and partner agencies should ensure an effective and accountable commissioning process for this client group.
Primary Health care as a central role in identification and provision of care. The anticipatory care approach is a promising one in the field of co-morbidity, with its focus on a proactive approach, targeting those most at risk. The evidence for the effectiveness of primary care interventions for alcohol misuse has been reviewed by SIGN, but the development of these services has been limited.
Recommendations
Anticipatory Care: There should be screening procedures for co-morbidity in place with appropriate responses to identification of problems in general practice and across Primary Care.
The development of an Enhanced Service for Alcohol Misuse in Primary Care following the demonstration of a strong evidence base in SIGN Guideline 74 should be considered. This anticipatory care approach would be of benefit to those with co-occurring mental health problems.
The Group supports the conclusion of Mind the Gaps that a model of identifying lead agency responsibility depending on problem severity is the preferred approach. The matrix below from the Department of Health Mental Health Policy Implementation Guide - Dual Diagnosis Good Practice Guide is a helpful representation.
Figure 1: The scope of co-existent psychiatric and substance misuse disorders
NB: The term "mental illness" includes cognitive impairment such as Alcohol Related Brain Damage ( ARBD).
- Poor mental health / Low severity substance misuse
The recommendations on Promotion, Prevention and Communications are designed to improve public awareness of the relationship between substance use, misuse and mental health. Frontline agencies in all sectors should provide advice and materials on this topic in order to reduce risk and harm.
- Mild/moderate mental illness / High severity substance misuse, including dependence.
The high rates of mental health problems in those treated for substance misuse are due to high rates of depression, anxiety and personality disorder (Department of Health 2004). There are strong associations between substance misuse and trauma, eating disorders and self-harm.
The mild to moderate forms of these problems, including ARBD, will be common among those with substance misuse and dependence, and substance misuse services should develop the knowledge, skills and capacity in psychological treatments to respond.
The disclosure of trauma and abuse, in particular sexual abuse, is common during assessment and treatment in substance misuse services. Staff should have skills in handling disclosure sensitively and competently. Some of these skills will be part of the core counselling skills necessary for effective substance misuse work and should be supported by a process of practice supervision.
The stepped care model for psychological therapies advocated in Delivering for Mental Health will improve the range of expertise and services in Scotland. The established evidence for the effectiveness of specific psychological therapies in alcohol dependence has been reviewed by NHSQIS and there is emerging evidence in other areas of substance misuse (ref NTA). The stepped care approach, including guided self management, from the Doing Well by people with Depression programme provides valuable principles for the organisation of services by NHS boards and partner organisations.
The development of evidence based psychological therapies (a further Delivering for Mental Health commitment) will broaden the range of services available to those with mental health and substance misuse problems. Recent reviews have shown the effectiveness of some psychological therapies on substance use behaviour and on broader functioning. ( NTA review, Health Technology Board for Scotland, NICE guidelines). Advancing the principles set out in Delivering for Mental Health it is important to extend access to include those with co-occurring mental health and substance misuse problems where appropriate.
The personal planning process outlined in the National Quality Standards for Substance Misuse Services will help ensure co-ordination of care where a range of services are involved.
Recommendations
Individuals with co-morbid disorders should have equal opportunities to accessing mainstream psychological therapies in Primary Care.
Substance misuse services should develop knowledge, skills and capacity in psychological treatments for substance misuse and to meet the mental health needs of their client group. These training needs should form part of the plan for psychological therapies currently being developed by NHS Education for Scotland under the Delivering for Mental Health Commitment 4 to increase the availability of psychological therapies.
- Severe Mental Illness and Substance Misuse, including dependence.
In the UK, the focus for specialist adult mental health services has been on severe and enduring mental illnesses in particular schizophrenia and bipolar disorder, though Delivering for Mental Health signals an intention to respond to a wider range of disorders. This severe and enduring group have the focus of most attention in the study of co-morbidity in the UK. (Cantwell 2003, Weaver and Tyrer 2004.)
For England, the Department of Health Dual Diagnosis Good Practice Guideline recommends that for people with severe mental illness who misuse drugs, including alcohol, the lead responsibility for care should lie with mental health services. This is described as the mainstreaming model. The rationale for this is that Mental Health services may be better placed to offer services such as assertive outreach, crisis management and long term care. This is supported by the findings of the Scottish Co-morbidity Research Group (Cantwell 2003) which found that those with co-morbidity in contact with mental health services, had levels of health and social functioning similar to other mental health service patients.
Another reason is that the capacity of services for those misusing or dependent on alcohol, stimulants and cannabis, the drugs most often used by those with severe mental illness, is limited. ( CARES)
The needs for substance misuse interventions should be met through a consultative and co-working arrangement with substance misuse services. Advice and support from substance misuse services should be developed to meet the needs of mental health services, specifically to help deal with cannabis and stimulant use.
The priority is that those local responsibilities are clear and the service gap for these vulnerable people previously identified in Scotland and elsewhere, is closed. There are a number of ways of organising services to achieve this and existing effective services should be supported. For other areas, the "mainstreaming" model is commended as a reliable approach for service development.
Recommendations
NHS mental health services should have the lead responsibility (including lead coordinating responsibility) for care for those whose mental health needs are severe and enduring and whose needs are best met within specialist mental health care.
While a recovery focus should be the predominant model, the Chronic Disease or problem model can be a useful approach for some people with co-morbid disorders.
Recommendation
Individuals with mental health problems and substance misuse problems should have the same commitment to chronic disease management as individuals with other chronic disorders, for example to the development of an Integrated Care Plan and single point of contact.
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