Emerald Group Publishing Limited
Article Type: Editorial From: Advances in Dual Diagnosis, Volume 8, Issue 1
“When 80 per cent of your clients have a dual diagnosis, asking whether the service needs a dual diagnosis worker is getting things the wrong way around”. So commented one of the contributors to a national “summit” organised by DrugScope, the national membership organisation for the drug sector and the UK's leading independent centre of expertise on drugs and drug use, on behalf of the Recovery Partnership on 3 November 2014 to take stock of policy on “dual diagnosis” as we enter the final phase of this UK parliament (2010-2015). It's a reminder of how central this issue should be for policy and practice across both sectors.
So what was the summit's conclusion? In a nutshell, that there are positive policy and practice developments – and a growing evidence base – to build on, but that the scope and pace of policy change is creating new and significant challenges for the integration of services, and all against a backdrop of austerity. The key themes will be familiar, including the challenges of joining up and integrating commissioning, the importance of personal relationships (and the disruption of these by the churn of structural reforms and frequent re-commissioning), the need for workforce development (not only for a minority of specialists but across workforces) and the importance of establishing clarity around ownership and accountability.
Policy developments referred to in the course of the discussion, included – in no particular order – abolition of the National Treatment Agency for Substance Misuse (and the “pooled treatment budget”), the creation of Public Health England, NHS England, the Health and Social Care Act 2012, public service reform including payment by results, the Work Programme, Transforming Rehabilitation, Health and Wellbeing Boards, Police and Crime Commissioners, “localism” and the development and impact of competitive tendering. This at a time when the Local Government Association calculates that central government funding for councils will fall by 40 per cent over the life time of this parliament.
Setting the compass in this period of radical and far reaching change, the UK Coalition Government's drug and mental health strategies (HM Government, 2010, 2011) both recognise that people with problems almost never have a “single diagnosis”, need a range of interventions and resources to support their “recovery” and that this requires integrated approaches to service delivery. There has also been a growing interest in both sectors in the social barriers to recovery – such as housing problems, lack of work or other meaningful activity and stigma and discrimination – as well as in the empowerment of service users and people in recovery, with a focus on asset and potential, and not simply risk and need.
From a clinical point of view contributors to the summit did not see much wrong with the good practice guide produced by the Department of Health over a decade ago (Department of Health, 2002). Its implementation, however, has been inconsistent and incomplete, and it is based on an NHS (and broader service) configuration that is now several iterations and a couple of restructures out of date. An expert reference group being facilitated by Public Health England is currently reviewing the guidance, with a view to producing a new resource to support the effective planning and commissioning of services and to oversee its implementation as a matter of priority.
A key impetus for this work has been a focus on crisis care provision, with drugs and alcohol featuring fairly prominently in the Mental Health Crisis Care Concordat (Department of Health and Concordat Signatories, 2014). Contributors to the DrugScope summit confirmed that in their experience people experiencing mental health crisis who were intoxicated were often excluded from health-based “places of safety” when they fell within section 136 of the Mental Health Act (2007) and were much more likely to end up in a police cell at a time of acute vulnerability and crisis. This has been a marginal issue in a lot of the debate about Section 136, and it is encouraging to see it getting the focus it needs.
At the other end of the spectrum, the UK coalition government has built on the Improving Access to Psychological Therapies (or IAPT) programme. The first ever mental health waiting time standards announced in October 2014 include a commitment that 75 per cent of people referred to IAPT will be treated in six weeks from April 2015. It remains to be seen how this will play out for people with co-existing drug and alcohol problems, who have often found it difficult to access IAPT provision (see IAPT, DrugScope and the National Treatment Agency, 2012). The other waiting time standard will also have significance for some people with a dual diagnosis as it pledges that people experiencing psychosis for the first time will begin treatment within two weeks (bringing them into line with cancer patients).
In another landmark for mental health policy, the principle of “parity of esteem” for physical and mental health was established in law by the Health and Social Care Act 2012 and is a core part of the Government's “mandate” to NHS England (Department of Health, 2013). On the face of it, that principle should encompass people with co-existing drug and alcohol problems, although it is questionable whether and how far this has been considered in policy development and implementation. The Mandate makes no reference to drug misuse or treatment (and only one to alcohol). In addition, despite the commitment to “parity of esteem” and the introduction of waiting time standards, funding for mental health services has actually fallen in real terms for the last three years. Behind the pledges on waiting times there may lurk the familiar demand of “more for less”. In some areas, the current reality for dual diagnosis clients appears to be less for less.
DrugScope's State of the Sector Survey 2013 asked drug and alcohol service managers about gaps in local service provision for their clients. Support for dual diagnosis and complex need came second after housing and housing support (DrugScope, 2013). In addition, 20 respondents said that access to mental health services for drug and alcohol service clients had worsened over the last 12 months, with only three saying that it had improved. One team manager commented: “the cuts in mental health provision seem to have had the consequence of pushing more of our clients out of services. Mental health workers seem to be harder to reach and engage with around joint work”.
The summit considered opportunities to develop a shared narrative and agenda around “recovery”, including the potential for the integration and collaboration of service user involvement and recovery networks across drug and alcohol and mental health sectors (there were interesting observations on the different cultures, approaches and dynamics of service user involvement across the two movements). The development of the “multiple needs” agenda and its influence on UK Government, led by the Making Every Adult Matter coalition (of which DrugScope is a founding member), was also recognised as a key development with significant cross-over to “dual diagnosis” policy. Making a virtue of necessity, it was felt that the demands from commissioners to deliver “more for the same” or “more for less” might be a catalyst for the development and/or integration of services, as this had the potential to reduce cost and improve outcomes … at least, up to a point. However, the squeeze on public spending was reported to be leading some services to increase thresholds and tighten criteria, exacerbating the familiar problem of people bouncing between services – plus ca change, plus c’est la meme chose. To reach out or retrench that is the question … and the answer may depend to a significant extent on the role of local planners and commissioners in choreographing joined up working.
The challenge now is to join up structures and services that have been divided in new and different ways. For example, mental health is the responsibility of NHS England, while drug and alcohol treatment is now one of the public health responsibilities of local authorities, as supported by Public Health England. (Another example, incidentally, is that the two sectors have been subject to radically different “payment by results” programmes, in approach, mechanism and outcome.)
In a recent parliamentary answer on drug and alcohol treatment for people with mental health problems, the Minister, Norman Lamb highlighted the role of Health and Wellbeing Boards, joint strategic needs assessments and joint health and well-being strategies. It remains to be seen how far local Boards have the interest, levers and influence to pull and hold services together for people with dual diagnosis in inclement weather and as the winds of changes blow. There is an interesting comparison with prison services where drug and alcohol and mental health treatment are both the responsibilities of NHS England – but the criminal justice system is another story with (e.g.) the legacy of the Bradley report on the diversion of people with mental health problems to build on and the full impact of the Transforming Rehabilitation reform of probation just around the corner. This highlights another key summit theme … uncertainty.
Articles in the current issue
There are four interesting papers in the current issue of Advances in Dual Diagnosis. Crane et al. (2015, pp. 4-17) review the literature on “Dual diagnosis among veterans in the United States” and highlight that veterans with dual diagnosis are at high risk for a range of adverse biopsychosocial and treatment outcomes. In the second paper, “Factors associated with smoking and smoking cessation among primary care patients with depression: a naturalistic cohort study”, Gilchrist et al. (2015, pp. 18-28) found that females and people with good or better self-rated health were significantly more likely to have quit, while people with a chronic illness or suicidal ideation were less likely to quit. Connolly et al. (pp. 29-41) discuss the benefits of involving key stakeholders in “Developing a dual diagnosis service in Cork, Ireland by way of Participatory Action Research”. In the final paper, “Preliminary evaluation of a forensic dual diagnosis intervention”, Tibber et al. (2015, pp. 42-56) present a “Preliminary evaluation of a forensic dual diagnosis intervention” in the UK.
1. “Mind calls on Government to plug mental health funding gap in Autumn Statement”, Mind News Release, 28 November 2015.
2. Ibid, p. 65.
3. For more information visit the MEAM web site at www.meam.org.uk.
Connolly, J., MacGabhann, L. and McKeown, O. (2015), “Developing a dual diagnosis service in Cork, Ireland by way of participatory action research (PAR)”, Vol. 8 No. 1, pp. 29-41
Crane, C.A., Schlauch, R.C. and Easton, C.J. (2015), “Dual diagnosis among veterans in the United States”, Vol. 8 No. 1, pp. 4-17
Department of Health (2002), “Mental health policy implementation guide – dual diagnosis good practice guide”, Department of Health, London
Department of Health (2013), “The Mandate – a mandate from the Government to NHS England: April 2014 to March 2015”, Department of Health, London
Department of Health and Concordat Signatories (2014), “Mental health crisis care concordat – improving outcomes for people experiencing mental health crisis”, HM Government, London
DrugScope (2013), “State of the Sector 2013”, p. 63 available at: www.drugscope.org.uk/Resources/Drugscope/Documents/PDF/Policy/SOS2013_Main.pdf
Gilchrist, G., Davidson, S., Middleton, A., Herrman, H., Hegarty, K. and Gunn, J. (2015), “Factors associated with smoking and smoking cessation among primary care patients with depression: a naturalistic cohort study”, Vol. 8 No. 1, pp. 18-28
HM Government (2010), “Drug Strategy 2010 – reducing demand, restricting support, building recovery: supporting people to live a drug free life”, Home Office, London
HM Government (2011), “No health without mental health- a cross-government mental health strategy for people of all ages”
IAPT, DrugScope and the National Treatment Agency (2012), “IAPT positive practice guide for working with people who use drugs and alcohol”
Tibber, M.S., Piek, N. and Boulter, S. (2015), “Preliminary evaluation of a forensic dual diagnosis intervention”, Vol. 8 No. 1, pp. 42-56