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Alcohol and mental illness: deus ex machina?
Article Type: Editorial From: Advances in Dual Diagnosis, Volume 4, Issue 3
Foreword by Liz Hughes, Editor
I am delighted that this issue of advances in dual diagnosis is guest-edited by three eminent experts in the field of alcohol and mental health. Professor Charlie Brooker is a senior mental health researcher, who has of recent times focused on the needs of mentally ill offenders within the criminal justice system (a much neglected group both in terms of resources and services). Damian Mitchell worked for the Department of Health in the Alcohol Improvement Programme until recently and now works as an independent consultant. Alison Wheeler was regional alcohol manager for Drinkwise Northwest, at the time of the project being reported in this issue.
This issue focuses primarily on the challenges raised by abuse of alcohol and the relationship of this abuse to mental illness – one aspect of so-called dual diagnosis. A number of the papers presented in this issue arise from a funded pilot project (Alcohol Improvement Project and Drinkwise Northwest) to examine alcohol and mental illness in one region of England, the North West. This project was lead by Charlie Brooker, and a small team of health researchers – Karen Tocque, John Currie and Liz Hughes.
Karen Toque, John Currie, Elizabeth Hughes and Charlie Brooker’s paper provides much needed evidence on the prevalence of the problem using data culled from routine NHS-data sets. She demonstrates that health inequalities remain intransigently hard to shift in that the prevalence of alcohol and mental health problems are more highly correlated with more deprived populations. Cost data were alarming for the North West with an innovative analysis showing that in 2009/2010 the estimated cost of admissions for dual diagnosis was estimated to be between £61 and £85 million to which a further £21 million can be added for the community treatment of dual diagnosis. Thus, as Toque argues, it should be obvious that especially in deprived communities, the reduction in dual diagnosis hospital admissions should be targeted by commissioners. The need for much more sophisticated commissioning for this group is underlined by Toque’s estimate of the total proportion of people with dual diagnosis engaged with services which is just 10 per cent.
John Currie provides an overview of the commissioning approaches employed in the region and he discusses these in some depth. Currie, as with Toque above, believes that the key is intelligence gathering and good quality relevant data. As he points out the dual diagnosis agenda is often subsumed by either the alcohol, drug or overall mental health needs assessment agenda and is, therefore, not detailed enough. For example, in the NW project, none of the five commissioners had undertaken an analysis of alcohol-related admissions, which we have seen it is disproportionately high cost to the NHS. Even where data are collected, they are not shared between alcohol/mental health commissioners as a matter of course. Currie discusses three main for delivery of services: liaison, parallel and integrated. In the liaison model, dual diagnosis is assumed to exist from the outset and the entire workforce within the mental health treatment system is regarded as competent in dual diagnosis work. As he points out, however, the outcomes of all three models have never been studied or evaluated and like other aspects of alcohol service delivery for those with a dual diagnosis, such as face to face clinical intervention, there is little robust research evidence of effectiveness. Currie argues that having a local champion for dual diagnosis in helping to ensure that local protocols are implemented, but Hughes in her paper again notes that no research has ever looked at this issue. Routine clinical outcomes are rarely audited within dual diagnosis services, as often there is contention about which clinical outcome measures should be employed. Currie argues that the potential for the implementation of identification and brief advice is great for those who are not dependent drinkers, but who are drinking at increasing levels and who are also likely to have a moderate depression or anxiety state. One model for the delivery of this training for non-specialist workers (such as those working in primary care or acute trusts), could be through local initiatives to increase access to psychological therapies. A focus for such interventions could well be local accident and emergency departments, but again robust evidence is needed. One important area that Currie raises in the Criminal Justice Sector where alcohol and mental illness are often features of those that offend indeed 57 per cent of all violent crime is alcohol-related. Substance misuse workers are often to be found in the CJ system whilst mental health professionals working in police stations, courts and in probation are much rarer. Meaningful diversion from the CJ system for offenders with a dual diagnosis is the main thrust of the bradley review of mental health of people in the criminal justice system (DH, 2009), but it is understood that implementation of the findings are being implemented in a highly variable fashion (Brooker and Sirdifield, 2011).
Liz Hughes looks at alcohol and mental illness from the provider perspective and lamented the fact the region’s largest third-sector provider did not participate in her survey. In the NHS, a broad range of interventions was offered, training and supervision were offered in a variety of forms throughout the patch, and possessed the broadest range of skill mix. Nonetheless, there was demand for further training on an inter-agency basis, clear gaps in services where identified (especially residential detoxification programmes), co-location of mental health and alcohol services was posited as a solution to the gaps identified in service provision, but as Hughes points out there is little evidence to support the commissioning of these organisational interventions. Hughes summarises by stating that “one of the biggest challenges remains the dispute at the interface between alcohol and mental health services” she argues that this dispute can only be addressed by a locally agreed strategy that defines dual diagnosis, develops joint working protocols and, therefore, entails shared agreements.
Alison Summers and Chinar Goel in a discursive paper contend that early intervention services for psychosis, where practitioners adopt a psychosocial approach, are better placed than “traditional services” to offer holistic approaches to the treatment of psychosis for clients with long-standing problems with substance misuse. They like many others in this edition acknowledge that evidence for interventions for substance misuse (within the context of dual diagnosis) is weak, however, their claim seems to rest on the fact that early intervention services are often better resourced and better trained than many others. The authors accept that the outcome for those that use substances in EI services are mixed and quote a study which suggested that heavy alcohol use was likely to me more persistent (Archie et al., 2007). It is noteworthy that the service described by Summers and Goel is offered within an area where the overall approach to dual diagnosis is the liaison model where all providers expect dual diagnosis to present and are trained to manage this presentation.
The North West project report on alcohol and mental illness (which is presented in this issue) was commissioned by Drink Wise North West following a substantial review of alcohol treatment services and pathways across the North West, which formed part of the National Alcohol Improvement Programme (Department of Health). At the same time, the NHS Alcohol Challenge, which was led by Ruth Hussey Regional Director of Public Health, senior Directors of the SHA, David Dalton, CEO of Salford Royal Foundation Trust and Drink Wise North West, identified that people with mental health and alcohol related issues present regularly at A & E, having a significant impact on services and the response required to support them. Drink Wise North West recognised that more information, intelligence and support was needed for areas dealing with this significant challenge, and the dual diagnosis report has presented a number of recommendations, which support workforce, service redesign and ultimately the service user. Over the coming months Drink Wise North West will be working closely with areas, to help with the JSNA process, new commissioning structures and workforce development, using the recommendations as a guide to improvement. Across the North West, there is great leadership on the alcohol harm reduction agenda, and the dual diagnosis report will present our champions and leaders with an opportunity to raise the issue of dual diagnosis and increase the support needed to really have a significant impact on improving the health and wellbeing of communities across the North West of England.
The outcomes of the report featured in this issue raise major challenges for policy development, commissioning and service delivery. Dual diagnosis has always been a thorny and somewhat intractable problem, which has been largely ignored by policy makers, planners and service managers alike. There are of course, pockets of good practice, but it is difficult to see, in the current climate of major organisational changes taking place within the NHS, how the needs of this client group are going to be adequately addressed in a consistent way across the country. There is evidence to suggest that GPs are worried about commissioning for mental health problems, because of their lack of knowledge about services for severe mental illness (www.rethink.org/how_we_can_help/news_and_media/press_releases/white_paper_to_hand.html). Moves towards “Clinical Commissioning Groups”, may broaden the focus for clinical commissioning, but it is far from certain how this will work for mental health services and even more so for dual diagnosis services. This is potentially further undermined by the commissioning split between Public Health England and the NHS Commissioning Board, with the former responsible for substance misuse commissioning through local authorities and the latter for mental health services via Clinical Commissioning Groups. This builds in an inherent fault line for services that span the divide and muddies the waters over responsibility for commissioning of services for those with co-morbidity. However, the new structures may provide a fresh way of thinking about, developing and commissioning services at a local level that truly meets the needs of the population. A renewed emphasis on “Joint Strategic Needs Assessment” and the establishment of “Health and Wellbeing Boards” may provide the vehicles for tackling “thorny” and “intractable” problems, but the process does need to be supported by a thorough analysis of need. The detailed work on the issues and needs around dual diagnosis, as detailed in this issue, provides North West commissioners (both NHS and local authority), with the type of evidence that should be available in every region to inform the JSNA and commissioning process. The “Payment by Results” (PbR) approach, that is being rolled out for mental health services (DH, 2011) and piloted for specialist alcohol treatment also provides an opportunity for improving the quality of care for people with co-morbidity, as it can align process for assessing and clustering clients according to need, indicating evidence-based packages of care and an improved focus on outcomes. What is being piloted for specialist alcohol treatment can be seen as an extension of the national mental health PbR programme and the draft assessment and clustering tool, is very similar in design and captures mental health and social functioning, alongside consumption and dependency scores – that is, it will pick up issues of co-morbidity. If implemented nationally, ultimately each area would have much more detailed information on numbers of clients with dual diagnosis, on which to base their commissioning and delivery plans. It remains to seen whether or not an inextricable problem is suddenly and abruptly solved with sleight of hand by the new commissioners – deus ex machina?
Charlie BrookerCB Offender Health.
Damian MitchellImproving Health and Wellbeing UK, Community Interest Company.
Alison WheelerDrinkwise North West.
For a full copy of the paper please contact either Charlie Brooker or Alison Wheeler.
The NICE guidelines for dual diagnosis are based on the expert panel’s view of good practice rather than research see NICE guidelines for dual diagnosis (Kendall et al., 2011).
Archie, S., Rush, B.R., Akhtar-Danesh, N., Norman, R., Malla, A., Roy, P. and Zipursky, R.B. (2007), “Substance use and abuse in first-episode psychosis: prevalence before and after early intervention”, Schizophrenia Bulletin, Vol. 33 No. 6, pp. 1354–63
Brooker, C. and Sirdifield, C. (2011), Two years after the publication of the Bradley Report: the view from clinicians on implementation
Department of Health (2009), “Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system”, DH, London, available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_098694 (accessed 2 August 2011)
Department of Health (2011), “Payment by results for mental health resources”, available at: www.dh.gov.uk/en/Managingyourorganisation/NHSFinancialReforms/DH_4137762 (accessed 2 August 2011)
Kendall, T., Tyrer, P., Whittington, C., Taylor, C. and Guideline Development Group (2011), “Assessment and management of psychosis with coexisting substance misuse: summary of NICE guidance.”, BMJ, Vol. 342, p. d1351
Alcohol Learning Centre (2011), “National Alcohol Treatment Payment by Results Pilots (web site news item)”, available at: www.alcohollearningcentre.org.uk/News/NewsItem/?cid=6628 (accessed 2 August 2011)