CitationDownload as .RIS
Emerald Group Publishing Limited
Copyright © 2013, Emerald Group Publishing Limited
Public Health England and treatment of clients with dual diagnosis
Article Type: Editorial From: Advances in Dual Diagnosis, Volume 6, Issue 2.
Until recently, the development of drug treatment services in England was overseen by the National Treatment Agency (NTA) – which was also assuming a wider role with respect to alcohol services. On 1 April 2013, the NTA – first created in 2001 – was abolished and its functions absorbed into a new body, Public Health England (PHE), which describes itself as “the expert national public health agency which fulfils the Secretary of State for Health's statutory duty to protect health and address inequalities, and executes his power to promote the health and wellbeing of the nation” (Public Health England (PHE), 2013, p. 2).
At the same time, there was a fundamental shift in control over drug and alcohol funding (now absorbed into a generic public health budget) to Directors of Public Health employed by local authorities. PHE clearly states that “improvements in the public's health has to be led by communities, rather than directed centrally” and that “PHE will not performance manage local authorities” (PHE, 2013, p. 7). Increasingly, decisions about investment in services for both substance misuse and mental health will be made at the local level. The key role for Directors of Public Health is only one of a number of radical reforms to strategic and commissioning structures, with GPs leading NHS commissioning of specialist health services through local Clinical Commissioning Groups, and a national NHS Commissioning Board responsible for prison health services, and some “tertiary” services including high and possibly medium secure mental health care. Health and Wellbeing Boards have now been established in upper-tier and unitary local authorities to co-ordinate local commissioning in this new landscape, with a responsibility to undertake local needs assessments and produce joint Health and Wellbeing Strategies. These are radical changes in the way both substance misuse and mental health services are planned and commissioned, with potentially profound implications for investment in and configuration of services for people with a “dual diagnosis”.
PHE's Health and Wellbeing Directorate have identified five key priorities including alcohol and drugs and mental health and well-being (PHE, 2013). These priorities are described as:
Helping people to live longer and more healthy lives by reducing preventable deaths and the burden of ill health associated with smoking, high blood pressure, obesity, poor diet, poor mental health, insufficient exercise and alcohol.
Reducing the burden of disease and disability in life by focusing on preventing and recovering from the conditions with the greatest impact, including dementia, anxiety, depression and drug dependency.
Protecting the country from infectious diseases and environmental hazards, including the growing problem of infections that resist treatment with antibiotics.
Supporting families to give children and young people the best start in life, through working with health visiting and school nursing, family nurse partnerships and the Troubled Families programme.
Improving health in the workplace by encouraging employers to support their staff, and those moving into and out of the workforce, to lead healthier lives (PHE, 2013, p. 6).
Despite both substance misuse and mental health being identified as key priorities for the PHE, mental health funding and commissioning remains the responsibility of the NHS (Department of Health, 2011a). In addition, the government has placed a strong emphasis on enabling local authorities to determine their own priorities, with PHE providing “expertise and advise”. A recent discussion paper by the Centre for Mental Health, DrugScope and the UK Drug Policy Commission (2012) argues that while these new arrangements will create opportunities for “innovative local approaches […] these reforms will have major implications for mental health and substance use services” (p. 3). They believe “joint commissioning of mental health and drug or alcohol services needs to become the norm” (p. 3) but identify a risk that commissioning of mental health and substance misuse sectors could become fractured if the plethora of new systems (national and local) are not effectively joined up, resulting in problems in the provision of integrated care to address mental health issues among clients with substance misuse problems and vice versa. The discussion paper highlights the need for an effective response to dual diagnosis to ensure the effective delivery of both the drugs strategy (Home Office, 2010) and the Mental Health Strategy (Department of Health, 2011b).
In conclusion, both PHE and the new local structures are in their infancy and the impact on the commissioning and delivery of services to clients with dual diagnosis remains to be seen.
Papers in the current issue
In “A study of the psychotropic prescriptions of people attending an addiction service in England”, Oluyase et al. (pp. 54-65) report a high rate of psychotropic prescribing among 1,537 clients newly referred for substance misuse treatment. In total, 56 per cent of clients were receiving prescriptions of antidepressants and anxiolytics at their first episode of treatment whilst 15 per cent were receiving antipsychotics. The authors conclude by questioning the appropriateness of these prescriptions, as proportions receiving these medications are higher than the prevalence of the associated disorders in studies among substance abusers (Weaver et al., 2003). This could be the result of the difficulty in determining independent from substance-induced mental disorders (Schuckit, 2006), and highlights the need for appropriate assessment among this client group.
In the second paper of this issue, Hilbery et al. (pp. 66-75) summarise the “Findings from the Making Every Adult Matter (MEAM) service pilots” that were implemented to improve coordination of existing local services for people with multiple needs including substance misuse and mental health. The findings show significant improvements in well-being for most clients participating in the pilots and changes in the use and cost of local services. The pilots are ongoing and further findings will be reported in the future.
The recent UK drug strategy (DoH, 2010) emphasises a recovery-based approach, especially for those with multiple and complex needs. In their commentary, “Recovery in mental health and substance misuse services: a commentary on recent policy development in the United Kingdom”, Bell and Roberts (pp. 76-83) describe how the independent development of the recovery concept in both sectors impacts the treatment of people with dual diagnosis. They stress the importance of addressing comorbid mental health issues among substance misusers to enhance their recovery potential.
The final paper, “Family of origin influences on the parenting of men with co-occurring substance abuse and intimate partner”, Stover et al. (pp. 84-94) examine the experience of being parented among substance misusing fathers with histories of intimate partner violence and how that impacts their parenting styles. A large percentage of the fathers experienced childhood abuse and reported negative images of their fathers and mothers most commonly due to father absence and abusive/harsh parenting by both parents. The study concludes that focus on multigenerational transmission of violence, substance abuse and trauma may be important areas to focus in intervention with father with co-occurring intimate partner violence and substance abuse issues.
Marcus Roberts and Gail Gilchrist
Centre for Mental Health, DrugScope and UK Drug Policy Commission (2012), Dual Diagnosis: A Challenge for the Reformed: A Discussion Paper, NHS and for Public Health England
Department of Health (2011a), Healthy Lives, Healthy People Consultation on The Funding and Commissioning Routes for Public Health, Crown, London
Department of Health (2011b), No Health Without Mental Health, Crown, London
Home Office (2010), The Drug Strategy 2010: Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug Free Life, HM Government, London
Public Health England (PHE) (2013), Our Priorities for 2013/14, Public Health England, London
Schuckit, M.A. (2006), “Comorbidity between substance use disorders and psychiatric conditions”, Addiction, Vol. 101 No. S1, pp. 76-88
Weaver, T., Madden, P., Charles, V., Stimson, G., Renton, A. and Tyrer, P. et al. (2003), “Comorbidity of substance misuse and mental illness in community mental health and substance misuse services”, The British Journal of Psychiatry, Vol. 183, pp. 304-13