West Berkshire Dual Diagnosis Strategy and Action Plan Substance Misuse 2004

Transcription

1 West Berkshire Dual Diagnosis Strategy and Action Plan Substance Misuse 2004 Document Author: Ratified by SMT on: Review Date: Document reviews/revisions: Bev Searle none Purpose: The dual diagnosis strategy provides a focus for the local commissioning and provision of services to people with severe mental health problems and problematic substance misuse, and includes the need for effective links with criminal justice services.

2 CONTENTS: 1 Introduction Background National Guidance Local stakeholder groups Locality Commissioning Group The West Berkshire Safer Communities Partnership (SCP) Joint Commissioning Group Local Implementation Team West of Berkshire Mental Health Sub Group Local Partnerships Needs Information Definition what is Dual Diagnosis? National Prevalence Local Mental Health Needs Information Ethnicity Learning Disability Physical Health Employment Local substance misuse information The local area Local Services Strategic Objectives Development and implementation of the local dual diagnosis service plan Development, implementation and audit of dual diagnosis protocols and care pathways Establishment of effective processes for needs assessment and performance monitoring Provision of appropriate training Coordination of Commissioning within the locality and across localities Action Plan...15

3 1 Introduction Evidence suggests that substance misuse among people with mental health problems should be seen as usual rather than exceptional; that treatment for substance misuse problems often improves mental health problems; and the healthcare costs of untreated people with dual diagnosis are likely to be higher than for those receiving treatment (from HAS Dual Diagnosis Standards 2001) The dual diagnosis strategy provides a focus for the local commissioning and provision of services to people with severe mental health problems and problematic substance misuse, and includes the need for effective links with criminal justice services. Within substance misuse, the strategy includes alcohol, solvents, over the counter and prescribed drugs as well as illegal drugs. There are also important links with Children s Services there are significant risks to the well being of children of parents who have severe mental health and substance misuse problems, and this is also addressed within this strategy. Both mental health and substance misuse service user groups experience the impact of stigmatisation and negative public attitudes which can also impact on staff of different services as well as negative attitudes about treatment efficacy. People with dual diagnoses may be excluded from both mental health and substance misuse services. Individuals with complex problems are at risk of falling between services policy development being split between two strategic frameworks and implementation between two stakeholder groups. This strategy aims to bring together national guidance, local needs information, service provision and development, in creating a framework and action plan to progress the commissioning and provision of services for people with dual diagnoses. 1

4 2 Background 2.1 National Guidance There is now a significant body of guidance on planning and development of integrated services, and some of the key documents are listed below: Mental Health policy Implementation Guide: Dual Diagnosis Good Practice Guide. DoH The National Service Framework for Mental Health. DoH Models of Care for Substance Misuse Services DoH 2002 Tackling Drugs to Build a Better Britain Substance Misuse and Mental Health Co-Morbidity (Dual Diagnosis) Health Advisory Service Standards for Mental Health Services Families that have alcohol and mental health problems: A template fro partnership working. Social Care Institute for Excellence Assessment and Management of Risk of Harm in Clients with Dual Diagnosis. Alcohol Concern and Drugscope Dual Diagnosis Toolkit. Mental Health and substance misuse. A practical guide for professionals and practitioners. Turning Point and Rethink Co-existing problems of Mental Disorder and Substance Misuse (dual diagnosis) an information manual. Royal College of Psychiatrists National guidance clearly states that Dual Diagnosis services should be delivered within mental health services, with the aim that people should not fall between the gaps of the various organisations which may provide services for them. Mental Health and Substance Misuse services should not use the identification of a primary diagnosis as a means to exclude people from services. In order to tackle this, the provision of dual diagnosis services should take place within mental health services, and should be supported by specialist substance misuse services. Local commissioning arrangements and service provision for both substance misuse and mental health services have developed considerably in the last two years in West Berkshire, and the current responsible groups are described below. 2

5 2.2 Local stakeholder groups Locality Commissioning Group Membership includes: Joint Commissioning, who works to the three localities within West of Berkshire; Wokingham, Reading and Newbury. Locality for Mental Health Services, who is accountable to West Berkshire Council, Berkshire Healthcare Trust and Newbury and Community PCT and is operationally responsible for local treatment services provided by BHT. DAAT Head of Community Care and Housing, accountable to Newbury and Community PCT and West Berkshire Council, is line manager for the Locality and is Lead Director in the PCT for Substance Misuse issues. The Locality and Head of Community Care and Housing currently share responsibility for chairing the Local Implementation Team (the local group responsible for the implementation of the national Service Framework for Mental Health) The West Berkshire Safer Communities Partnership (SCP) The SCP comprises the Crime & Disorder Reduction Partnership (CDRP), Drug & Alcohol Action Team (DAAT) and the Youth Offending Team (YOT) and is chaired by the West Berkshire Council Chief Executive, with the deputy Chair being the Police Area Commander. It meets on a quarterly basis and its remit is to set the strategic direction in relation to crime, disorder, drug misuse and youth offending and to monitor the performance of the CDRP, DAAT and YOT. The SCP reports directly to the West Berkshire Partnership (WBP), which is the Local Strategic Partnership and is currently chaired by a West Berkshire Council Ward Member Joint Commissioning Group There is an overall West of Berkshire commissioning group that makes the wider links across the area and a Locality Commissioning Group (LCG) that focuses solely on West Berkshire. Both these groups use the DAT treatment plans as a tool to invest in and performance manage a treatment system that delivers equitable results, this includes, needs analyses, commissioning services, monitoring and evaluating services, and manages finances. 3

6 2.2.4 Local Implementation Team The West Berkshire Mental Health Local Implementation Team (LIT) is the key group for the development and monitoring strategies for people with mental health problems and their carers. The LIT is a multi-agency group which includes service user and carer representatives, as well as staff and managers from health, social care, education and non-statutory provider organisations. The LIT will oversee the implementation of the Dual Diagnosis Strategy as a part of its responsibility for the implementation of the National Service Framework (NSF) for Mental Health, and will undertake annual reviews and updating of the strategy. This will be linked with the annual review of the The West Berkshire Mental Health Commissioning Strategy which provides a framework for decisions about service provision for people with mental health problems for West of Berkshire Mental Health Sub Group This group, responsible to the West Of Berkshire Partnership Board, includes representatives from the West of Berkshire PCT s, Unitary Authorities and Berkshire Healthcare Trust. Its role is to ensure effective cross-locality planning and provision of mental health services. 2.3 Local Partnerships Partnership working is central to our approach to commissioning and service provision in West Berkshire, as we believe that it secures the best outcomes for service users, through the most cost-efficient use of resources. West Berkshire Council has an integrated Community Care and Housing Directorate, enabling strong links between Housing Strategy, Housing Operations, Supporting People, and Community Care. All management posts in local mental health services carry both health and social care responsibilities, and are jointly accountable to the commissioning and/or provider organisations. Partnership working with service users and carers in particular is of critical importance - the foundation provided by strong partnerships enables us to ensure that our services develop in an integrated way, and are enhanced and enriched by the healthy challenge resulting from the involvement of a diverse range of stakeholders. 4

7 3 Needs Information 3.1 Definition what is Dual Diagnosis? There are complex relationships between mental health and substance misuse problems for various reasons: Substance misuse (even on only one occasion) and withdrawal may lead to mental health problems or symptoms- for example drug-induced psychosis. Intoxication and dependence may produce psychological symptoms. Substances may exacerbate or alter the course of pre-existing mental health problems sometimes people with mental health problems may use substances in an attempt to self medicate A primary mental health problem may precipitate problematic substance misuse, which may in turn lead to more serious mental health problems. The extent to which substance misuse causes mental health problems remains the subject of significant debate. There are strongly held views, which can sometimes cloud key issues and make informed debate challenging. There is more agreement that substance misuse may trigger or exacerbate mental illness. There is a clear need for local stakeholder involvement in determining a definition which then forms the foundation for service commissioning and delivery. 3.2 National Prevalence There is an increased prevalence of substance misuse among people with mental health problems around a third to a half of people are affected. British studies have identified that alcohol and cannabis are the drugs most frequently used by individuals with mental health problems. Alcohol misuse is the most common form of substance misuse, and drug misuse often coincides with alcohol misuse. Homelessness is frequently associated with substance misuse problems. Community Mental Health Teams (CMHT s) typically report that 8-15% of their clients have dual diagnosis problems, although higher rates may be found in inner cities. Prisons have a high prevalence of drug dependency and dual diagnosis. 5

8 (From Dual Diagnosis Good Practice Guide) Substance misuse among people with mental health problems has been associated with significantly poorer outcomes including: Worsening psychiatric symptoms Increased use of institutional services Poor medication adherence Homelessness Increased risk of HIV infection Poor social outcomes including impact on carers and family Contact with the criminal justice system Substance misuse is also associated with increased rates of violence and suicidal behaviour. A local Substance Misuse Needs Assessment is being coordinated by the DAT is currently in progress. A Community Needs Assessment has been completed by West Berkshire Council and analysis and comparison with census data is currently in progress. 3.3 Local Mental Health Needs Information The information provided below has been drawn from the West Berkshire Mental Health Commissioning Strategy (2004). The generally accepted prevalence rate for mental health problems is based on a survey (Goldberg, D and Huxley Common Mental Disorders Routledge 1982) which states that 1 in 4 people will have mental health problems at any given time. (Source: If we extrapolate this down to the West Berkshire population aged 18 and over based on mid-year estimates 2002, it would suggest that there are currently 18,316 adults with mental health problems Prevalence of specific mental health problems is taken from Office of National Statistics (ONS) 2000 Psychiatric morbidity among adults. The following table estimates the number of West Berkshire residents having a particular mental health problem at any one time based on 2002 mid-year population estimates, and includes the number of cases estimated for

9 Mental Health Problem Prevalence rate No of cases 2002 No. of expected cases 2010 Anxiety 4.7% 5,165 5,621 Depression 10% 10,990 11,960 Phobias 1.9% 2,088 2,272 OCD 1.2% 1,319 1,435 Schizophrenia 0.3% Manic depressive illness has a lifetime prevalence rate of 1%, meaning that 1,439 West Berkshire residents will experience this at some point in their life. Numbers of people receiving mental health services from West Berkshire Council Open client base as at 31st March of each year Ethnicity West Berkshire has a relatively small number of people from minority ethnic backgrounds, at 2.6% of the whole population (all age groups) Of the total 551 people (adults and older people) receiving a service from West Berkshire Council as at 31 st March, the ethnicity breakdown by number and percentage of people receiving services is as follows: White British = 511 (93%) White Irish = 11 (2%) Other white = 5 (0.9%) Mixed white/caribbean =1 Mixed white/black African =1 Other mixed background =1 Asian/Asian British Indian =1 Asian/Asian British Bangladeshi =1 Other Asian background =5 Black/Black British Caribbean =1 Not stated =13 (2.4%) 3.5 Learning Disability The Foundation for People with Learning Disabilities quote that 25-40% of people with a learning disability also have mental health problems. This would equate to between 1,031 and 1,651 of the group of 4,127 people with a learning disability in West Berkshire also having a mental health problem. A number of individuals within this subgroup will also have substance misuse problems. 7

10 3.6 Physical Health People with mental health and substance misuse problems are at increased risk of physical health problems as a result of both diagnoses: some mental health problems mean that people have reduced motivation to look after themselves in terms of diet and exercise, or lack opportunities to do this. In addition, some treatments require careful monitoring and may pose risks if this is not undertaken. A large number of people with severe and enduring mental health problems smoke, and are therefore at risk of smoking related health problems. Physical health problems related to substance misuse are clearly significant and variable according to the type and amount of substance used. There is good evidence to suggest that diet and exercise can have a significant benefit in terms of mental health, however, people with co-exisiting substance misuse problems have significant challenges in terms of accessing support with this. 3.7 Employment People with mental health problems have the highest rate of unemployment amongst people with disabilities. 1 Only around 13% of people with mental health problems are in employment, compared with around 33% of people with other long-term health problems. (Sly, F. Duxberry R. and Tillsley, C (1995) Disability in the Labour Market Findings from the Labour Force Survey) 3.8 Local substance misuse information The local Drug Action Team (DAT) population aged is 81,467, with an estimated number of problem drug users ranging between 700 and 828 (two different data sources) National Treatment Agency (NTA) figures state that at year end 2003/4 there will be 174 people in treatment, with a target of 189 for 2004/5. Progress towards this target is on track, with 120 people in treatment at the end of quarter two. The following information is taken from the West Berkshire Crime Disorder and Drugs Audit

11 The percentage of offenders with alcohol or drugs problems relating to offending are significant at least 25% of offenders for alcohol (n=223) and at least 24% of offenders for drugs (n=207) 2. Drug Problems relating to Offending by Offence Type Death/Driving Violence Sex Burglary Robbery Vehicle Theft Theft and Handling Fraud and Forgery Criminal Damage Motoring Drugs Other Indictable Road Traffic 1 3 Public Order Other Summary No Yes 3.9 The local area West Berkshire shares in the overall affluence of the South East. It is home to a number of well-known national and international companies. A strong industrial base, characterised by new technology industries with a strong service sector and some manufacturing and wholesale organisations, combine to give West Berkshire one of the lowest unemployment rates in the country at less than 1%. As stated previously, West Berkshire covers more than half the total area of Berkshire and its population is by far the most scattered of all the unitary authorities in Berkshire While the majority of residents live in settlements west of Reading and in the major towns of Newbury, Hungerford and Thatcham, much of the district is rural. More than 60% of the area is classified as Areas of Outstanding Natural Beauty. The rural aspect of much of the district also presents many challenges. Services can be distant, public transport less viable and the supply of affordable housing cannot keep pace with demand. West Berkshire has a smaller and more scattered ethnic minority population compared with each of the other Berkshire unitary authorities and with England as a whole. 2 Based on data supplied by NPS information department there may be significantly more (as informed by local probation office). A large number of incomplete entries exist within this field 9

12 The impact of these locality features on local services is significant: The generally high affluence of the region and of West Berkshire can mask pockets of real deprivation and exclusion. The District does have communities with individuals and families who experience particular difficulties as a consequence of being poor within a generally wealthy region. Housing is a critical strategic concern with accommodation costs consistently among the highest in the country. This has resulted in a shortage of affordable homes for local people, including key public and private sector workers, near to where they work. Sufficient and affordable housing in rural areas is also a major concern, often resulting in young adults unable to buy or rent accommodation in areas where they grew up. The low numbers of people from a black and minority ethnic group makes the provision of culturally sensitive care more difficult. The wide geographical area of the District and the dispersed nature of much of the population makes access to services difficult and service delivery relatively expensive. Low unemployment makes staff recruitment problematic, particularly in services such as home care and residential care. West Berkshire has an ageing population. Among older people, the biggest proportional increase in West Berkshire has been in the 85+ age group which has increased by about one-third since the 1991 census, to a total of 2,301 people in the 2001 census. With a rise of 29% in this age group forecast over the next ten years, by 2011 the total West Berkshire population over 85 years of age will be nearly 3,000. These demographic changes will place additional pressures on local statutory services to ensure a range of supports are accessible and available where people live. For isolated rural communities this may mean additional transport links to services and the increased availability and use of broadband and other ICT technologies to provide local access to information about community care, housing and other Council services. Increased need for home adaptations or more specialised accommodation geared to allow as much independence as possible while supporting changing abilities is also likely. 10

13 4 Local Services Turning Point Provides both Structured Day Care and Outreach Services within the locality. A Service Level Agreement outlines the aims and objectives of the service, required activity and outcome targets linked to the provision of funding from the local pooled treatment budget. Thames House This is the service provided by Berkshire Healthcare Trust, commissioned by the West of Berkshire Primary Care Trusts and Unitary Authorities through their local treatment plans. Recent local reorganisation has resulted in the designation of specific sessions for the locality, and a local substance misuse service manager. There is a Service Level Agreement in place in line with that described above. Two Saints This is a Direct Access Homeless Hostel. A significant number of residents have substance misuse, mental health problems or dual diagnosis. Floating Support is provided through Supporting People funding. Temporary Accommodation West Berkshire Council has 36 units of TA for homeless people. A number of people in TA have either mental health or substance misuse problems or dual diagnosis. Two Tenancy Support Workers funded by Supporting People provide individual support to people while in TA, which is continued through Floating Support when they secure a permanent tenancy. Criminal Justice Services The Criminal Justice and Court Services Act (2001) requires all offenders, including suspects, to be liable for drug testing at each stage of the criminal process. Drug Treatment and Testing Orders (DTTOs) provide one response to people identified as having a drug problem. Community mental Health Services Service components include; Crisis Response Team Two, multidisciplinary patch teams Assertive Outreach Service Day Services 11

14 Resource This is a voluntary sector mental health service operating within Reading and Newbury, working to a recovery model, emphasising employment opportunities for service users. Inpatient Services These are provided by Berkshire Healthcare Trust at Prospect Park Hospital in reading. There are a number of designated detox beds within one of the acute inpatient wards. Residential Rehabilitation This is commissioned, but not provided locally. Through Care and After Care funding is being used locally to provide two posts, focussed on meeting the needs of people with complex needs. One of these workers will be linked to the CMHT, and the other to the Direct Access Hostel. This project will be managed and monitored by the DAAT. 12

15 5 Strategic Objectives 5.1 Development and implementation of the local dual diagnosis service plan. A Project Group is to be set up to include at least one representative from the Locality Commissioning Group and representatives from Treatment Providers, Mental Health and Criminal Justice Services. This group will consider appropriate planning information, undertake a planning workshop and submit an agreed strategy to the LIT and other relevant groups for final sign off. A lead clinician will be designated to represent the provider services, with the Head of Community Care and Housing undertaking the role of lead commissioner for Dual Diagnosis. The development of a clearer way of working on the part of both mental health and substance misuse services will be included in the service plan based on the following broad principles; Substance misuse services will provide specialist support, consultancy and training to mental health services to support the mainstreaming of clients with mental health problems. Mental health service will provide support to drug and alcohol services to enable them to work effectively with people with less severe mental health problems 5.2 Development, implementation and audit of dual diagnosis protocols and care pathways. This will follow from the development of the Service Plan, following the formulation of an agreed local definition of dual diagnosis. The Care Pathways are really Care Coordination protocols and will include the key role and contribution of each of the local provider agencies. This work needs to link to both Clinical Governance and training strategies. A specific protocol to address the needs of families will be developed by local partners in accordance with national guidance. 5.3 Establishment of effective processes for needs assessment and performance monitoring. The initial dual diagnosis service plan will be formulated on the basis of existing planning information. It is recognised that this needs to be improved in order to effectively review and refine the plan in future. All people with severe mental health problems and problematic substance misuse will be subject to the Care Programme Approach (CPA) Information about individual needs will be collated from Care Plans and aggregated to enable a more detailed analysis of the needs of individuals. 13

16 An audit of front line staff will be carried out in order to establish their awareness of need, their experience of working with this group of service users, and their views on gaps in service provision. Users and Carers will be involved in the needs assessment process. Consideration will be given to the particular needs of people of Black and Minority Ethnic origin. The service plan will include performance monitoring, and mapping of existing targets, outcome and activity data will be undertaken. In addition, local commissioning, planning and service delivery will be audited against the HAS Standards for Dual Diagnosis: Level One: commissioning, planning and integration. Level Two: inter- and intra- agency organisational issues. Level Three: organisation of care. Level Four: service delivery. 5.4 Provision of appropriate training. In dual diagnosis, and for mental health service in substance misuse, and for substance misuse service providers, in mental health. Assertive Outreach workers will be trained and equipped to work with dual diagnosis, and adequate numbers of trained staff will be included within all components of the community and inpatient services. Risk Assessment training will include harm in service users with dual diagnosis. 5.5 Coordination of Commissioning within the locality and across localities Ensure appropriate and effective links are in place across the West of Berkshire and Berkshire- wide. This is required to address acute inpatient care (provided by Berkshire Healthcare Trust on a West of Berkshire basis), as well as to share expertise and achieve cost efficient solutions to common problems. The Acute Care Forum and the Joint Commissioning Group will have a key role in ensuring and monitoring cross-locality commissioning and provision. 14

17 6 Action Plan Objective 1. Development and implementation of local dual diagnosis service plan Key Targets Actions Target date Lead Officer Set up project group, Identify membership, agree project plan, key outputs and timescales. Dec 2004 Locality Project group to produce service plan Planning information, to be considered and workshop to be undertaken July 2005 Locality Objective 2. Development, implementation and audit of dual diagnosis protocols and care pathways Key Targets Actions Target date Lead Officer Identify key role and contribution of stakeholder organisations Develop dual diagnosis protocol for work with families Develop care pathways for service user groups Identify all local stakeholders. Establish local project group to draft proposals based on SCIE guidance April 2005 August 2005 Locality Locality Head of Children s Services As above July 2005 Locality 15

18 Objective 3. Establishment of effective processes for needs assessment and performance monitoring Key Target Actions Target date Lead Officer Gather existing local needs info Aggregate CPA needs info Link with Needs Assessment and census analysis Audit service staff Seek service user and carer views Address needs of people of BME origin July 2005 Quality and Performance Locality Map existing performance data Collate health and social services data, and local performance against targets. Identify areas for improvement and incorporate into future service and treatment plans Sept 2005 Quality and performance manager Locality Audit locality against HAS Standards Undertake pilot audit to test local application of standards Oct 2005 Head of Service Refine standards and undertake full audit 16

19 Objective 4. Provision of appropriate training Key Target Actions Target Date Lead Officer Plan and implement training for staff Develop training programme in accordance with guidance in Toolkit. Provide and evaluate training for Mental Health, substance misuse and Assertive Outreach Workers Feb 2005 Feb 2005 Locality DAAT Objective 5. Coordination of commissioning and service delivery within and across localities Key Target Actions Target Date Lead Officer Evaluate Dual Diagnosis Strategies of West of Berkshire for cross locality implications Agenda for discussion at MH Sub Group meeting Develop appropriate plans Jan 2005 Locality Develop joint proposals for mental health inpatient services Agenda for discussion at Acute Care Forum March 2005 CMHS Link with MH Commissioning Strategy Incorporate dual diagnosis in annual commissioning review July 2005 Head of Service 17