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1 OPR53 Lincolnshire Partnership NHS Foundation Trust (LPFT) Dual Diagnosis Document Type and Title: DOCUMENT VERSION CONTROL Dual Diagnosis - Policy Authorised Document Folder: New or Replacing: Document Reference: Operational Replacing OPR53 Version No: 4 Date Policy First Written: 14 November 2007 Date Policy First Implemented: November 2007 Date Policy Last Reviewed and Updated: August 2011 Implementation Date: August 2011 Author: Approving Body: Specialist Services Business Manager Clinical Policy & Practice Committee Approval Date: August 2011 Committee, Group or Individual Monitoring Clinical Policy and Practice Committee the Document Review Date: September 2012 LPFT OPR53 v.3 August

2 Contents Page 1. Introduction 3 2. Purpose & Scope 4 3. Duties 7 4. Process/Arrangements to Address the Needs of Dual Diagnosis 8 Service Users 5. Development of Policies and Procedures Consultation, Approval and Ratification Process Review and Revision Arrangements including Version Control Dissemination and Implementation of a Policy Policy Control including Archiving Arrangements Monitoring Compliance with and Effectiveness of Policies & Procedures References Associated Documentation Glossary of Terms Appendices 14 One Two NHS Lincolnshire/Lincolnshire County Council Dual Diagnosis Strategy for Lincolnshire Mental Health Services Liaison/Referral to Substance Misuse Services Flow Diagram Three Substance Misuse Services Liaison/Referral to Mental Health Services Flow Diagram Four Five Policy Implementation Plan Policy Monitoring, Audit & Feedback Summary LPFT OPR53 v.3 August

3 1. Introduction 1.1 In the Mental Health Policy Implementation Guide (2002) Louis Appleby stated supporting people with dual diagnosis mental illness and substance misuse alcohol and/or drugs is one of the biggest challenges facing front line Mental Health Services. The complexity of issues makes diagnosis, care and treatment more difficult, with this group of service users being at higher risk of relapse, readmission to hospital and suicide. 1.2 The National Confidential Enquiry into suicide and homicide by people with mental illness (Manchester University 2006) identified substance misuse as a significant factor in over half reported cases of suicide. There was also over representation among those who committed suicide within this cohort. 1.3 The National Service Framework for Mental Health - Five Years On (December 2004) concluded Services for people with dual diagnosis mental illness and substance misuse the most challenging clinical problem that we face. 1.4 New Horizons A Shared Vision for Mental Health (DOH 2009) indicated that up to half of people with mental health problems may misuse alcohol or drugs. It continued that Dual Diagnosis is associated with: Increased crimes of violence committed by those with mental illness Increased rates of attempted and completed suicide Poor compliance with medication and other treatment More treatment failures for both conditions Homelessness Increased risk of harm to children and to vulnerable adults High relapse rate in both conditions resulting in longer and more frequent periods of hospitalisation 1.5 It went on to state that Dual Diagnosis is one of the most challenging problems in mental health care and requires collaborative working between a number of agencies. 1.6 The term dual diagnosis covers a broad spectrum of mental health and substance misuse difficulties that someone might experience concurrently. Some of the possible explanations for this complex condition include: A primary mental health problem precipitating or leading to an episode(s) of substance misuse Increase in substance misuse affecting the course of mental ill health Intoxication leading to psychological symptoms Substance misuse and/or substance withdrawal leading to mental health difficulties LPFT OPR53 v.3 August

4 2 Purpose & Scope 2.1 LPFT is committed to working in partnership with Mental Health and Drug & Alcohol commissioners, providers and third sector agencies to ensure a collaborative approach to address the needs of dual diagnosis service users. 2.2 Both NHS Lincolnshire and Lincolnshire County Council Mental Health Commissioners approved a Dual Diagnosis Strategy for Lincolnshire 2006 (Appendix One). This strategy was the result of a stakeholder consultation event led by the regional NIMHE/CSIP lead and lead Health Commissioner. 2.3 There were considered eight key challenges to be addressed if Lincolnshire Services and mainstream providers were to meet the needs of those with dual diagnosis as recommended within DOH 2002 Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide. These were: 1. Develop a shared definition of dual diagnosis which is clear and reflects the experience and needs of Lincolnshire. 2. Formal sign up from all partner agencies to the definition. 3. Consider the need for, if any, specialist dual diagnosis services to provide specialist support to mental health services. 4. Ensure all assertive outreach staff have training in how to work with dual diagnosis and have the skills and support to do this. 5. Ensure that there are sufficient staff within community mental health services and substance misuse services who are trained in dual diagnosis. 6. Fully map out the range of services available and identify the actual need against the availability. 7. Develop and agree the care pathway and clinical governance guidelines for dual diagnosis including mechanisms for preventing and resolving any disputes between services. 8. Ensure that all service users with severe mental illness using substance misuse services are subject to the Care Programme Approach, and have had full risk assessments in line with mainstream mental health service standards. 2.4 The Lincolnshire Strategy highlighted 10 outcomes and objectives within the Implementation Plan. 1. Development of a joint care and referral pathway for individuals with dual diagnosis. 2. Full implementation of Care Programme Approach (CPA) for individuals with dual diagnosis across substance misuse services or substance misuse services to be subject to the annual CPA Audit. 3. Development and sign off of a formal information sharing protocol across substance misuse and mental health services. LPFT OPR53 v.3 August

5 4. Development of a county-wide joint training plan for substance misuse awareness for mental health services and the criminal justice system. 5. Development of a joint training plan for substance misuse awareness for all mental health services in Lincolnshire. 6. Development of a dual diagnosis best practice and awareness training package for Lincolnshire, including primary care practitioners. 7. Development and evaluation of options for a model of service delivery. Current capacity of existing services to be evaluated and decision made as to whether the existing server can deliver the model of other additional capacity or a new dedicated service is required. (It is intended that once service delivery models are explored a fit for purpose model will be included in the NHS Lincolnshire Commissioning Plan ). 8. Sufficient capacity to meet the needs of individuals with dual diagnosis including common mental health problems to be included in the development of primary care mental health services and the care pathway to reflect this. 9. Information for service users, carers and professionals and made widely available raising both awareness of dual diagnosis and providing signposting and referral pathway information. 10. Needs assessment of user and carer needs in the Black and Minority Ethnic community of Lincolnshire to be carried out through Community Development Workers. 2.5 Although the Lincolnshire Strategy was approved 2006, its implementation was delayed 2006/2007 due to local PCT reconfiguration. 2.6 The 10 outcomes and objectives within the Strategy s Implementation Plan, were progressed during under the NHS Lincolnshire Local Implementation Team (LIT) Dual Diagnosis Work Stream, reporting to NHS Lincolnshire and Lincolnshire County Council Joint Governance Mental Health Group. 2.7 In order to review these Dual Diagnosis Guidelines, it is necessary to review the progress of the implementation of the Dual Diagnosis Strategy, as they must be viewed within the context of the local achievements and developments. The LIT Dual Diagnosis work stream has been led by the Lincolnshire NHS Planning & Health Outcomes Programme Manager as project sponsor, with LPFT Specialist Services Business Manager and policy author being the Project Lead. 2.8 The work stream consists of a cross agency, multi stakeholder Steering Group whose membership is represented as follows: LPFT Consultant Psychiatrist Mental Health, Substance Misuse Clinical Lead and Specialist Services Clinical Director Business Managers for the following LPFT divisions: Psychological Therapies and Primary Care, Adult Services and Specialist Services LPFT OPR53 v.3 August

6 Substance Misuse providers LPFT Substance Misuse Team Leader, Addaction Team Leader, Drug and Alcohol Team (DAAT) Commissioner National Offender Management Assistant Chief Officer 2.9 For the NHS Lincolnshire led Dual Diagnosis work stream and Steering Group concentrated on Action (7) of the Dual Diagnosis Strategy Outcomes and Objectives Implementation Plan: - Development and Evaluation of options for a model of service delivery. Current capacity of existing services to be evaluated and a decision made as to whether the existing server can deliver the model of other additional capacity or a new dedicated service is required In essence this concentrated on measures to assess the nature of demand and needs of Dual Diagnosis service users locally: the Interim Dual Diagnosis Adult Care Pathway, and data collection exercise launched June 2008, for 6 months until January The analysis, outcomes and actions for implementation of this exercise and follow up measures are yet to be approved or published. Combined with which the Lincolnshire Dual Diagnosis Strategy is currently undergoing commissioner review and authority for implementing the revised Strategy is likely to transfer from the NHS Lincolnshire as the lead organisation to the local Drug & Alcohol Action Team (DAAT) in The time frames for both the Strategy revision and transfer of lead organisation are yet to be set Therefore within this local context, the current Dual Diagnosis practice and processes can best be described as a mainstreaming approach, of parallel service delivery between Mental Health commissioned services and Substance Misuse commissioned services. It remains that LPFT are not specially resourced to provide an explicit dual diagnosis service or interventions. However both LPFT Mental Health and Substance Misuse Services are working with service users who present with a dual need of mental illness and substance misuse issues Given this context, that the strategy has not yet been fully realised, LPFT staff are addressing the needs of Dual Diagnosis service users without the following being explicitly in place. An agreed working/operational definition of Dual Diagnosis Integrated Care Pathway, explicitly stating Dual Diagnosis provision as opposed to describing Mental Health and Substance Misuse parallel, joint partnership working Information sharing protocol Explicit criteria for accessing Mental Health and Substance Misuse Services that specify and include Dual Diagnosis Clarity over provision for older people with mental health dual diagnosis, including provisions for alcohol related cognitive impairment LPFT OPR53 v.3 August

7 Clarity over specialist and specific dual diagnosis services and specific treatment interventions, rather than parallel, complementary interventions either substance misuse or mental health, being delivered simultaneously 2.13 Given the above the purpose of these guidelines is to describe the joint working arrangements, to make the parallel provision as effective as possible. Thus identifying each services principles of care, mechanisms for referral and communication processes, ensuring joint working and mutual support are reinforced. 3. Duties 3.1 LPFT has a duty to ensure it has clinical guidelines in place for the management of service users with a dual diagnosis/dual need of mental health problems and substance misuse. 3.2 LPFT is committed to implementing joint agency partnership working arrangements recognising that the needs of this service user group are best met and require collaborative working between a number of agencies. 3.3 The Board of Directors (the Board) has a legal responsibility to ensure that the Trust policies and protocols are in place to effectively address the needs of service users with dual diagnosis. It is also a criterion under the NHSLA Risk Management Standards. 3.4 The Executive Committee/Approving Committee have responsibility for development, implementation, review, monitoring effectiveness and approval of the policy and procedures on behalf of the Board. Responsibility for monitoring the effectiveness of dual diagnosis procedural guidance lies with the Clinical Policy and Practice Committee. 3.5 The Director of Nursing and Strategy will identify a policy lead and ensure that Dual Diagnosis practice and procedures are reviewed in line with guidance and the development of the Lincolnshire Dual Diagnosis Strategy. 3.6 It is the responsibility of Executive/Associate/Deputy/Assistant Directors/ General Managers, Heads of Service to ensure that: Dual Diagnosis procedures and practice are managed within their own department or service, in line with this guidance Team managers and other management staff are given clear instructions about policy arrangements so that they in turn can instruct staff under their direction There are mechanisms ensuring staff are informed of any changes to the guidance There are systems in place to record the necessary arrangements have been made in line with the implementation plan for this guidance 3.7 Every member of staff has a responsibility and duty to identify need under CPA procedures and if the service user has a dual mental health and substance misuse need to refer for a complementary assessment. LPFT OPR53 v.3 August

8 3.8 Similarly under Assessment & Care Planning, incorporating CPA procedures and Clinical Risk Assessment Incident Reporting procedures, staff have a responsibility to report unmet need through the existing risk management, governance and monitoring arrangements. 3.9 The responsibility for ensuring the implementation of the Lincolnshire Dual Diagnosis Strategy lies with the lead Health Commissioner NHS LINCOLNSHIRE currently in negotiation to be delegated to the DAAT structures for delivery and achievement LPFT has a responsibility as the main mental health provider to ensure its services are represented on the forums responsible for implementing the Lincolnshire Dual Diagnosis Strategy LPFT has a responsibility as the main health provider of Substance Misuse Services (both drugs and alcohol) to ensure these services are represented on the forums responsible for implementing the Lincolnshire Dual Diagnosis Strategy. 4. Processes/Arrangement to Address the Needs of Dual Diagnosis Service Users 4.1 The following defines the liaison/referral/complementary assessment process between LPFT Mental Health Services and countywide Substance Misuse Services and incorporates the Care Programme Approach, MANCAS/HoNOS and risk criteria for Mental Health Services and alcohol AUDIT and prescribing inclusion criteria for drug services and risk assessment procedures for substance misuse services. 4.2 At best current operational practice and processes can be described as a mainstreaming approach: parallel provisions until the Lincolnshire Strategy 10 outcomes are fully realised. 4.3 These guidelines should be seen as working alongside and in harmony with those services available and treatment options provided by LPFT. This document should be read in conjunction with other related LPFT Policies, Procedures and Guidelines reflective of LPFT s existing commissioned provision of services for service users with mental health/substance misuse needs. 4.4 Each Service User should be able to access specialist services, generic services or a combination of both, based on their individual needs and the providers commissioned Service Specification and any inclusion and exclusion criteria. As each service is operating within its current commissioned delivery criteria, it is essential that both generic and specialist services are committed to working collaboratively, to identify need and improve governance and risk management, by contributing to identifying unmet need. 4.5 Referrals through any route will require assessment as to whether the Service Users needs can be appropriately met within that service, or whether complementary joint working is required if a Service User s needs cannot currently be met by the service, then unmet need should be identified on the Care Plan and reported through risk management procedures. 4.6 The operational liaison/referral flow charts do not replace specific services operational policies or service schedules, but should be seen as working in harmony with those policies and guidance that describes the services available and treatment options provided by LPFT. It incorporates both in-patient and community provision, and all service delivery divisions. LPFT OPR53 v.3 August

9 4.7 Liaison/referral arrangements for Mental Health Services referral to Substance Misuse Services are attached at Appendix Two. This is via the existing commissioned single point of access provided by Addaction. 4.8 Liaison/referral arrangements for Substance Misuse Services referral to Mental Health Services are attached at Appendix Three. This is via the existing commissioned Single Point of Access via the Primary Care GP and/or direct referral to team/services. 4.9 The Dual Diagnosis definition used during the Interim Dual Diagnosis Adult Care Pathway remains operational: Primary mental health problem precipitated and leading to an episode(s) of substance misuse Increase in substance misuse affecting the course of mental ill health Intoxication leading to inappropriate psychological symptoms Substance Misuse and/or substance withdrawal leading to mental health difficulties should be referred for a complementary assessment 4.10 Both the definition and liaison referral arrangements are intended to be interpreted broadly and not to exclude service users from a complementary assessment, parallel service delivery or joint working As the guidelines describe existing generic provision they have limitations: they are not a comprehensive set of rules for the management of dually diagnosed service users nor do they describe specialist or specific dual diagnosis services and treatment interventions. However there are a number of important principles that overarch any individual care package and joint working arrangement that may be agreed for a particular service user, within the existing service provision arrangements Therefore the following guiding principles characterise the current, operational practice, liaison and joint working arrangements. - If the service user meets criteria for mental health services the Care Coordinator responsibilities and CPA are with Mental Health Services - All services ensure service users are subject to CPA (mental health) Care Planning (Substance Misuse), Care Coordination and have full risk assessments which are regularly reviewed - Risk Management plans are carried out subject to Trust policy and guidance - Mental Health and Substance Misuse Services work jointly to contribute to care plans, treatment plans and risk management plans. This covers and offers the range of partnership liaison services from joint assessments, joint working to one off stand alone telephone advice/consultation between providers, services and teams LPFT OPR53 v.3 August

10 - Mental Health and Substance Misuse Services utilise existing external partnership arrangements for opportunities of joint working, ensuring a comprehensive package of care e.g. Rethink, Housing providers, OASIS Carers Support - Any disputes between services and providers should be resolved via informal dispute resolution process, using the immediate Line Manager and management structure of each practitioner, team or service. It is likely that this will include a multi-disciplinary Team discussion. If this does not bring about a conclusion, a senior manager may assess and resolve the matter. In the unlikely event that it cannot be resolved by a senior manager it may be referred to the Medical Director/Director of Nursing for a final position on the issue - Any unmet need (including that due to service specifications, eligibility criteria not including dual diagnosis specifically, or Teams, Services and Providers failing to undertake complementary assessment, parallel provision and joint working) will be recorded in the Care Plan. If lack of provision constitutes to a heightened risk this is reported via Risk Management procedures and recorded on Sentinel and monitored accordingly, via the monthly Risk Review Group 5. Development of Policies and Procedures 5.1 LPFT have had guidelines relating to Dual Diagnosis since October They were revised in August 2008 to incorporate the Interim Dual Diagnosis Adult Care Pathway, and data collection exercise in line with the Strategy s Implementation Plan. Consequently during 2009/10 the Trust has focused on reviewing the existing guidance, gap analysis, lessons learnt from the Interim Dual Diagnosis Adult Care Pathway and Strategy development. The learning and emerging issues from all of the above have been transferred and incorporated in this revised guidelines Implementation Plan, as detailed in Appendix Four. Therefore they are evidently intrinsically linked to the Lincolnshire Dual Diagnosis Strategy and the multi stakeholder LIT work stream. 5.2 Currently the Strategy is undergoing both commissioner transfer and review, in line with more recent publications: National Mental Health Development Unit: Developing a Capable Dual Diagnosis Strategy 2009 and DoH Local Routes: Guidance for Developing Alcohol Treatment Pathway December Therefore these clinical guidelines have not been benchmarked against other Trusts due to the unique local position and the existing mainstreaming approach of parallel service delivery. 5.4 These guidelines do however provide evidence for the NHS Litigation Authority (NHSLA) Risk Management Standards of Mental Health and Learning Disability Trusts 2010/11 Standards 4.3. Clinical Care: process for managing the risks associated with the management of service users who present with a dual diagnosis of mental health problems and substance misuse. 6. Consultation, Approval & Ratification Process 6.1 The policy will be consulted upon, approved and ratified in accordance with COR11: Development, Implementation and Management of Policies. 6.2 The relevant Executive Committee, is identified in the appendices to COR11. LPFT OPR53 v.3 August

11 7. Review & Revision Arrangements Including Version Control 7.1 The policy will be reviewed 2 yearly by the policy lead in accordance with COR11. Revision may occur earlier if relevant new legislation or guidance is issued, including that from NHS Litigation Authority. 7.2 Both the Executive Committee monitoring the effectiveness of the policy and the commissioning lead agency for the Dual Diagnosis Strategy may also call for an earlier review on the basis of the reports it receives and local developments. 7.3 Corporate and Legal Services will maintain a Version Control Sheet as per COR Dissemination and Implementation of a Policy 8.1 It will be the responsibility of the Director of Nursing & Strategy to take the lead for the development, implementation and review of this policy. This will be in keeping with the guidance set out within the COR11 Policy for Development, Implementation and Management of Policies, Procedures and Guidelines. 8.2 The policy will be made available to all staff within the Trust and is accessible on the Trust website. 8.3 The Corporate & Legal Services will be responsible for ensuring the current version is accessible and that changes or new versions of the policy are advertised, as they are reviewed and issued. 8.4 The Learning & Development Department will take the lead for ensuring the relevant mandatory training relevant to Dual Diagnosis as detailed in PER25 mandatory training is available. 8.5 The Policy Lead has responsibility for ensuring the following: All heads of departments within LPFT are informed of the policy update and the need to disseminate it to their staff groups To both update and review the policy in line with guidance received, the development of the Lincolnshire Dual Diagnosis Strategy and requirements from the Executive Committee/Approving Committee, based on the reports it receives That the Implementation Plan (Appendix Four) designed to achieve full compliance with the Policy Monitoring, Audit & Feedback Summary Appendix Five is realised, and achieved within the designated timeframes. This includes reporting challenges to implementation, to both the Director of Nursing & Strategy and the Executive/Approving Committee 9. Policy Control including Archiving Arrangements 9.1 Corporate and Legal Services will retain a copy of each policy for a minimum of 10 years in line with the recommendations contained within 'Records Management NHS Code of Practice' (2006). 9.2 Individuals wishing to obtain previous versions of this policy should contact Corporate & Legal Services. LPFT OPR53 v.3 August

12 10. Monitoring Compliance with and Effectiveness of Policies and Procedures 10.1 LPFT will adhere to any governance and monitoring requirements as detailed in the implementation of the Lincolnshire Dual Diagnosis Strategy. LPFT will ensure that future requirements will comply with NHSLA Management Standards Existing LPFT governance arrangements that are able to monitor issues arising from current operational practice, the implementation of both the strategy and the guidelines are to be capitalised upon. Therefore these guidelines utilise existing reporting and monitoring mechanisms were dual diagnosis is relevant: Incident Reporting, Assessment & Care Planning, Handling Comments & Complaints They include internal and external systems of monitoring and action planning. The full range of processes for monitoring compliance with and the effectiveness of the procedural document are detailed in Appendix Five Policy Monitoring, Audit and Feedback Summary. They include review and monitoring of the minimum requirements within the NHSLA Risk Management Standards. 11. References 1. Mental Health Policy Implementation Guide Dual Diagnosis Good Practice Guide (DoH/1999) 2. National Confidential Enquiry into Suicide & Homicide by People with Mental Health Illness (Manchester University 2006) 3. National Service Framework for Mental Health Five Years On (DoH/2004) 4. New Horizons: A Shared Vision for Mental Health: Cross Government Strategy: Mental Health Division (Dec. 2009) 5. Lincolnshire NHS and Lincolnshire County Council Dual Diagnosis Strategy for Lincolnshire 6. Developing a Capable Dual Diagnosis Strategy A Good Practice Guide National Mental Health Development Unit (June 2009) 7. Local Routes: Guidance for Developing Alcohol Treatment Pathways (DoH/Dec 2009) 8. Records Management NHS Code of Practice (2006) 12. Associated Documentation 12.1 As stated previously these clinical guidelines work in harmony with existing LPFT strategies, policies, procedures and other guidelines. Therefore it links with a number of existing LPFT documentation. Detailed below is not an exhaustive list, but those that are particularly relevant are: Multi- Agency COR29 Information Sharing Protocol OPR35 Direct Payments Policies COR10 Child Protection Policy & Good Practice Guidance LPFT OPR53 v.3 August

13 COR27 INF07 INF10 OPR02 OPR03 OPR14 OPR16 OPR17 OPR20 OPR21 OPR22 OPR25 OPR34 OPR47 OPR48 OPR52 RM01 RM05 RM10 Deciding on Community Care Expenditure Access to Health & Social Care Information Sharing letters with service users Safeguarding Adults Management of Drug and Alcohol Misuse Assessment and Care Planning Appraisal of Carer Need Medicine Management Clinical Risk Management Discharge and Transfer Consent Domestic Violence Policy MAPPA Controlled drug management Delivery of physical healthcare Self administration of medications Handling Comments & Complaints Confidentiality Incident Reporting 13. Glossary of Terms AUDIT COR 11 CPA CSIP DAAT DOH HoNOS LCC LIT LPFT MANCAS MAPPA NHSLA NIMHE NSF Alcohol Use Disorders Identification Test LPFT Corporate Policy 11: Policy for Development, Implementation & Management of Policies, Procedures & Guidelines Care Programme Approach Care Services Improvement Partnership Drug & Alcohol Action Team Department of Health Health of the Nation Outcome Scales Lincolnshire County Council Local Implementation Team Lincolnshire Partnership Foundation Trust Manchester Care Assessment Schedule Multi Agency/Public Protection Arrangements NHS Litigation Authority National Institute of Mental Health in England National Service Framework LPFT OPR53 v.3 August

14 APPENDIX ONE LPFT OPR53 v.3 August

15 DRAFT DUAL DIAGNOSIS STRATEGY LINCOLNSHIRE Introduction This document has been produced in order to provide a structure for the development of a strategy for the management of dual diagnosis in Lincolnshire. It will act as a basis for a confirm and challenge process at the end of which it is hoped that the product will be a shared and agreed plan on how to go forward on this key policy area which effects the lives of many people today. This process will take place against a mixed background of influences and circumstances, whilst adult mental health and drugs treatment services have undergone recent and often radical modernisation, there remains in both areas significant gaps, in both range and capacity of services available. In the case of alcohol services these remain woefully inadequate with little hope of improvement in the situation until 2007 at the earliest due to financial constraints. However we can expect the level of change in services to reduce as the emphasis changes from structural change to service improvement, therefore we have and excellent opportunity to develop, agree and drive forward a shared plan on dual diagnosis. Definition The term dual diagnosis covers a broad spectrum of mental health and substance misuse difficulties that someone might experience concurrently. Some of the possible explanations for this complex condition include: A primary mental health problem precipitating or leading to an episode(s) of substance misuse Increase in substance misuse affecting the course of mental ill health Intoxication leading to psychological symptoms Substance misuse and/or substance withdrawal leading to mental health difficulties Substance misuse among individuals with mental health difficulties has been associated with significantly poorer treatment outcomes including: Increased rates of in-patient episodes Poor medication concordance Increased risk of HIV and other related conditions Involvement with the criminal justice system Homelessness General Social exclusion Deterioration in mental health symptoms Generally poor social outcomes particularly relating to carers and family members Recent reports into homicides committed by people with mental health difficulties identified substance misuse as a significant factor in over half the reported cases, there were also over-representation among those who committed suicide within this cohort. LPFT OPR53 v.3 August

16 National picture the way forward: 2006/07 CSIP National Headline Management Plan Purpose and scope The overall purpose and scope of the programme is to develop a process and measurable outcomes that will improve and develop the experience of people with co-existing substance misuse and mental health difficulties, (dual diagnosis) their carers and families. Also to promote the social inclusion of people with dual diagnosis through supporting and implementing the recommendations of the Dual Diagnosis Good Practice Guide, NSF Five Years On, the Social Inclusion report, and other key national policy drivers Activity Develop indicators for dual diagnosis as part of the acute in-patient review in partnership with the Health Care Commission Support a group to meet and develop indicators which will influence this review To explore partnerships with Universities and Higher Education providers, linking the role of existing Dual Diagnosis networks and work based/distance learning. This will provide supporting structures for service development with local links to academic institutions and CSIP Disseminating a competency-based framework for dual diagnosis in partnership with CCAWI, and contribute to the dual diagnosis module of the 10 Essential Shared Capabilities Develop an integrated and inclusive Dual Diagnosis programme within the DH and across other departments, including the Home Office and NTA Further develop training in aspects of dual diagnosis specifically to pilot the Assertive Outreach Team training in a number of centres across the country. The programme is represented at and will contribute to: o Promoting Linkages between Criminal Justice Integrated Teams and Mental Health Services Guidance Document (Home Office) o Strategy for Prisons(DH) o Good Practice Guide (Turning Point) National benchmarking exercise for Dual Diagnosis In collaboration with Skills for Health development of the Interventions programme, to include team and role profiles for delivery of services for people with a dual diagnosis Support implementation and in-use evaluation and development of work-based resources Outcomes Indicators for Dual Diagnosis will be included in the Annual Health Check 2006/7 Stakeholders agree and test a process linking service development, Higher Education Establishment s and regional networks. Agree a dissemination and implementation strategy with central communications and CCAWI Establish working relationships with DH led Dual Diagnosis/Substance Misuse oversight group, and establish governance through Health and Social Care Criminal Justice Programme. Identify pilot sites for AO team training, pilot materials, followed by evaluation and wider dissemination Pilot carers resource, evaluation and wider dissemination Clarify national picture for dual diagnosis services (commissioning, models, etc) Dual Diagnosis team and role profiles available via Skills for health web based resource LPFT OPR53 v.3 August

17 Specific products in this financial year Prod No Product 1 An agreed set of indicators which will reflect best practice and performance for NHS Trusts in relation to Dual Diagnosis service provision 2 A replicable process of partnership working, piloted in at least one region 3 Updated version of the CD library resource and national events How outcome is measured Approved by HCC Report and evaluation Engagement of all dd leads 4 Capabilities framework Inclusion and reference within relevant training strategies 5 Carers resource Feedback from relevant partners and carer leads 6 AO training pilot Report and evaluation Delivery Date October 2006 April 2007 July 2006 events ongoing throughout the year May 2006 dissemination ongoing throughout the year July 2006 Early Prisons Strategy April Develop methodology for national benchmarking exercise, pilot and collate data April Skills for Health development Evaluation & Testing Feb 07 Local context and prevalence: There is no clear picture of the local prevalence of dual diagnosis within Lincolnshire, however anecdotal information suggests that particularly with the growing numbers of individual with highly complex problems and needs dual diagnosis is a norm rather than and exception. Little is known of how many of the 90% of individuals with mental health problems seen in primary care have a dual diagnosis, however there is growing evidence of high levels of alcohol problems within Lincolnshire presenting in primary care, and local assessment by Lincolnshire DAAT suggests that the prevalence of drug problems is significantly higher than national estimates for a similar community. With the establishment of a county wide assertive outreach service a new service based on national policy guidance which positively sought to engage service users whose mental health problems were compounded by substance misuse and often chaotic lifestyles which go with it, has brought to notice the significant numbers requiring such a model, with 232 individuals currently receiving this service across the county. LPFT OPR53 v.3 August

18 In terms of those currently receiving care from mental health services under the care programme approach it is not known what proportion of the total experience substance misuse problems but this may be between one third and a half of those with severe problems (Dept of Health 2003). This is clearly a matter for further local investigation. Individuals with complex problems including dual diagnosis are generally over represented in either requests for out of county placements or actual placements. A needs assessment carried out in 2004/5 looking at the needs of Lincolnshire people in out of county placements and low secure beds identified high levels of problematic substance misuse, along with both severe often treatment resistant mental illness, but also with personality disorder which required treatment. In terms of prevalence of substance misuse problems it is expected that by March 2006, more than 2000 individuals will have presented at local agencies seeking formal treatment for dugs problems, with the full range of problems including, Heroin, crack cocaine, amphetamine and problematic cannabis use. The numbers with alcohol problems seeking treatment is unknown as most present in primary care seeking help from their GP however local estimates suggest that there are 3 individuals with alcohol problems for every 1 with a drug problem suggesting a potential group of 6000 with significant treatment needs. The Lincolnshire DAAT drugs audit 2005 provides full details of the profiles of drug related presentations in Lincolnshire for further analysis. The resources available to Lincolnshire substance misuse and mental health services remains at a relatively low level, with Lincolnshire DAAT receiving funds at a lower level than is needed to meet actual need, with low levels of historic funding from Health and social care partners. Lincolnshire mental health services resources are also below national average, with alcohol treatment services probably being the lowest level in England: a total budget of 262,000 for a population of 650,000. Based on Stakeholder Consultation Event a clearer picture of the local context has emerged. The view from the carer movement in Lincolnshire is that they often find themselves and the service user trapped in disputes between mental health and substance misuse services, having difficulty accessing a package of care which may involve both. They also identify sometimes feeling trapped between primary care services who seek to exclude substance misuser s from access to mental health intervention or offer only a substance misuse treatment intervention rather than a comprehensive package to meet their needs. Both substance misuse services and mental health services acknowledge that care pathways are unclear. There is only patchy mutual understanding and awareness of each others means of operation with a significant need for improved awareness of mental health issues amongst substance misuse workers and equally significant need for an understanding of substance misuse issues amongst mental health workers. Both those in specialist mental health services and those in primary care mental health service referral pathways are often thought to be torturous, inconsistent and unreliable and both services feel stigma remains an issue that is unresolved. The criminal justice system and in particular the probation service finds inconsistent care pathways unclear and have experienced being caught between disputes between mental health and substance misuse services for their client group, problematic. Equally they acknowledge their own need to have increased awareness and training of not only mental health and substance misuse issues separately but how these can be managed, identified LPFT OPR53 v.3 August

19 and supported together. All partners however clearly identified that the lack of alcohol treatment services across all tiers is a significant issue. In terms of meeting the needs of an increasingly diverse population in Lincolnshire, whilst data on ethnicity is gathered in both services there has to date been no systematic attempt to asses the needs of this population, this will be a key task for the planned Community development workers to be recruited as part of the NHS and NSF plans. Mainstreaming This is a key element for Lincolnshire, there are eight key challenges to be addressed if we are to meet the needs of those with dual diagnosis (adapted from DoH 2002): 1. We must develop a shared definition of dual diagnosis which is clear and reflects the experience and needs of Lincolnshire. 2. We must get formal sign up from all partner agencies to the definition 3. We must consider the need for if any for specialist dual diagnosis services to provide specialist support to mental health services 4. We must ensure all assertive outreach staff have training in how to work with dual diagnosis and have the skills and support to do this 5. We must ensure that there are sufficient staff within community mental health services and substance misuse services who are trained in dual diagnosis 6. We must fully map out the range of services available and identify the actual need against the availability We must develop and agree the care pathway and clinical governance guidelines for dual diagnosis including mechanisms for preventing and resolving any disputes between services 9. We must ensure that all service users with severe mental illness using substance misuse services are subject to the care programme approach, and have had full risk assessments in line with mainstream mental health service standards. Provision The Health Advisory Service. (Abduirahim 2001) recognise three distinct means of providing dual diagnosis services, "Serial treatment models, where psychiatric and substance-use disorders are treated consecutively with little communication between substance-misuse and psychiatric services. It is argued that serial models with separate treatment services are not appropriate in the majority of cases. Patients tend to be shunted between services that are inadequate to meet their needs. Moreover, some argue that many substance-misuse services are insufficiently supportive of this group, as they place emphasis on client motivation and personal responsibility. Parallel models, where substance-misuse and mental health services establish liaison to provide the two services concurrently. Some NHS trusts have set up specific liaison posts between psychiatry and substance misuse to facilitate patient assessment and referral. In other trusts, while there is nominal commitment to such a model, the practical LPFT OPR53 v.3 August

20 representations of such a service are not satisfactory and liaison may also be a recipe for passing the buck. 13 It has also been noted that substance-misuse and mental health services may operate referral criteria that specifically exclude co-morbid patients, particularly in the residential rehabilitation sector. Integration models: clinical experience emerging from the USA suggests that the successful treatment and management of dual diagnosis disorders is best achieved through an integration of substance-misuse and psychiatric treatment. It is increasingly argued that integrated treatment specifically for co-morbidity must underpin an approach based on assertive community treatment, and that specific interventions must provide treatment for both types of disorder without cross-referral to other agencies. Evidence also suggests that clinical teams must provide a treatment approach that incorporates motivational and behavioural interventions, relapse prevention, pharmacotherapy and social approaches". Proposals for provision It is therefore proposed that a refined model of parallel service is developed in the short term, incorporating the best practice elements of integrated services without the need for wholesale service reconfiguration or separation. Such a model would provide for; Specialist liaison and intervention posts based within drug intervention teams. Agreed pathways of care between mental health and substance misuse services Mental health training and awareness for all substance misuse practitioners Substance misuse awareness training for all mental health practitioners, with identified substance misuse link workers (having in depth training and development) within community mental health services. Operational and strategic review of service delivery and resource utilisation. Nationally evidence based and values based interventions at primary and secondary and tertiary levels of care. The range of potential engagements with services can be shown in the model below. Current provision in primary care, mental health and substance misuse services provide the mainstream involvement without the need to separate the service user off into any other 'specialism'. At the same time the model provides for specialist knowledge and intervention to occur both directly with service users and carers, and indirectly in a supportive capacity to practitioners in mainstream care and treatment. The National Treatment Agency recognises this option as a Joint liaison / collaborative approach, whereby, "The care of the patient is jointly managed by both services Joint working between mental health and substance misuse services Joint responsibility Ensures the skills and expertise of both spheres of healthcare is utilised The model of collaborative working facilitates capitalising on the skills and expertise of the general mental health services and the specialist substance misuse services" (NTA 2002) Minkoff (2001) has developed a model to describe the context of dual diagnosis by exploring the severity of substance misuse and of mental health, and thus plotting service provision against need. LPFT OPR53 v.3 August

21 Severity of problematic substance misuse High High / High e.g. a dependent drinker who experiences increasing anxiety e.g. an individual with schizophrenia who misuses cannabis on a daily basis to compensate for social isolation QUADRANT 3 QUADRANT 4 e.g. a recreational misuser of dance drugs who has begun to struggle with low mood after weekend use Low QUADRANT 1 e.g. an individual with bi-polar disorder whose occasional binge drinking and experimental misuse of other substances de-stabilises their mental health QUADRANT 2 High Severity of mental illness (from CNWL Strategy For Dual Diagnosis Service Provision 2003) Thus, people falling into quadrant one would be treated within primary care for both their substance use, mental ill health and physical healthcare. those assessed as being in quadrant 2 may require treatment within secondary mental health services (possibly with advice and guidance from liaison workers), and primary care regarding physical health care people in quadrant three would require support from substance misuse services (possibly with advice and guidance from liaison workers), and primary care regarding physical health care whilst people whose needs are met within quadrant four should receive care and treatment from both substance misuse services and from community mental health link workers, with specialist support from liaison workers regarding evidence based practice, access to tertiary services, and primary care regarding physical health care Role and function of substance misuse/ mental health liaison case workers "The dually diagnosed client is likely to present in a multiplicity of settings, from A&E departments late at night, housing departments and police stations following arrest to drop-in clubs and drug teams. Clients whose needs are not met by treatment services are perhaps more likely to become involved in the criminal justice system. There is a need for partnership working between specialist treatment providers and criminal justice agencies if the needs of this client group are to be addressed holistically and comprehensively." (Corteen 2004) LPFT OPR53 v.3 August

22 It is proposed that the liaison workers should be based within substance misuse services providing a case management model to complement the existing drug intervention and harm minimisation programmes "Lehman (1995 as cited in Ley et al. 2000) found that abuse of alcohol or drugs is associated with increased rates of violence and suicide, poor compliance with treatment, early psychotic breakdown, homelessness, criminal behaviour and increased rates of hospitalisation among the severely mentally ill." (NTA/ DOH 2002) Essentially the liaison workers will ensure an integrated approach within a parallel service provision. In achieving this aim they will; Develop an assertive outreach approach, as many clients do not respond to more traditional treatments. Deliver a flexible, client-centred model, providing short term brief interventions, as well as longer term case management. provide screening, and specialist assessment Engage clients in order to assess fully their complex needs. Assess and manage risk, which is considered a central and critical factor in this process. Ensure collaboration with a wide range of agencies vital to the overall process, Provide training and development to colleagues who practice within mental health services and /or substance misuse services provide advice, information and supervision to staff within generic services Challenge stereotypical perceptions that sometimes become apparent in respect of substance misuse in general. enhance liaison from the substance misuse, criminal justice and mental health services, and cross fertilisation of information Respond to requests for crisis assessments as required Commission and purchase care in consideration of specialist and continuing care needs Diversity "People from ethnic minorities Though definitive studies on the influence of culture and ethnicity upon individuals with a dual diagnosis have yet to be conducted, it is known that severe mental illness and substance misuse present differently across cultures and ethnic groups. For example, ethnicity is associated with poor access to services and with different meanings and values attributed to drugs and alcohol. Service provision must therefore be congruent with and sensitive to the needs of each ethnic group." (DOH 2002) The Health Advisory Service (2001a) recommends that attention is given to special populations in relation to co-morbidity. Mental health services for older people should explicitly tackle the misuse of alcohol and tranquillisers. The needs of young people with co-morbidity must be addressed by child-centred services. Strategies should be in place to work with homeless people in the care and management of those with mental health and substance misuse co-morbidity. Commissioners and providers should ensure that all local services are able to meet the diverse needs of the local populations and that the services are accessible to black and minority ethnic groups and effective at meeting their needs. Mental health professionals should consider post-traumatic stress among clients with co-morbidity and among refugees and asylum seekers in particular. The assessment and care of women should take into account gender-specific issues. LPFT OPR53 v.3 August

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