DUAL DIAGNOSIS TASK GROUP

DUAL DIAGNOSIS TASK GROUP Dual diagnosis describes people who experience mental health disorders alongside drug or alcohol misuse. Either of these conditions may exacerbate the other and they could also be a barrier to accessing treatment. A dual diagnosis usually involves more than just the issues of mental health and substance misuse. For example, issues can arise with physical health and wellbeing, social functioning, money and housing. 1 INTRODUCTION The Health, Community & Care Overview and Scrutiny Committee were aware that people with a dual diagnosis might be experiencing difficulty with accessing support, particularly housing. Members of the committee learned of some instances where patients had found it difficult to access the services they needed, particularly housing services. This led to a suggestion that the public sector treats the individual but is often reluctant to provide accommodation, and Members suspected that in some cases the needs for treatment and housing were not being met due to a breakdown in partnership working, and that district councils and the voluntary sector struggled to provide the kind of supported accommodation which is necessary. The one-page scoping strategy based on Members initial concerns is attached at Appendix 2.. 2 MEMBERSHIP The members of the task group were drawn from the Health, Community & Care Overview and Scrutiny Committee. Gloucester and Cheltenham, the main urban centres of Gloucestershire were a particular focus of the review, so invitations were issued to Gloucester City and Cheltenham Borough councillors, in addition to those district members who are members of the committee. Cllr Kate Haigh, Gloucester City Council (Chair) Cllr Jan Lugg, Gloucester City Council Cllr Penny Hall, Cheltenham Borough Council Cllr Andrew Gravells, Gloucestershire County Council Cllr Margaret Ogden, Tewkesbury Borough Council 1

3 WHO DID WE SPEAK TO? 5.1 The task group spoke to a range of people involved in dual diagnosis work in the county. These included: John Chilton, Dual Diagnosis Nurse Consultant, 2 gether NHS Foundation Trust Ros Alstead, Director of Quality and Performance, 2 gether NHS Foundation Trust Katie Conlon, Supported Housing Team, 2 gether NHS Foundation Trust Martin Shields, Director of Housing Services, Gloucester City Council Jude Parkin, Area Business Manager for Gloucestershire, Stonham Housing Chris David, Mental Health Project Manager, Independence Trust Emma, Mental Health Project Worker, Independence Trust Members of the Independence Trust Dual Diagnosis Recovery Group Marianne Bubb-McGhee, Head of Prison, PVP and Homeless Healthcare, HMP Gloucester Garry Mills, independent financial advisor, Vice Chair of the Gloucestershire branch of the Royal British Legion 5.3 The task group members would like to thank everyone who attended meetings or provided written information, in particular for the open and honest way in which they provided information. 6. WHAT DID WE LEARN? Mental health care Evidence in this section was given by John Chilton, Dual Diagnosis Nurse Consultant. 6.1 Dual diagnosis is not a new problem, but it has been misunderstood and underestimated for a long time. Substance misuse may lead to, or exacerbate, mental health problems. Alcohol is the most widely used substance in Gloucestershire, but tobacco and cannabis are also easily available. Prejudice can be a major barrier to providing treatment, and there are very few rehab centres nationally. 6.2 National data suggests that a third of all mental health patients have a dual diagnosis, or complex need. The numbers affected are still relatively small, but in John s opinion it is a big issue. One in four people with complex needs come from dysfunctional families or have suffered sexual abuse. Young men aged 18-24 are most at risk of suicide or self-harm. Large population centres show a higher level of need, known as the urban effect. In Gloucestershire this relates to Gloucester and 2

Cheltenham in particular. People gravitate to these urban centres because of their lifestyle, or because the services they need tend to be based in urban centres. 6.3 Complex needs make up the core business of 2 gether. The Trust employs John Chilton as a dual diagnosis nurse consultant, based at Wotton Lawn. This is the only substantive post in Gloucestershire, funded by the Drug and Alcohol Team (DAAT) and the NHS. There may be funding pressures on this and other posts in the future. John is currently undertaking a PhD in dual diagnosis and service development, working with the Independence Trust. His PhD work is driving the development of integrated practice using a harm reduction model, and he considers the Independence Trust to be a crucial non-nhs partner in the dual diagnosis debate. There is huge potential to work with the voluntary sector on education, training and care pathways. 6.4 The National Dual Diagnosis Confederation is made up of nurses and medics, and meets quarterly. Currently there is no national dual diagnosis lead, but there is a regional lead at NHS South West. 6.5 Housing is one of the biggest issues facing people with dual diagnosis. Accessing housing is not always the main issue, but maintaining it can be an issue. This is because illness may make it difficult for individuals to meet the conditions of their tenancy agreement. Once a tenancy with a housing association is lost, it can be difficult to get another tenancy. 6.6 Three years ago, Dr Rob Macpherson ( 2 gether NHS Foundation Trust) put together plans for a piece of work on accommodation in Gloucestershire, but it was difficult to start it. National projects looking at these issues have also failed because funding is limited to a set period of time and then does not continue. 6.7 A new dual diagnosis strategy was developed in 2009. Despite there being no funding attached to the strategy, Gloucestershire still has more resources compared to other parts of the country, and has been developing good practice for three or four years. Gloucestershire runs a two-year treatment programme, and service users and carers have given good feedback about it. There are a number of advisory and support groups, including the Dual Diagnosis Advisory Group, the Working Age Management Board and the Early Intervention Carers Group. 6.8 The Litigation Authority has made dual diagnosis training compulsory for all existing mental health staff. Students on the University of Gloucestershire social work degree course now receive dual diagnosis training. It has also been mandatory for all 2 gether staff since 1 April 2010. Gloucestershire also has a supervision network for GPs, social workers and any other medical professionals, which can be accessed by completing dual diagnosis training. 6.9 Although multi-agency approaches can be an effective way of delivering services, they can appear terrifying to the individual. This statement was backed up 3

by evidence from service users later in the group s enquiries. There needs to be a way of presenting the services in a straight-forward way which puts the individual at ease. Some of the mental health service staff we spoke to felt that greater scope for partnership working and better use of resources exists. Resources are vital to service provision, and integrated practice is the best way of delivering services. Early intervention can save money over time, by preventing problems becoming more serious. Housing 6.10 There are several housing providers in the county, working on behalf of the borough and district councils. Typically, up to 50 percent of housing clients might have a mental health need, although not necessarily diagnosed, and up to 70 percent of clients might use alcohol, drugs or both. A housing provider might have floating support units and accommodation based units, but these will not all be mental health beds. An example of this is Stonham Housing, which has developed its own rehab programme, including support from the Independence Trust and floating mental health support from Rethink. Each organisation involved in programmes such as these should be encouraged to take ownership of its responsibilities. 6.11 Local authorities with responsibility for housing have more control over housing services than they do over treatment services. However, local authorities should be able to influence how housing services work with partner agencies in mental health care, keeping in mind that each district has a slightly different approach. 6.12 Supporting People is a major source of funding for services provided by housing providers. The new five year Supporting People Strategy for Gloucestershire will impact on the voluntary sector. Supporting People leads a supported housing group which brings housing providers together. 6.13 The district and borough authorities have a statutory responsibility to offer help to the homeless. Homelessness officers work closely with mental health services and housing providers to ensure that people are adequately catered for. Gloucester City Council was given an additional grant for homelessness work in January 2011. 6.14 The housing duty of a council differs for people aged under 25, people aged over 25 and for people in private rental tenancy. Private housing may be used when there is no council accommodation available. Housing officers can also find emergency accommodation when required, usually on a bed and breakfast basis. Housing officers are also responsible for discussing changing circumstances with clients, including pre-discharge conversations about on-going support. They will 4

support clients into their own tenancy if appropriate. They help with resolution of rent arrears problems. Benefits can be paid direct to landlords with the consent of the client. The housing provider view is that housing staff are very professional and deal with known abusive clients calmly. Clients need to have the will to help themselves, as providers can only do so much to help, although they are all working towards independent living. However, clients may not be offered housing because they cannot meet the required conditions, for example paying rent on time, co-operating with officers or behaving anti-socially. High risk people are better off in an individual flat with floating support than in shared accommodation, to reduce the risk to themselves and to others. 6.15 The group was concerned about whether bed and breakfast accommodation was appropriate for people with a dual diagnosis. The length of time that clients stay in bed and breakfast accommodation depends on the individual/family/couple. B&Bs have no support of any kind and are used as an immediate emergency last resort solution. The aim is to get the client into supported accommodation as soon as possible. The use of bed and breakfast also depends on the available vacancies, whether the client needs to move to a specific area and the level of support required. Gloucester City Council pays for the accommodation, and then arranges the payment with individuals benefits, which can cause instant arrears. The client has to engage with the city council otherwise the bill will not be paid and the B&B will evict them. At the end of 2009/10 there were nine people in B&B accommodation in Gloucester. 6.16 Available help includes: a. Funding from the Department of Communities and Local Government. Tenancy Start-up Funding can be used to clear previous debt to a landlord, helping someone get into a new tenancy, or to sustain an existing tenancy. It is limited funding so councils have to allocate it carefully. b. Temporary accommodation is provided for 28 days to support someone while they look for their own accommodation. If they don t succeed in finding accommodation they are evicted from the temporary accommodation and sent back to the start of the process, but many people turn to the night shelter because the temporary accommodation is removed. They may then become long-term residents at the night shelter. At this stage, help from a GP (perhaps medication or referral to rehab) or support from a day centre is necessary to stabilise them in order to help them find permanent accommodation. 6.17 Housing providers told us that landlords can be reluctant to accept people as tenants due to their history and often try to put restrictions into contracts, e.g. payment of arrears before they can move in or money management measures. Criteria are restrictive and cases can be bounced around between services. If people have the capacity to do so, they have to be left to make their own decisions, but 5

problematic behaviours can repeatedly send dual diagnosis clients back to the beginning of the process. Some of the county s housing agencies have signed up to an Eviction Protocol. Eviction is a last resort and is used in cases of anti-social behaviour or when rent arrears build up. If someone is given a second chance after being evicted, it is often given with conditions. 6.18 Housing officers also told us that there is a drift from rural areas into the city. This drift can be led by availability of work, housing, or by acquaintances living there already. The local authority housing departments say this puts excessive pressure on their services. Some housing providers encourage people to choose where they would like to live, and they told us that new supported housing is needed in Tewkesbury and the Forest of Dean. However, other services would be needed around the housing, and without these services the new housing would have little value. 6.19 There are over 400 beds available across a large number of providers, 250 of which are provided by 2 gether NHS Foundation Trust in Cheltenham, Gloucester and Stroud. These are contracted by Supporting People. The Supported Housing Team acts as an estate agent. There are landlords who are solely contracted to 2 gether, therefore if the property is empty the landlord has no income, so it can be in everyone s interests to use the available property appropriately. 6.20 If a client does not have the capacity to manage money themselves, the Client Affairs Team at Gloucestershire County Council have appointee status for managing client money. Client income is assessed and rental is banded according to personal benefits. Personal contributions are between 15 and 86 per week. Those who fail to pay their personal contribution may be evicted. Expectations are made clear to each client at the start. There is a warning system to flag up problems, which leads to staff intervention with timescales and targets, and possibly a referral to debt counselling. 6.21 Substance misuse recovery is made up of positives and negatives, which can help and hinder progress. A treatment programme may force someone to move away from an area where they were surrounded by negative influences, which would help them to move on. On the other hand, they may have to move away from their support network, which might hold them back. It is also important to remember that mental capacity can fluctuate. 6.22 Housing agencies would like to be enabled to help people further, as contracts with providers often prevent them from doing things which they know they have the resources to do. Services are often client-led. At the start of this inquiry we were led to believe that partnership working was an issue, but the local authority housing officers who we spoke to did not agree. 6

Finance 6.23 The group spoke to Garry Mills, a financial adviser based in Podsmead, an area of severe financial deprivation in the city. Up to 40 percent of his clients have a mental health issue, and 45 percent are ex-service personnel, which often means that their situation is more complex. He is the only prison in-reach worker in the county. 6.24 Mental health is challenging, and there is still a stigma surrounding it. Staff who help mental health sufferers with financial problems lack training. It is vital to listen to what the client says, and to ask appropriate questions to find out the key issues. Early diagnosis is key, but this is hindered by the fact that, in Garry s opinion, several organisations around the county still work in silos. He also believed that officers could be empowered to do more when they meet a client. 6.25 Every person and the problems they face should be looked at holistically. Hospital in-patients appear to be looked at in isolation, only taking account of how they are while they are on the ward, but it would be helpful to also look at what is happening at home while they are an in-patient, for example who is looking after correspondence and bills. 6.26 A council tax disregard is one way that local authorities can help people in financial difficulty. These disregards are allowed in the Financial Act under the Mental Health Act (1983), which covers severe mental impairment (SMI). Garry Mills conducts an annual survey of local councils about council tax revenue. Gloucester and Cheltenham have a combined population of 250,000. In 2010 there were 240 SMI recognised as full disregard for Gloucester council tax, and 220 in Cheltenham. It was surprising that there were less than 500 people with SMI, and we presume that there are more people with SMI who haven t applied for a council tax disregard, perhaps because they don t know that they are eligible to do so. People suffering from mental impairment need help to understand what their financial liabilities are. Garry Mills expressed concern about a lack of communication between agencies. He gave an example of a patient with no family, who might be in and out of Wotton Lawn regularly as an inpatient but the council is not informed by the hospital, so council tax arrears build up. 6.27 Medical opinion sometimes concludes that a person is socially excluded by choice, but Garry Mills believes that mental ill health and substance dependency are not lifestyle choices. Mental health episodes are not isolated incidents, so he suggested that treatment and help needs to be more continuous. He has made 2 gether and other agencies aware of the problems he has observed while interviewing clients. 7

HMP Gloucester 6.28 At HMP Gloucester the patients with dual diagnosis are cared for by the Integrated Drug Treatment Service (IDTS) employed by Gloucestershire Care Services and the In-Reach Community Psychiatric Nurses (CPN) who work for the 2 gether Trust. The IDTS team have two Registered Mental Health Nurses (RMN) and one Registered Mental Health Nurse Handicaps (RMNH) who work across the substance misuse, alcohol and mental health boundaries. 6.29 With the In-Reach CPNs, the patients have access to housing via the 2 gether Trust Accommodation Team. If they have a primary diagnosis of substance misuse they will also have access to housing via the Community Substance Misuse Service. If the primary diagnosis is mental health then there will be access to housing via the recovery teams following assessment. 6.30 Prison staff work with the Offender Management Unit and their Housing Officer to gain accommodation. Prisoner s housing needs are identified early on in their stay and the teams work hard together to get the appropriate accommodation. This approach could be communicated to other agencies. There are some barriers in that prisoners will not always flag up that they have housing issues and may even give false addresses so that issues are not flagged up. The Housing Officer has access to many different types of housing, but there are very few agencies who will take dual diagnosis patients. The main placement within Gloucester City is Claremont House, which is only available through the Gloucestershire Homeless Prevention Service. Claremont House is also the only assessment centre in Gloucester City. 6.31 There are some individuals who will not engage at all and are really difficult to house. They choose not to engage and so a few do leave custody with no fixed address. If these individuals are local, the Prison Healthcare Team liaise closely with the Homeless Healthcare Team based at The Vaughan Centre in Gloucester who will pick up their health needs and signpost them to appropriate agencies such as English Church Housing or the night shelter. The Community Psychiatric Nurse in the Homeless Healthcare Team will pick up any cases that are released without accommodation but who have a recognised dual diagnosis and will signpost accordingly. 6.32 The prison has good links with the Courts so that if a prisoner is released and the Court is aware that person will be homeless, the court staff contact prison healthcare staff so that they can liaise with the Homeless Housing Team, the Vaughan Centre and the night shelter. Work is being done with the Gloucestershire Housing Teams on a Countywide Review of Homeless Accommodation and with Probation on a Personalisation Pilot on Integrated Offender Management. 8

6.33 We were told that it is difficult for the appropriate teams (e.g. mental health and housing) to assess prisoners on short sentences, so they often fall through the gaps. The reality seems to be that it is extremely difficult to find accommodation for prisoners with a dual diagnosis and a criminal offence within Gloucestershire. Perhaps a key worker for short-term prisoners from the local area would be able to start putting things in place soon after sentencing, in preparation for release. What do service users say about their experiences of treatment? 6.34 Cllr Kate Haigh and Cllr Penny Hall visited members of the Dual Diagnosis Recovery Group on 17 December. This is a group of service users, facilitated and supported by the Independence Trust, providing a forum for them to share their experiences with others and to get advice. 6.35 Three recovery group members were present. They were very open in their responses and gave honest accounts of their experiences. They were grateful for the opportunity to offer feedback on the programme to date. Case Study 1 A young man with no fixed address. He stays with friends and moves on regularly. This suits his lifestyle but is not very secure. A feature of his condition is that he disappears for weeks on end. He had a room in a hostel in London Road, but was evicted because he went to stay with friends and was out of contact with the hostel management. Case Study 2 A gentleman in his sixties, manic depressive, married. He regularly has crises, but the Crisis Team takes too long to come out to him, so he calls an ambulance to take him to the accident and emergency department at Gloucestershire Royal Hospital. This is a regular occurrence, and he knows what he needs to stabilise. He is given medication and respite, and is discharged when stable again. He knows he is misusing the emergency services but in his opinion the Crisis Team aren t responsive enough. There is also an upper age limit for admissions to Wotton Lawn, so he can t access specialist mental health treatment there. However, this upper age limit is going to be removed in 2011. The task group supports the removal of this limit. While the gentleman is in hospital, he worries about his wife, and if the crisis is really bad, he may be unable to ask whether she is being looked after. This is also commonly experienced by women with children, who are unable to ask what is happening at home. 9

Case Study 3 A woman, recovering alcoholic. After following an inpatient detox programme she was sent home without any support. She couldn t leave her house for six months and found it impossible to be anywhere near alcohol without feeling the need for a drink. Even walking past recycling boxes containing empty bottles or cans produced a craving. She finally found the support group, which has really helped her. She can now leave her house and is getting ready to look for employment and regain her independence. 6.36 Our long discussion with the service user group supported the recommendations which we had been formulating in terms of supporting individuals with one key worker. It seemed that all of these people would have benefited from one person to contact in times of need, who would then coordinate the care and advice that they needed. 6 CONCLUSIONS Turning Point, the UK s leading health and social care organisation, said recently on its website that dual diagnosis needs to become a bigger priority at a national, regional and local level. New ways of working and examples of good practice are emerging all the time. It is clear that Gloucestershire has the potential to lead the way in this, and share good practice with other areas, but there is more work to be done in order for this to happen. The county has an excellent resource in the form of John Chilton, but we are concerned about what will happen if he leaves, in particular whether the post would be refilled, and the loss of experience and knowledge that this would cause. Through the course of our discussions it became very apparent that it is important that the needs of the individual come first, and treatment of both the mental health disorder and the substance dependency should be approached at the same time through joined-up working. It is also important that changes in the way that services are commissioned do not lose sight of service delivery and quality. There is more that could be done in terms of flexibility of housing, particularly where health, social care and housing providers work together. A lot of services could be delivered through joint working if the processes existed. Service users with a dual diagnosis typically use NHS services more and cost more than service users without a dual diagnosis. Stronger links between mental health service provision and drug and alcohol service provision combined with better workforce and awareness, could provide a better service and potentially save money. More investment in mental health services is needed from everyone in the county, being careful not to prevent collaboration through tendering and contracts. 10

Partnership working is key to all of our recommendations, and we would like to see agencies working closely together to provide the best service possible for individuals. If someone has the capacity to make decisions for themselves, it is really important that they are offered choices and offered support with decision making. They should not feel that they are being judged on the decisions they make. Providers of all services should look at the whole person and their life holistically rather than concentrating wholly on the issue directly related the service being provided. People are individuals, and there is no one size fits all solution. If someone can t access the service they need when they need it, it is no good to that person, no matter how good the service is judged to be. Getting the services right now will prevent problems in the future, and early diagnosis increases an individual s chance of recovery. As John Chilton told us, if providers can get it right for a marginalised group such as this, the methods used are likely to work for everyone across the board. In February 2011, NICE published guidelines on alcohol-use disorders, which suggest that appropriate training is given to all healthcare staff to enable them to identify patients who may be misusing alcohol. This backed up our thinking that more training might benefit staff and service users in the county. We were interested to learn about the Common Assessment Framework (CAF), used by the Family Intervention Project (FIP) to assess the needs of antisocial families. Key workers liaise and coordinate multi agency services in conjunction with other key services such as the police, housing authorities, the Youth Offending Service and many more. There is also an early intervention scheme, which in effect deals with referrals that do not meet the Family Intervention Project criteria. The aim of this is for the key worker to signpost cases to relevant agencies to ensure that they are receiving support, such as parenting programmes, as well as enforcement. We also felt that temporary accommodation could be more flexible to give people the opportunity to get back on their feet when things went wrong, or more time to find a more permanent housing solution, which would help them to address or resolve other issues in their lives. The new NICE guidelines on alcohol-use disorders suggest that people who are homeless should be offered residential rehabilitation for a maximum of three month, and help with finding stable accommodation before discharge. A key worker could start the process before someone leaves a detox programme or rehabilitation. There is scope for further scrutiny of dual diagnosis in the future, as we have only touched on a few of the issues which affect people in the county. One area of future work might be to examine whether the eviction protocol used in the county is reducing the number of evictions annually. 11

7 RECOMMENDATIONS 7.1 We address our recommendations to 2 gether as service providers, NHS Gloucestershire as commissioners, Gloucestershire County Council, district and borough councils of Gloucestershire and housing providers. 7.2 In line with the county council s scrutiny monitoring process, we will seek progress reports after 6, 12 and 18 months. 7.3 The recommendations of this task group are: Recommendation 1 The task group recommends that 2 gether NHS Foundation Trust should explore ways of working with voluntary services and supporting that work with appropriate training. Recommendation 2 The task group recommends to 2 gether NHS Foundation Trust and to the Independence Trust that dual diagnosis/complex needs training should be offered to any professional who deals with mental health patients, including the police, housing associations and GPs. We suggest one GP per practice should be trained, to act in an advisory capacity for partners in the practice. Recommendation 3 The task group recommends to all mental health care providers that no-one should leave a detox programme or a mental health admission without a plan for follow-up in place. The follow-up plan should be appropriate to the individual and should include whether they going somewhere safe and secure, and whether they are checked to make sure they are staying on track. The task group also had concerns about what happens when someone is not in a position to ask for help, and who would find out that they need help in those cases. GPs should consider taking referrals from family members and concerned friends and then act on those referrals as a preventative measure. Recommendation 4 The simpler the interaction between the user and the service, the more effective the service will be. Using the Family Intervention Project as a model, the task group suggests that a Common Assessment Framework across all the agencies involved, and a key worker for each service user, would facilitate easier access to services and would ensure continuity and trust. Each key worker would need a named backup worker to cover for illness and holidays. Recommendation 5 The task group supports the suggestion made by Garry Mills that people should receive more treatment at home, or in a central but non-hospital setting for those 12

with no fixed address. Initial assessments in particular could be done at home, and part of that assessment could consider whether home is an appropriate location for further treatment. Therefore the task group recommends that 2 gether NHS Foundation Trust investigates the development of a dual diagnosis specialist service for the Trust and for key stakeholders, building on the dual diagnosis care cluster. The specialist service would also provide the specialist training, support and supervision that are required in health and social services. This would enable a more joined up way of working. Recommendation 6 More emphasis is needed on ways of helping people to pay their rent. When a service user moves into accommodation, whether private or housing association, they could be asked whether they would like to have their benefits paid straight to the landlord. Future reductions in benefits will be an issue, but not enough is known about those reductions at the present time to enable us to comment. Recommendation 7 The task group recommends that there should be more flexibility of temporary housing and that the NICE guideline about residential rehabilitation for a maximum of three months is incorporated into procedures as it would provide a really strong basis to maximise a service user s recovery chances. Recommendation 8 At the end of our study we were concerned that continuous financial advice provision was in some doubt, and that if current services cease, other agencies should consider how they will integrate proper financial advice into their role. 13

GLOSSARY Drug And Alcohol Team (DAAT) Local Area Agreement (LAA) National Dual Diagnosis Confederation NHS Litigation Authority Mental capacity Floating support Rethink Night Shelter Silo working Council tax disregard Mental Health Act Severe mental impairment A small team working county wide on the delivery of drug and alcohol outcomes of the Local Area Agreement An agreement between the county council and a partnership of local public and voluntary organisations. It sets a range of improvement targets aimed to help partners concentrate on working to achieve their top priorities and to make a real difference for local people A national group which represents clinicians working with dual diagnosis patients. Handles negligence claims and works to improve risk management practices in the NHS Sufficient understanding and memory to comprehend a situation and the consequence of an action which is taken The name given to support services that are delivered to people in their own home, rather than in a supported housing/hostel environment, an office or clinic. These services help people to develop the life skills and social and community networks necessary to live independently A charity which helps everyone affected by severe mental illness recover a better quality of life A direct access night shelter for single homeless men and women, open all year round from 8.00am to 8.00pm. It is run by GEAR (Gloucestershire Emergency Accommodation Resource) A way of working which keeps things separate or compartmentalised This applies to a Severely Mentally Impaired person occupying a property. If someone becomes a permanent resident in a hospital and has no main home elsewhere, they might also meet the criteria for the disregard Introduced in 1983, this Act is intended to help doctors deal with patients who may have a psychiatric disorder. Under the Act, patients can be sectioned or detained against their will and given treatment A state of arrested or incomplete development of mind which includes severe impairment of intelligence and social functioning and is associated with abnormally aggressive or seriously irresponsible conduct. The 14

RMN RMNH Turning Point distinction between severe mental impairment and mental impairment is one of degree and the assessment of the level of impairment is a matter for clinical judgement Registered Mental Health Nurse Registered Mental Nurse Handicap A leading health and social care organisation, providing services for people with complex needs, including those affected by drug and alcohol misuse, mental health problems and those with a learning disability 15

Broad topic area Specific topic area Ambitions for the review How do we perform at the moment? Who and how should we consult? Background information SCRUTINY REVIEW ONE PAGE STRATEGY Appendix 1 Health, Community and Care Dual Diagnosis - This relates to the condition of a person who experiences co-existing drug/alcohol misuse and mental health disorders. Either of these conditions may exacerbate the other, and either may be used as a barrier for accessing treatment. It is important that the needs of the individual are placed first, and treating both the mental health and alcohol/ drug difficulty together should be approached together. To understand how dual diagnosis is currently approached in the county which services are commissioned, who provides them, where are they provided, what do they cost. To explore the need for housing for vulnerable people at county council level, and to investigate the situation for people with a mental illness who sleep rough, To establish links between county and district services provided through the Gloucestershire Community Health and Wellbeing Partnership. To identify good practice and share it, encouraging other areas to try the same approach. It remains an issue in the county where the public sector treats the individual but sometimes is reluctant to provide housing or accommodation. It is an area where partnership working seems to break down. District and Borough Council housing departments GCC Housing Strategy Officers 2gether NHS Foundation Trust The Independence Trust Day and residential care providers Service users Gloucestershire LINk Supporting People NHS Gloucestershire GCC Strategic Directors Group Down and Out (St Mungo s, December 2009) No one left out (Dept for Communities and Local 16

Government, November 2009) Building Better Lives: Getting the best from strategic housing (Audit Commission, September 2009) Single Conversation consultation (GCC, launched November 2009) Written statement from Healthcare Team at HMP Gloucester about treating prisoners with a dual diagnosis and their release procedures NICE clinical guideline 115 Alcohol-use disorders: Diagnosis, assessment and management of harmful drinking and alcohol dependence (issued February 2011) Support How long will it take? Outcomes Elizabeth Power, Scrutiny Team, Gloucestershire County Council, tel 01452 425204 April to October (report to HCC OSC on 8 November) To make appropriate recommendations on improving partnership working between all the organisations involved in the dual diagnosis process. 17