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Worcestershire Mental Health Partnership NHS Trust Policy Data Unique Identifier: CP0030 Ratified by: Governance Committee Ratification Date: 5th March 2007 Review Interval: Three Years Version Update: Review Date: March 2010 Owner: Chief Operating Officer Service Manager for Substance Misuse, Senior Drug Worker/RMN and Reviewer: Senior Drug Worker/RGN Responsible Forum: Clinical Effectiveness Document Type: Clinical Policy Superseded Policy:

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If printed, copied or otherwise transferred from its originating electronic file, this document must be considered to be an uncontrolled copy. When documents are updated, notification will be circulated throughout the organisation. Policy amendments may occur at any time and you should always consult the PDF file held on the Trust’s Intranet.

Project Leads –

Claire Foster Senior - Drug Worker/ RMN Jo Spicer - Senior Drug Worker/RGN

Project Team –

Hugh Thomas - Service Manager for Substance Misuse Dr Will Monteiro - Lead Consultant Mental Health Barney Colgan - Team Leader Alcohol Advisory Ron Howard - Programme Lead for Mental Health Paulette Cook - PA to substance misuse service manager

Foreword In preparation for this project, we have looked at the following strategies in an attempt to adapt a similar model locally: Strategy for the development of Dual Diagnosis Services in Sandwell Dual Diagnosis ‘A strategy for County Durham & Darlington’ West Sussex Health and Social Care Trust; Dual Diagnosis Care Pathway/Flowchart Kingston CDAT Dual Diagnosis Model



Introduction 1.1 Substance misuse is more common amongst adults with mental health problems than in the wider population. The coexistence of mental illness and substance misuse disorders, commonly referred to as dual diagnosis, has, over the years, increasingly been seen as a major challenge to services and the staff working in them. However, it is generally accepted that 30-50% of people with a severe mental illness (SMI) also have problems with substances (Sandwell 2005). It is difficult to accurately establish such prevalence rates, as there is a lack of consistency in the definitions, measurement tools and time frames used in research studies. 1.2 Drug and alcohol use can invariably make mental health assessment difficult but not impossible. The Dual Diagnosis Good Practice Guide DOH (2002) states that the primary responsibility for the treatment of individuals with severe mental illness and problematic substance misuse should lie with mental health services. This approach is referred to as ‘mainstreaming’ and aims to lessen the likelihood of people being shunted between services or losing contact completely. Secondary treatment services should co-operate to meet the needs of people with dual diagnosis through existing mental health and drug and alcohol services. Any interventions designed to meet these needs should be reflected in individualised care plans that are jointly developed and agreed with clients, their family or carers, and other appropriate treatment/support agencies. 1.3 The aim of this protocol is to ensure general mental health services and substance misuse services in Worcestershire work together as closely as possible to provide an integrated, seamless service to clients with both a mental illness and a substance misuse problem.


Definition 2.1 The definition of Dual Diagnosis is the presence of problematic drug and/or alcohol use in someone with a severe and/or enduring mental illness. 2.2 A severe and/or enduring mental illness is defined as one that would warrant the person being referred to secondary mental health services in the absence of problematic substance use. 2.3 Problematic substance use is defined as that which would warrant the person being referred to the drug or alcohol service in the absence of a mental illness.


However these definitions should be interpreted flexibly, bearing in mind the “potentiating” effect of moderate substance use in someone with a mild to moderate mental illness. 3

Eligibility 3.1 This service is available to individuals aged 18 years and over, who conform to the definitions set out in section 2 above and who live within Worcestershire or who are registered with a Worcestershire GP.


Duties - Putting the service user first 4.1 All people that present to services with a severe Mental Illness and a Drug and/or Alcohol Misuse problem must receive an assessment for both aspects of their presentation. 4.2 The appropriate Adult Mental Health Team will assess mental state and the appropriate Community Drug/Alcohol Team will assess the Substance Misuse issues. 4.3 Wherever possible the assessment should be undertaken jointly to reduce duplication and to assist in the development of knowledge of either mental illness or substance misuse for staff who may be unfamiliar with one or other field of work. Only in exceptional cases should the assessment be undertaken separately. 4.4 People with dual diagnoses can initially present to either Mental Health or Substance Misuse Services. It is the responsibility of the service that the client first contacts, to “hold” the case until a full assessment has been completed and to notify its partner service that such an assessment is required. 4.5 In keeping with national directives, the expectation is that a client with a dual diagnosis will also have a severe mental illness e.g. schizophrenia, bi polar affective disorder, severe depression. They will therefore be in receipt of an enhanced Care Programme Approach. The management of the case will be the responsibility of the mental health team assisted by staff from Drug/Alcohol service. However, if the mental health issues are minimal i.e. mild to moderate depression and/or anxiety it may be appropriate following assessment that case management will be the responsibility of an appropriate substance misuse worker who will be able to access a named mental health worker for assistance as required. 4.6 Following assessment, both teams will identify suitable workers who, together with the client wherever practicable, will formulate a single care plan to which both services will 3

contribute. Any amendment to any element of the care plan will be notified to the client and to any member of either team involved in its delivery. 4.7 Where case management is disputed, the consultants from both services will discuss who is the most appropriate person to undertake the role of Responsible Medical Officer. This in turn will enable team leaders to identify an appropriate key worker/care co-ordinator. If the situation remains unresolved, the matter will be reported to the Director of Medical Development who will facilitate a decision. 4.8 Occasionally a person will be engaged with one or other service and only after some time will it emerge that they have dual diagnosis issues. As soon as this becomes apparent, contact with the partner service must be made in accordance with 3.4 above. 5

Services for alcohol users 5.1 In Worcestershire, the Worcestershire Community Alcohol Team (WCAT) works collaboratively with the Worcestershire Mental Health Partnership Trust to provide a community response to those affected by either their own or someone else’s misuse of alcohol. 5.2 WCAT will actively assist Mental Health services in assessing people with a Mental Illness and an alcohol problem in line with these guidelines.


Care Coordination 6.1 As the principal case manager, Mental Health Services will lead on the care coordination process using their agreed Care Programme Approach tools. Substance Misuse staff will need to familiarise themselves with these by undertaking suitable training. A multidisciplinary Care Programme Approach Review will be the mechanism for working through any disagreements between professionals and agreeing a single care package.


Principles of service development 7.1 These guidelines have been developed in order to support local and national targets (Appendix 1). 7.2 Examples of good practice exist within Worcestershire but usually as a result of individual staff initiative and informal networks being developed. Some service users have benefited from these arrangements but in order to provide this service to all clients a more formal 4

service structure needs to be put in place. 7.3 Many service users with dual diagnosis needs have tended to receive services in ‘series’ or ‘parallel’. These methods have been found to be much less effective than the ‘Integrated Model’ which requires concurrent provision of both mental health and substance misuse interventions. Integrated treatment for dual diagnosis must embody an approach based on assertive community treatment which involves all service providers, both statutory and non- statutory. (Appendix 2) 7.4 Needs led provision should be reflected in all services. Referrals to mental health and substance misuse services will be received and processed as per the integrated care pathway (Appendix 3). 7.5 The Dual Diagnosis Good Practice Guide (DOH 2002) offers direction for services to meet the needs of those with severe mental illness and substance misuse problems (Appendix 4). 8

Principles of service delivery 8.1 Treatment and interventions offered to service users should be based on harm minimisation approaches. 8.2 To that end, all clients entering the service will receive a base line physical health check in line with the Trust’s policy and any health needs identified will be met by Trust staff working closely with the client’s General Practitioner. 8.3 A network of ‘link workers’ will be established in each clinical area to develop their skills in order to support and enable their colleagues to work more effectively with dual diagnosis. 8.4 The role of the link worker will be developed to provide joint assessments, clinical supervision, consultation, and contribution to training and ongoing support. 8.5 In order to ensure effective cooperative working between the two services staff will undergo relevant training that will be regularly updated. (See Appendix 5). 8.6 The numbers of Dual Diagnosis cases will be recorded by using agreed definitions and measurement tools.

The subsequent data will then be utilised to inform contracting,

service development and training needs. 8.7 Capacity of services will be reviewed to ensure that there is sufficient staff available to 5

provide the role of ‘link worker’. 8.8 Drug treatment protocols in mental health and substance misuse services to be reviewed to ensure that they are joint and adhered to. 8.9 In emergency situations, to ensure that there are no unnecessary delays to the provision of assessment and/or treatment, the principles incorporated in sections 3.4 and 3.8 of these guidelines will apply. 8.10 This protocol will also apply to the management of in patients with dual diagnosis issues. 9.

Monitoring Compliance With and the Effectiveness of Procedural Documents The cover of all documents ratified for use within the Trust, as defined by the Policies of Policies 2008, contains the following information:  the designated senior manager with responsibility [Owner] for the document;  an appropriately skilled professional [Reviewer] who will lead the development or review of the document; and  the forum [Working Group] with responsibility for monitoring compliance and signing off the document prior to ratification The Owner will ensure the Working Group yearly work plan contains the actions required to ensure;  the document is reviewed, signed off and ratified, as per the policy matrix, by the agreed date  reviews include mapping current evidence and appropriate consultation  where key performance indicators are developed they are objective, adequate, quantitative, practical and reliable  a mechanism is developed for monitoring implementation [reporting processes or audits]  areas of none compliance or risks are reported to the Governance Committee for appropriate action to ensure improvements in performance occur


half yearly report to the Governance Committee address compliance, effectiveness and risks


References Abdulrahim (2001) Substance Misuse & Mental Health Co-morbidity (Dual Diagnosis) Crawford et al (2001) Research and Guidance, DOH Department of Health (2002) Mental Health Policy Implementation Guide, Dual Diagnosis Good Practice Guide Department of Health (2004) Alcohol Harm Reduction Strategy for England Department of Health (1999) The National Service Framework for Mental Health Dual Diagnosis, A Strategy for County Durham & Darlington (draft) Kingston CDAT Dual Diagnosis Model (1998) National Institute for Mental Health in England (NIMHE) Developing Services For people with Dual Diagnosis National Treatment Agency (2002) Models of Care for the treatment of adult drug misusers Sandwell (2005) A Strategy for the Development of Dual Diagnosis Services The Social Exclusion Report (2000) Mental Health and Social Exclusion West Sussex Health & Social Care Trust ‘Dual Diagnosis’ Care Pathway/Flowchart


Appendix 1 The National Treatment Agency for Substance Misuse set out guidance for the care of those with Dual Diagnosis in the service framework ‘Models of Care’ (2002) Models of Care (2002) offers detailed guidance on service models, assessment, treatment, care pathways and training, emphasising integrated approaches and collaborative working as the way forward. The National Alcohol Harm Reduction Strategy for England (March 2004) set out the government’s strategy for tackling the harms and costs of alcohol misuse in England. The strategy recognises the need for co-ordination of services and commits to working within the Models of Care framework on integrated care pathways. The Social Exclusion Report – Mental Health and Social Exclusion (June 2004) examines how to attack the cycle of deprivation linked to mental health problems (including considering the role of substance misuse). The National Service Framework for Mental Health– Five Year Review identified Dual Diagnosis as one of the most pressing problems facing mental health services on a day-to-day basis. The main areas it highlighted were: 

The need for better collaboration between community drug and alcohol teams and mental health teams.

Training for mental health staff in the assessment and clinical management of substance misuse.

The need for intensive efforts to prevent drug misuse, including cannabis use in people with severe mental illness.

The prevention of drug misuse in inpatient units.

The National Institute for Mental Health in England (NIMHE) supports the National Service Framework for mental health that there is further action required to develop services for people with a Dual Diagnosis. They identify that mental illness and substance misuse is the most challenging clinical problem that we face. Rethink and Turning point have produced a practice guide for professionals – ‘Dual Diagnosis toolkit, 9

Mental Health and Substance Misuse’. Health Care Commission directives 2006 Department of Health define Dual Diagnosis as, ‘A broad spectrum of mental health and substance misuse problems that an individual might experience concurrently. The nature of the relationship between these two conditions is complex’ (DOH 2002)


Appendix 2 ‘Serial’ refers to the person having to resolve their substance misuse problem before mental health services become involved. ‘Parallel’ refers to both mental health and substance misuse services providing care at the same time, yet not communicating effectively. Guidance and evidence suggests that services need to work together in collaboration to effectively meet the needs of service users


Appendix 3 Mental Health/Substance Misuse Interface Care Pathway Guidance notes Point (1) Referrals will be accepted from; clients self referring, GP’s, Turning Point, Criminal Justice, Probation, Mental Health Services, Acute Trusts. Information required from referrer; 

Consent to referral being made (if not self referral)


Date of Birth


GP (practice name if GP not known)

Brief drug history

Mental Health History (including any current concerns)

Physical Health Concerns (if any)

Current prescribed medication

Any social services involvement (child protection)

Point (2) Initial assessment and Comprehensive assessment are two distinct stages in Substance Misuse Services and should be represented as such in the care pathway. Initial assessment will be carried out in order to establish urgency of need for action and Risk Assessment by Substance Misuse Services.


Point (3) The Comprehensive Assessment will be undertaken at this stage. This will determine the most appropriate treatment service in relation to substance misuse (refer to NTA tier system, I.e. CDT, Community Alcohol Team). If joint working between mental health and substance misuse services is required then joint care plans should be negotiated to avoid service users having two or more plans of care. Care co-ordination (CPA) responsibility will lye within mental health for those clients subject to Enhanced CPA until their involvement has ended. Care co-ordination will then revert back to substance misuse care coordination procedures as opposed to CPA. For clients not subject to Enhanced CPA care co-ordination will be agreed between services involved in that clients care.


Mental Health/Substance Misuse Interface Care Pathway for Worcestershire

Substance Misuse Services

Mental Health Services

Referral received (1)

Referral received

Initial Assessment (2)

Initial Assessment



Significant Mental Health Issues Identified?


Significant Substance Misuse Issues Identified? Is Joint Assessment needed? Agree Service Responsibility for Care Co-Ordination (3)

Agree Care Plan


Agree Care Plan






Appendix 4 The guidance outlines the need to ensure that mainstream service providers are prepared and equipped to work with dual diagnosis. Clinical Governance – Policies and protocols must reflect the needs of people with dual diagnosis including: 

Managing substance use on In Patient Units to ensure that arrangements are clear.

Shared treatment protocols are required which can be applied in substance misuse and mental health services.

Clear arrangements between services for care co-ordination and risk assessments.

Services must respond to need and prevent people being passed from one service to another

There is an expectation that staff will work with client motivation rather than excluding people from services and adopt a supportive approach to service users.

Ensure that people are included, not excluded from the services they need.

Ease of access to services.

People with severe and enduring mental illness require care from mainstream mental health services.

Range of treatment options, treatment protocols in place.

Ensure that effective information sharing and communication systems are in place.

Involving families and carers in providing care.


Appendix 5 Research and Guidance (DOH 2002, Crawford 2001, Mears et al 2001) identified the need for effective, individually tailored systems of training and development for staff working with dual diagnosis. The guidance stressed the importance of staff development being delivered on an ongoing basis and having three strands; to foster closer alliances between services, equip staff with theory and skills and provide practice development and supervision. Locally there has been some training offered to mental health staff around substance misuse. This has been something that has been carried out both formally and informally and varied from short sessions at ward level e.g. after shift handover to whole day training sessions. Whole day training These days were planned and delivered by CDT staff and left open to who attended from mental health services. Feedback received from the Kidderminster training day was that the session was very well received and useful however, attendance did not reflect a multi-disciplinary approach. This was also reflected in the feedback received from the Redditch training day. Local ideas Basic mental health awareness and basic drug awareness for mental health workers and substance misuse workers respectively, is something that should form part of the core mandatory training for this professional group. This we hope would help to ensure that referrals are made to the most appropriate agencies to meet that particular clients needs. How can we address these training issues locally? Community Drug Team staff could incorporate training for their staff into joint team meetings, i.e. invite representatives from mental health to deliver short training sessions. Mental health services staff could invite representatives from substance misuse services to deliver basic drug awareness training for all staff. Advanced training Previously training has been offered at a more advanced level at the University of Worcester in conjunction with Community Drug Team staff. This training could be used for the designated link 16

workers from mental health and substance misuse services to enhance their skills in order to support their colleagues at each base. The Substance Misuse and mental Health Co-Morbidity guide (Abdulrahim2001) Identifies the importance of training for all mental health and substance misuse staff. It is identified that mental health services should have a substance misuse training strategy pertaining to all staff and professional groups. It also states that the training of staff of substance misuse services should include recognition and care of service users with mental illness, and collaborative working with mental health services


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