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Article citation: Cheryl Kipping, (2011) "Editorial", Advances in Dual Diagnosis, Vol. 4 Iss: 2, pp. -
At the time of writing this Editorial, the government’s “pause” to reflect on its proposed health and social care reforms has come to an end. The Future Forum, the group overseeing the “listening exercise”, must now report on what they have heard.
One group that fed into the consultation was the All Party Parliamentary Group (APPG) on Complex Needs and Dual Diagnosis. This group, co-chaired by Lord Victor Adebowale, (chief executive of Turning Point and a member of the Future Forum) and David Burrowes, conservative MP for Enfield, Southgate, held a special meeting to canvas views. A report of the meeting and the key points that were forwarded to the Future Forum along with a link to the full response are included in this issue (see News section). Many of the themes identified are not new but are issues of increasing concern in light of the government’s proposals, particularly at a time of disinvestment in the health and social care system.
Several of the papers in this issue illustrate themes identified by the APPG and provide glimpses of the potential benefits of taking on board the APPGs recommendations and consequences of not doing so. Readers will know that collaborative working at a strategic level, between services and with service users is a prerequisite for effectively meeting the needs of people with a dual diagnosis. This is a theme that pervades the APPG response and the papers in this issue. Competition between providers is likely to disincentivise partnership working and increase fragmentation of services as they bid against each other for contracts – a point highlighted by the APPG. My fear about the reforms is that much of the good work achieved over the past ten years will be lost. If it is to continue, it will be down to the commitment, flexibility and innovative approaches of people working in services. This issue of Advances in Dual Diagnosis provides examples of great work that is being undertaken across the country to promote more effective care for people with a dual diagnosis.
Moving on to the papers, then, one of the APPG’s (2011, p. 3) concerns in relation to the reforms was the potential lack of accountability for addressing the health equalities of the most excluded groups, particularly those not seen as “compliant, mainstream or cost effective”. Sarah Anderson’s paper highlights the multiple and complex health and social care needs of women attending ANAWIM, a women’s centre in Birmingham. The paper focuses on the women’s mental health needs and identifies how a simple initiative, a mental health nurse from the local dual diagnosis team spending a day each week within the centre, enabled the women to access appropriate care.
The nurses’ specialist mental health knowledge and skills, along with her flexible approach and links with local mental health services enabled her to engage with the women, conduct assessments, sometimes jointly with centre staff, facilitate pathways into care and make access to some services more streamlined, deliver interventions, such as an emotional well-being group, and provide some mental health training for the centre staff so that they could more effectively support the women. The initiative demonstrates the value of collaborative work between agencies, particularly voluntary and statutory sector providers and shows how, together, their complimentary skills and practice, can enhance service provision.
Reductions in funding threaten to inhibit such initiatives and Sarah Anderson reports that funding of the women’s centres is uncertain. The APPG (2011, p. 3) warn of the potential consequences of excluding groups such as those using ANAWIM; “their issues will not disappear but potentially escalate and be even more challenging and expensive”.
In my own organisation, disinvestment has resulted in an initiative similar to the one described by Sarah coming to an end. Dual diagnosis practitioners provided sessions in voluntary sector substance misuse services to support them in working with people with mental health problems. They conducted mental health assessments, provided training, advice and supervision to enable the substance misuse staff to work more effectively with this group, facilitated pathways into mental health services when this was required, and supported mental health service users to access the substance misuse service when this was desirable. Similar provision utilising the practitioners’ substance misuse expertise was provided to mental health services. This sharing of expertise and building bridges between services was highly valued but the dual diagnosis posts have been lost. In seeking to find new ways forward, we are now learning from the experience of Richard Edwards and his colleagues in Avon and Wiltshire Mental Health Partnerships (NHS) Trust.
Richard Edwards’ paper describes how a dual diagnosis link worker scheme designed to promote good practice and improve partnership working can be developed and supported across a large organisation. Link workers are not a quick fix and take time, energy and commitment to establish. Many organisations attempted to set them up in the early days of dual diagnosis developments with limited success. Without the key components highlighted by Richard such as strategic support (the model being embedded into organisational strategy), role clarity, team-level managerial support, attention being given to the development needs of those taking on the role (e.g. training, supervision), and taking time to build networks between services they are unlikely to be sustained. Partnership working is central to this initiative. Enhancing the role of service users in the project is identified as the next area for development.
Alix Hind’s paper focuses on service user involvement and highlights the dual benefits of ensuring service users are partners in planning and developing services: services are improved and involvement activity can help service users’ recovery. Alix is passionate about improving services and it is clear that she and her service user involvement colleagues are achieving considerable success in shaping service developments in Nottinghamshire. As well as being a key player in local service user panels, Alix has run an anti-stigma campaign, is part of a mentorship project where service users mentor senior Trust staff, has been employed as a peer support worker in mental health services and is now setting up a peer support worker role in substance misuse services. In addition, consideration is being given to involving service users on tendering panels, so she may soon be influencing commissioning decisions too.
One of the APPG recommendations is that commissioners should ensure that the needs of people with complex needs are heard so that services are designed to reflect their priorities and needs. There is no doubt that Alix is working hard to ensure that services are designed to reflect service user needs. The principle of shared decisions advocated in the White Paper: No Decision About Me Without Me (Department of Health, 2010) needs to encompass both individual care and treatment decisions and decisions about the future shape of service provision.
Some of my consultant nurse colleagues and I visited the Woodlands unit, a new inpatient drug detoxification unit, which Alix was instrumental in developing. It is very impressive. Historically, many mental health and substance misuse services have been housed in poor quality buildings, reflecting the low status and stigma associated with these “disorders”. Providing service users with a comfortable, high quality environment that demonstrates that they are valued, and accompanying this with good quality care can be an important first step to recovery.
This can be built upon by valuing service users’ expertise and supporting the development of their confidence and skills by involving them in service improvement initiatives, further enhancing recovery, as demonstrated by Alix. Alix’s story is inspiring but highlights that recovery takes time. Last year, I expressed concern that the Drugs Strategy consultation and the National Treatment Agency (NTA) Business Plan were equating “recovery” with abstinence and it appeared that time limits for achieving this were being proposed (including a time limit for substitute prescribing – NTA, 2010; Kipping, 2010). The somewhat strident messages from the government and NTA appear to have been toned down and the drugs strategy (HM Government, 2010) acknowledged that there are many people on substitute prescribing who have jobs. A long history of drug use cannot be overcome in a few months: Alix has been on a methadone prescription for over four years and is continuing to work towards her ultimate goal of being completely substance free. The government is rightly, keen to measure service user outcomes. Given that continued funding for services is likely to be contingent on achieving outcomes it is essential that appropriate indicators are selected, particularly for those with multiple complex needs. I am sure that Alix and her colleagues would be able to help develop these.
Dave Hearn’s paper revisits the thorny issue of drug detection dogs. While almost everyone would agree that mental health services should provide a substance free environment within which people with severe mental distress can receive care and treatment, identifying how best to achieve this is far from clear, particularly if a culture that is therapeutic and respects people’s privacy and dignity is to be maintained. Around 50 per cent of people on psychiatric inpatient wards have problems with alcohol and/or drugs and many continue to use during their admission: Phillips and Johnson (2003) found that more than 80 per cent of those with substance misuse problems continued to use on the ward. While policy and good practice guidance emphasise that drug and alcohol issues should be a core component of mental health care and that local policies and protocols should be in place to maintain a substance free environment (Department of Health, 2006; National Institute for Health and Clinical Excellence, 2011), no national guidance has made explicit mention of drug dogs, yet many trusts employ them.
In a rather different slant on working in partnership Dave’s paper provides an overview of the experiences and learning of the medium and low secure services at South London and Maudsley NHS Foundation Trust as they have grappled with the challenges of maintaining a safe, substance free environment. Like many others, I am not entirely comfortable with the use of drug detection dogs, an approach that appears controlling and custodial, however, neither am I comfortable with hearing reports of some people’s first experience of using illicit drugs being on mental health wards, or vulnerable service users being coerced into “lending” money to others or going to pick up and/or store drugs for them, or of service users and/or staff being assaulted as a consequence of the deterioration in someone’s mental state triggered by use of substances.
As Dave emphasises, the use of drug detection dogs should be only one part of a wider strategy to address dual diagnosis needs. Dave’s paper is a welcome addition to the debate and helpful in promoting thinking about some of the challenges.
The final items in this issue are reports of recent APPG meetings (the one held in response to the “listening exercise” and one on the Bradley review), an update on making every adult matter (MEAM) and notice of a forthcoming conference. In a future issue of the journal, we will publish a paper on the forthcoming MEAM-Revolving Doors Agency Vision Paper for multiple needs and exclusions, which will be launched in the autumn, so look out for that.
There is no doubt that we are working in difficult times. Hopefully, changes will be made to the government’s health and social care reform proposals that will help to improve the care and treatment of people with dual diagnosis. David Burrowes said that the litmus test of the reforms would be how effectively they worked for people with dual diagnosis/complex needs. We wait to see what changes there will be, and over the longer term, the impact they will make on services and service users.
All Party Parliamentary Group on Complex Needs and Dual Diagnosis (2011), Response to Future Forum, available at: www.turning-point.co.uk/whoarewe/appg/Documents/APPG_Future_Forum_response.doc
Department of Health (2006), Dual Diagnosis in Mental Health Inpatient and Day Hospital Settings, Department of Health, London
Department of Health (2010), Equity and Excellence: Liberating the NHS, The Stationery Office, Norwich
HM Government (2010), “Drugs strategy: reducing demand, restricting supply, building recovery”, available at: www.homeoffice.gov.uk/publications/alcohol-drugs/drugs/drug-strategy/drug-strategy-2010
Kipping, C. (2010), “News: government consults on drug’s strategy”, Advances in Dual Diagnosis, Vol. 3 No. 3, pp. 43–5
National Institute for Health and Clinical Excellence (2011), Psychosis with Coexisting Substance Misuse Clinical Guideline 120, National Institute for Health and Clinical Excellence, London, available at: http://guidance.nice.org.uk/CG120/QuickRefGuide/pdf/English
NTA (2010), NTA Business Plan 2010-11, NTA, London, available at: www.nta.nhs.uk/uploads/nta_business_plan_2010_11%5B0%5D.pdf