Document name: Clinical Management of Service Users with Dual Diagnosis (mental health and substance use) Document type
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- Document type: Policy Staff group to whom it applies
- Distribution: The whole of the Trust How to access
- Approved by: Trust Board Developed by
- Director leads: Tim Breedon Contact for advice
- SOUTH WEST YORKSHIRE PARTNERSHIP FOUNDATION NHS TRUST Policy for the Clinical Management of Service Users with Dual Diagnosis 1 Introduction
- 3 Development of policy
- 6 Addressing the needs of service users with a dual diagnosis
- Internal and external joint working arrangements
- Care planning and treatment intervention
SOUTH WEST YORKSHIRE PARTNERSHIP FOUNDATION NHS TRUST Policy for the Clinical Management of Service Users with Dual Diagnosis 1 Introduction 1.1 Provision of good quality services for people with a dual diagnosis (co-existing mental health and substance misuse disorders) should be central to modern mental health care (University of Manchester 2006). Evidence indicates that 30-50% of people in contact with mental health services have co-existing substance misuse problems and in some clinical areas the prevalence is much higher. Around 75% of people in contact with drug and alcohol services have co-existing mental health problems ( Weaver et al 2002, Strathdee 2002) and there is an increasing emphasis on incorporating assessment and treatment of mental health problems into substance misuse treatment (DH et al 2007). Addressing dual diagnosis, however, presents significant challenges to service providers (DH 2004). Mental health services locally are developing on an integrated basis; in partnership with the four local authorities. All references within the policy to trust services and staff imply involvement of local authority staff and services. 1.2 Although the term ‘dual diagnosis’ has been widely adopted it has been criticised as it implies just two diagnoses whereas people may have multiple diagnoses and a range of associated physical, psychological and social needs. 1.3 People with a dual diagnosis have often found it difficult to access treatment due to the separation of mental health and substance misuse services and their differing care/treatment philosophies. Furthermore, the range and complexity of needs often experienced eg housing, physical health, financial, frequently requires multiple service providers to collaborate if comprehensive care is to be provided. 1.4 To date, dual diagnosis developments, nationally and locally, have largely focussed on adults of working age. Dual diagnosis is, however, an issue which crosses the life span. 1.5 DH (2002) guidance advocates an integrated approach to service provision whereby both mental health and substance misuse problems are addressed at the same time, in one setting, by one team. The DH guidance sets out a broad framework for identifying which services are likely to be best placed to meet the needs of different groups of service users. Each local area is required to build upon this framework, to comply with NICE guidance (2010, 2011a, 2011b), and ensure that care pathways are in place to facilitate transitions between services. 1.6 As well as the risk which dual diagnosis service users have of falling between services, when they are in treatment, the co-existing problem is often not detected or overlooked (eg Noordsy 2003, Barnby et al 2003). This can result in misdiagnosis and inappropriate treatment (Carey and Correia 1998). In substance misuse services lack of attention to mental health issues can adversely affect treatment outcomes and retention in services (DH et al 2007). 1.7 More specific risks associated with co-morbidity of mental and substance misuse disorders include: violence; self-harm; suicide; self-neglect; abuse and exploitation; accidental injury; unstable accommodation/homelessness; a range of physical health problems including hepatitis B and C and HIV; poor compliance with medication; worsening of psychiatric symptoms; increased use of institutional services; poorer social outcomes, contact with the criminal justice system, disengagement from services and social exclusion (see for example Banerjee et al 2002, DH 2002, University of Manchester 2006, DH et al 2007). 1.8 People with a dual diagnosis may be particularly vulnerable to being socially excluded as they face the double impact of mental illness and problematic substance use. 1.9 The risks associated with dual diagnosis are likely to have a significant impact on the carers/family and children of services users. Addressing the needs of these groups should also be a priority for services. The welfare of children is paramount and this policy should be read in conjunction with the policy and procedures on the protection, safeguarding and promoting the welfare of children. 1.10 The evidence base regarding which treatment models and interventions are most effective when working with this group is limited (Cleary et al 2008), however, research and national guidance provide some indicators of the required components (eg Drake et al 2001, DH 2002). These include taking an approach which is comprehensive, assertive, staged (linking interventions to the person’s readiness to change), and focused on motivation and long term goals. 1.11 To equip staff to work effectively with this group national guidance has consistently identified the need for staff training (eg for mental health staff-HAS 2001, DH 2002, NIMHE 2003, DH 2004, DH 2006a, DH 2006b, NICE 2010, 2011a, 2011b, University of Manchester 2006 eg for substance misuse staff – HAS 2001, DH 2006c, DH 2006d, DH et al 2007. Training should be available to all staff (qualified and unqualified) and at basic and advanced levels, according to need. All staff in this service area need to be aware of Local Authority policies and developments within social care eg Direct Payments and Personalisation. 1.12 The Dual Diagnosis Capability Framework (Hughes 2006) identifies capabilities for working with this group at three levels (1 ‘core’, 2 ‘generalist’, 3 ‘specialist) and provides a framework against which training can be mapped. The capabilities are matched against the Ten Essential Shared Capabilities, Knowledge and Skills Framework, Drug and Alcohol National Occupational Standards and Mental Health National Occupational Standards. Clinical staff working in mental health services should have level 2 capabilities. Those in dual diagnosis specialist roles would be expected to operate at level 3. 1.13 Guidance highlights the need for training to be followed up with practice development and supervision as training in isolation will have limited benefits. 1.14 The template below, derived from Department of Health (2002) guidance, outlines which service providers are generally best placed to lead care and treatment delivery for different groups so that care is delivered in line with the integrated model. The diagram below sets out a more detailed framework to inform local care pathway development.
severity of substance use 2 Purpose of Policy 2.1 This policy identifies the Trust’s expectations regarding the management of people with a dual diagnosis – co-morbid mental health and substance misuse problems. More specifically it sets out requirements for minimising the range of risks which can be associated with this group. 2.2 This policy should be read in conjunction with the Practical guidance on the management of illicit substances for the South West Yorkshire Partnership NHS Foundation Trust which deals with specific issues associated with minimising the use of drugs and alcohol on Trust premises and managing the situation when this does occur. 2.3 Other Trust policies and guidance which should be read in conjunction with this policy are: Medicines Code Controlled drug procedures Patient and Public Involvement Policy Medicines Management Strategy Physical Healthcare Policy Adult Abuse Protection Policies Framework for the Management of Illicit Substances on Inpatient Wards Confidentiality Policy Care programme approach policy and procedures Policy and procedures on the protection, safeguarding and promoting the welfare of the children The Maudsley Prescribing Guidelines are also a valuable resource, providing information on clinical assessment of substance use, setting out good practice in relation to implementing pharmacological interventions, and highlighting potential interactions between prescribed and non-prescribed/illicit drugs and alcohol. 3 Development of policy 3.1 This policy builds on work which has been developing in Wakefield to meet clinical need and national guidance and the developing services within Calderdale, Kirklees and Barnsley. 4 Scope 4.1 This policy relates to all clinical services including Adults of Working Age, People with a Learning Disability, Older Peoples Services and Forensic 4.2 Dual diagnosis is defined as the co-existence of mental health and substance misuse problems. This broad definition is intended to be inclusive so that the needs of the wide range of people with co-existing conditions coming into contact with the Trust are considered regardless of the severity of their mental illness (including personality disorder) and/or their substance misuse problem. Beneath this broad heading specific definitions are in place across the areas of Wakefield, Calderdale, Kirklees and Barnsley. 5 Duties 5.1 The policy will be signed off by the Executive Management Team of South West Yorkshire Partnership Foundation NHS Trust. 5.2 The Adults of Working Age Service Line of the Business Delivery Unit is responsible for overseeing implementation and monitoring of the policy as it relates to our own area and work with partner agencies. 5.3 Within the Dual Diagnosis Service Meeting (Wakefield), Dual Diagnosis Implementation Group (Kirklees), Calderdale meeting and Barnsley Dual Diagnosis meeting the dual diagnosis leads are responsible for supporting implementation and monitoring. 5.4 The Dual Diagnosis and Substance Misuse Advisory Group is responsible for reviewing and updating the policy every three years; supporting area dual diagnosis leads and strategic groups in developing local strategies, implementation plans and monitoring processes. 5.5 Team managers are responsible for implementation of the policy within their services. 5.6 Team managers are responsible for ensuring their staff have attained dual diagnosis competencies at the appropriate level for their role. 5.7 The training department is supportive of this arrangement providing the necessary infrastructure within the areas of Wakefield, Kirklees, Calderdale and Barnsley; local groups exist to facilitate and coordinate the delivery of relevant training. 5.8 All clinical staff are responsible for being familiar with the policy and associated policies and complying with them. 6 Addressing the needs of service users with a dual diagnosis 6.1 For the Trust to deliver high quality clinical care to people with a dual diagnosis, the needs of this group should be considered in the development of all clinical work streams. 6.2 People with a ‘dual diagnosis’ often experience a range of complex needs associated with their mental health and substance misuse eg physical health, financial, housing, childcare, criminal justice. To provide effective care and treatment it is essential to work collaboratively with service users themselves; their carers, family and friends; and partner agencies. 6.3 In line with DH (2002) guidance the Trust supports delivery of an integrated treatment model whereby service users have both their mental health and substance misuse needs addressed at the same time. As commissioning priorities and service configurations are different in each PCT area they will need to develop plans with the Trust for delivering services within this model. The districts of Kirklees, Calderdale, Wakefield and Barnsley have developed their own unique arrangements as follows: Kirklees has developed a service which includes a part time Consultant Psychiatrist and Advanced Practitioner who provide an integrated response, providing a comprehensive mental health and substance misuse problems and appropriate initiation of evidence based treatment plans. They engage individuals with mental health problems into substance misuse services by collaborative working with Lifeline and support those individuals in Lifeline access to appropriate mental health services. Wakefield has developed the Wakefield Integrated Substance Misuse Service (WISMS). The model is delivered by Turning Point, Spectrum and South West Yorkshire Partnership Foundation Trust (SWYPFT) with Dual Diagnosis Practitioners supported by the Nurse Consultant ensuring an effective evidenced based approach. Calderdale shares the part time Consultant Psychiatrist with Kirklees who works closely with Calderdale Substance Misuse Service and wider mental health services across SWYPFT. In Barnsley there is a part time Advanced Practitioner role supporting developments within the wider mental health services and a specialist assessment clinic for dual diagnosis takes place within the Barnsley substance misuse services; which are provided in collaboration between SWYPFT and Phoenix Futures. The commissioned Barnsley Substance Misuse Service is led by a Consultant in Substance Misuse. 7 Internal and external joint working arrangements 7.1 To ensure effective communication within and between SWYPFT each area (Wakefield, Calderdale, Kirklees and Barnsley) should have a strategic dual diagnosis group which includes stakeholders from partner agencies and service user representation. In Kirklees it is called the Kirklees Dual Diagnosis Steering Group; Wakefield has the Dual Diagnosis Service Meeting and Dialogue Groups and Calderdale has the Dual Diagnosis Steering Group and Barnsley has the Dual Diagnosis Steering Group. It oversees the operation of any dual diagnosis team, and details of training provision and arrangements for assessing service users’ experiences of service provision. Strategies must be reviewed every three years. All strategies and their associated documentation should be available on the Trust intranet. 7.2 The dual diagnosis leads will support implementation and monitoring of their local strategies. S/he should be able to influence strategically within the locality, have good relationships with key stakeholders within and outside the Trust, and, ideally, working towards capabilities at level 3 in the dual diagnosis capability framework.
Drug and Therapeutics Sub-Committee 
Dual Diagnosis and Substance Misuse Advisory Group
Barnsley Calderdale Kirklees Wakefield 7.4 On occasions there will be differences of opinion regarding which service(s) is best placed to lead the care delivery of an individual and/or the appropriate contribution of specific services to the care package. If, following initial discussion between staff directly involved in a particular case, differences of opinion are not resolved, a multi-professional meeting should be arranged. The dual diagnosis leads are well placed to convene this. The meeting should include the individuals GP, staff directly involved with the case, the team managers and consultant psychiatrists of the relevant teams, a social care perspective, as well as any dual diagnosis practitioner/champion involved. The consensus view should be documented and reviewed through the care programme approach. 7.5 The dual diagnosis leads in each area should systematically collate information regarding these challenging cases. This information might include teams/individuals involved, diagnosis, type and severity of substance use, service gaps. Cases should be reviewed over the previous six months involving the Psychiatrists in Substance Misuse, Nurse Consultant and Advanced Practitioners within the AWA Service Line of the Business Delivery Units so that common themes can be identified, areas of unmet need highlighted and pathways adapted with recommendations to the strategic dual diagnosis groups. It will remain a regular item for discussion at the Dual Diagnosis and Substance Misuse Advisory Group; a sub group of the Drug and Therapeutics Sub Committee. 7.6 When a referral is received into mental health services, requesting an assessment of a service user who has mental health needs and is using alcohol or drugs, an appropriate assessment will be offered. The decision NOT to provide care for an individual can only be made following an assessment. In line with CPA policy and guidance (DH 2008), when a mental health team is not going to provide care within the CPA framework for someone with a dual diagnosis a rationale for this decision will be documented within the healthcare record. 7.7 Some people with a dual diagnosis have short periods of contact with services but tend not to maintain this despite having needs and being potentially at risk of self-harm, self-neglect, physical health problems, accidents, suicide and violence to others. They are often people with mild to moderate mental health problems who do not meet criteria for secondary mental health care and are unwilling or unable to access substance misuse services. Services need to work together to consider the needs of each individual, ensure that risk is carefully assessed, information shared (including with the person’s GP) and a flexible and timely response taken when risk escalates or there are opportunities for engagement. 7.8 Regardless of local commissioning and service configurations the Trust expects adherence to the standards set out in the following sections which are recognised as core components of good quality care for people with a dual diagnosis and essential for identifying and managing risk.
The families and carers of people with a dual diagnosis can be important partners in care delivery. They will require information and support to help them fulfil this role. Even in situations where service users do not consent to the active involvement of family/carers Trust staffs still have a statutory responsibility to consider their needs and a carer’s assessment should always be offered.
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