Many substance users also have mental health problems, and find it difficult to access services. Collaborative working brought services for both problems together
In this article…
- Prevalence and problems of dual diagnosis
- Identifying and filling gaps in services
- Integrating practice between statutory and voluntary sectors
Lois Dugmore is nurse consultant in dual diagnosis, Leicestershire Partnership Trust
Dugmore L (2010) Partnership working in dual diagnosis. Nursing Times; 107: 7, early online publication.
Many mental health clients also have problems with drugs and alcohol use. This article describes how a collaborative project at Leicestershire Partnership Trust is addressing the needs of mental health clients with dual diagnosis. It outlines the aims of the project, the successes and challenges faced, and provides guidance on setting up a collaborative service.
Keywords: Dual diagnosis, Integrated care, Mental health, Substance use
- This article has been double-blind peer reviewed
Five key points
When setting up an integrated service:
- Have terms of reference for the practitioner role
- Develop an ethos of harm minimisation and drug reduction
- Ensure staff can share practice to learn from each other
- Enable clients to see all relevant professionals in one appointment
- Undertake shared risk and needs assessments
Dual diagnosis refers to mental health clients who also have problems with alcohol and non-prescribed drugs. It is complex.
Historically, clients have only been able to access either a mental health service or a substance use service, meaning many fall between services (Department of Health, 2002).
Access to voluntary service drug treatment is commissioned on the basis of self-referral, with people walking in off the street and asking for help with a range of issues (Box 1). This means that every day brings a new group of clients with issues requiring a number of interventions. People who attend drug services come from all walks of life; many work full time, while others are on benefits or come via the criminal justice route and rely on voluntary sector organisations for help. Many will present initially to third sector organisations.
Box 1. Presentation
People attend drug services with a range of issues including:
- Criminal justice;
- Family breakdown.
According to Drake (2001), the best way to provide an effective service for people with dual diagnosis is through shared skills and practice. Hughes (2006) also recommends an integrated approach to service provision, where mental health and substance misuse problems are addressed at the same time, in one setting, by one team. This article demonstrates how integrating working practices between NHS statutory services and voluntary third sector organisations can improve care and engagement for people with dual diagnosis.
A third of mental health service users are affected by dual diagnosis, as well as up to 50% of substance misuse service users and 70% of prisoners (Mental Health Network, 2009). In 2008, national clinical director for mental health Louis Appleby said: “The management of people with dual diagnosis remains an area of concern, and one of high priority for mental health policy and within clinical policy” (Department of Health, 2009a). Department of Health guidance recommends integrated practice when working with dual diagnosis clients (DH, 2009b; 2007; 2002), yet many services are commissioned separately and have little integration in practice (DH, 2007).
Dual Diagnosis Good Practice Guidelines (DH, 2002) set out a broad framework for identifying which services are likely to be best placed to meet the needs of different groups of service users. With the prevalence of dual diagnosis having doubled in the last 15 years (MHN, 2009), different approaches are needed to engage individuals with treatment. Each local area is required to build on this framework and ensure that care pathways are in place to facilitate transitions between services. Persuading clients to engage with services and ensuring they receive the right treatment are key priorities.
Developing the service
Baseline is a voluntary organisation drop-in service offering help to stimulant users. It was set up to provide an open-access service for advice, information and treatment interventions for problematic stimulant users.
Staff identified gaps in services after noting that many clients also had mental health problems, and were struggling to access psychiatric services. There was also a lack of clarity about individual roles and responsibilities of the staff and services.
This prompted staff to consider whether service users’ needs could be better met by working together with mental health servicesand offering them a joint needs assessment. It was essential that the new service have a number of criteria in place (see 5 key points), with the aim of offering:
- Open access for advice, information, harm reduction and drop-in;
- Access to structured treatments;
- Outreach services;
- Complementary therapies;
- Crisis intervention;
- Washing and laundry facilities;
- Snacks, cooking and nutrition;
- Support with housing, benefits and debt advice;
- Social and relaxation facilities.
Missing from this list was mental health intervention. Baseline staff were requesting assistance from mental health services for clients accessing the drop-in service who were experiencing mental health problems.
It was crucial that the service would be local and keep clients in mainstream services (DH, 2009). Baseline was developed to meet the needs of people using stimulants because a needs-led assessment had identified the gap; however this client group had unmet mental health needs. We agreed that this need could be met by a mental health practitioner attending one day a week.
With information sharing protocols in place, teams could discuss clients and work towards the best outcomes for each individual. The service also provided a “one-stop shop”. Some service users find it difficult to enter mental health service premises, so attending a drop-in service, and being seen by a mental health professional there enables them to engage with mental health services in familiar and unthreatening surroundings.
When developing strategies around dual diagnosis, the National Mental Health Development Unit (NMHDU, 2008) recommends using strategies to engage all parties in meeting the needs of dual diagnosis clients, and working collaboratively to achieve this. In meeting local needs it is essential to know your local population and be able to engage them. In terms of staffing the project, it was essential that the worker was a qualified mental health practitioner who was able to make decisions and carry out assessments. This role was carried out with clinical supervision, by a trust nurse consultant in dual diagnosis.
The project was piloted for six months. The nurse consultant was available for one morning a week; it was important to offer the service on a set day so clients would know when it was available, and could book an appointment if they preferred. A total of 47 clients saw the nurse consultant for a variety of reasons (Box 2).
Box 2. Referrals
Substance users were referred to the nurse consultant for a variety of reasons:
- Poor memory;
- Anger management;
- Personality disorder;
- Low self-esteem;
- Suicidal ideation;
- Low mood.
Role of the mental health practitioner
The nurse consultant’s role was to provide assessment and signpost clients to other services; he also provided advice to staff, telephone support to clients if required, and worked alongside voluntary service workers sharing and delivering skills as part of a two way process. This collaborative working also helped the nurse consultant to develop skills in issues around substance use.
The majority of clients were unaware of how or where to access mental health services, so the nurse consultant also provided ongoing support and informal training to drug/alcohol workers on mental health issues, whether or not they were related to substance use. This was done on an informal basis with staff talking to him about aspects of a client’s presentation they were concerned about, or symptoms being presented. This also enabled the nurse consultant to learn more about substance use and its effects on their client group.
The nurse consultant collated evidence on the number of clients seen and referred into services. Clients gave verbal feedback about their experiences, which were positive and demonstrated that integrated working helped them to gain access to the services they needed.
Client comments included: “I found it really helpful. The mental health practitioner knew exactly how I felt and didn’t laugh like my mates do.”
Baseline reported increased confidence in staff around working with clients who had mental health problems, knowing they could access services for clients they were concerned about. The nurse consultant reported it had increased his awareness of the impact of substance use on mental health, and given him greater understanding of individuals’ needs related to substance use. It is essential that initiatives such as this are sustainable and have measurable outcomes.
The main challenge associated with the initiative was staffing - the service went from one mental health practitioner attending every week to four different ones rotating, which changed the cohesive approach. Other challenges included allaying the fears of voluntary sector workers around mental health and addressing the mental health practitioners’ own issues towards substance users. This was done on an informal basis but both groups of staff would have benefited from training.
In the long term, roles need to be commissioned in line with local policy and be part of clear robust care pathways. There also need to be clear roles and responsibilities for each organisation.
The pilot project was a success and has been rolled out to the wider mental health organisation, offering support to members of other teams who visit Baseline, and advice and assessment on a weekly basis. This now includes an early interventions team for younger adults and early interventions. There has also been an increase in teams providing staff for the drop in clinic, including crisis, assertive outreach, inpatient settings, and community mental health teams. This allows our workforce develop their skills, as well as being able to provide ongoing support to dual diagnosis clients who would otherwise find it difficult to access services.
With contributions from and thanks to Michael Hagiioannu, LCPT, and Melton community mental health team
Department of Health (2009a) New Horizons: a shared vision for mental health. London: DH.
Department of Health (2009b) Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system. London: DH.
Department of Health (2007) Dual diagnosis in mental health inpatient and day hospital settings. London: DH.
Department of Health (2002). Mental Health Policy Implementation Guide. Dual Diagnosis Good Practice Guidelines. London: DH.
Drake R et al (2001) Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Services; 52: 469–476.
Hughes E (2007) Closing The Gap: A capability framework for working effectively with combined mental health and substance use problems (dual diagnosis). Mansfield: Centre for Clinical and Workforce Innovation, University of Lincoln.
Mental Health Network Briefing (2009) Seeing Double: meeting the challenge of dual diagnosis. London: MHN.
National Mental Health Development Unit (2008) Developing a Capable Dual Diagnosis Strategy. A Good Practice Guide. London: DH.