Better care for people with co-occurring mental health and alcohol/drug use conditions – new national guidance for commissioners and providers
It is very common for people to experience problems with their mental health and alcohol/drug use (co-occurring conditions) at the same time. Research tells us that mental health problems are experienced by the majority of drug (70 per cent) and alcohol (86 per cent) users in community substance misuse treatment (Weaver et al., 2003; Delgadillo et al., 2012). Death by suicide is also too common, with a history of alcohol or drug use being recorded in 54 per cent of all suicides in people experiencing mental health problems (Appleby et al., 2016). High prevalence of these co-occurring conditions has been found among many of the following populations; people in prison and those in the criminal justice system (The Bradley Commission, 2009); children, young people and adults in alcohol and drug treatment (Public Health England, 2015; Weaver et al., 2003; Delgadillo et al., 2012); individuals presenting to hospital emergency departments in mental health crisis (Care Quality Commission, 2015); and people experiencing severe and multiple disadvantage (Bramley et al., 2015).
Both alcohol and drug use and mental ill-health are associated with physical health problems and early death (Hayes et al., 2011). Evidence tells us that intoxication is a significant risk factor for death by suicide, and that people addicted to opiates are four times more likely to die by suicide than the general population (Pierce et al., 2015). Smoking is highly prevalent among both people with mental health conditions and those who use alcohol/drugs, and is a significant contributor to illness and death among this group (Hurt et al., 1996).
Evidence from service user and provider surveys suggests that people with co-occurring conditions are often unable to access the care they need from both mental health and addiction services (The Recovery Partnership, 2015). Individuals experiencing mental health crisis may experience difficulty in accessing care due to intoxication (in spite of the heightened risk of harm that this brings (Darvashi et al., 2015)).
We know from listening to the experiences of service users and service providers that people with co-occurring conditions very often find themselves excluded from care because services tend to be commissioned to respond to one presenting need of the person, be that alcohol or drug use, mental health or homelessness. We also know that intoxication is often used as a reason to exclude people from services, in spite of the additional risk of harm and death this can result in.
Voices from the Frontline: listening to people with multiple needs and those who support them (Making Every Adult Matter (MEAM) Coalition, 2015) presents qualitative data drawn from interviews with individuals and support services which describes a persistent failure of services to work collaboratively to support people with multiple and complex needs, and the inadequacy of a support system which “treats people based on what it considers to be their primary need, be that mental ill-health, dependence on drugs and alcohol, homelessness or offending”.
Other evidence suggests that there are still significant gaps at both strategic planning and service delivery level – and the situation may be worsening.
The Recovery Partnership’s (2015)“State of the Sector” report for 2015/2016 surveyed 176 drug and alcohol treatment services in England and 20 per cent of respondents stated that access to mental health services had worsened in the previous 12 months.
To tackle this, Public Health England (PHE), supported by NHS England, will shortly be publishing new national guidance “Better care for people with co-occurring mental health and alcohol/drug use conditions”. This guidance is aimed at commissioners and providers of mental health and alcohol and drug treatment services. It also has relevance for all support services that have contact with people with co-occurring conditions. It has been co-produced with members of the expert reference group for co-existing substance misuse with mental health issues, and in consultation with experts through experience, service providers, practitioners, commissioners and policy leads.
The new guidance supports implementation of the Five Year Forward View for Mental Health (The Mental Health Taskforce, 2016), including current and forthcoming development of a comprehensive set of evidence-based treatment pathways. It also represents an action from the Mental Health Crisis Care Concordat national action plan.
We want to encourage commissioners and service providers to work together to improve access to services which can reduce harm, improve health and enhance recovery, enabling services to respond effectively and flexibly to presenting needs and prevent exclusion.
Two overarching principles support these aims:
Everyone’s job: commissioners and providers of mental health and alcohol and drug use services have a joint responsibility to meet the needs of individuals with co-occurring conditions by working together to reach shared solutions.
No wrong door: providers in alcohol and drug, mental health and other services have an open door policy for individuals with co-occurring conditions, and make every contact count. Treatment for any of the co-occurring conditions is available through every contact point.
Scope of guidance
The guidance is clear that no one should be excluded from care because they are not considered “ill enough”, or because they engage in harmful/hazardous rather dependent use of alcohol or drugs. We need to be better able to respond to people who present in mental health crisis while intoxicated, and ensure that they can access the care and recovery support they need when the crisis has been resolved. This guidance covers all substances, all levels of dependency, harmful use (including tobacco use and states of intoxication. It also covers all mental health conditions – from anxiety and depression to more severe mental illness. It is for all ages, from children to adults (including older adults), and all settings (including prisons and other prescribed places of detention).
The guidance is intended to be read alongside existing NICE (2016) guidance, particularly “coexisting severe mental illness and substance misuse – community health and social care services”.
Guidance for commissioning and delivery of care
To support the principles of “everyone’s job” and “no wrong door” we have suggested the following priorities to guide commissioning and delivery of care:
agree a pathway of care which will enable collaborative delivery of care by multiple agencies in response to individual need;
appoint a named care coordinator for every person with co-occurring conditions to coordinate the multi-agency care plan;
undertake joint commissioning across mental health and alcohol/drugs including primary care, criminal justice settings and specialist/acute care, supported by strong, senior and visible leadership;
enable people to access the care they need when they need it and in the setting most suitable to their needs;
commission a 24/7 response to people experiencing mental health crisis, including intoxicated people;
commission local pathways which enable people to access other services such as homelessness, domestic abuse or physical healthcare; and
make an assessment of people’s strengths and aspirations for the future and make sure people are helped to access a range of recovery supports while recognising that recovery may take place over a number of years and require long-term support.
A framework for delivery of care
The new guidance also recommends a framework for delivery of care based on the following factors:
strong therapeutic alliance;
collaborative delivery of care;
care that reflects the views, motivations and needs of the person;
care that supports and involves carers (including young carers) and family members;
therapeutic optimism;
episodes of intoxication are safely managed; and
stop smoking advice/support is a routine part of care.
The guide points to a number of resources available to support development of a competent workforce with the requisite values, knowledge and skills, include those with sufficient expertise to provide clinical leadership and supervision. There are links to implementation prompts for commissioners and providers, and further sources of help and information are included at the end of the document.
Dr Luke Mitcheson (PHE and South London and Maudsley NHS Foundation Trust) has been involved both in developing the new national guidance for co-occurring conditions, and also the new NICE guidelines:
Changes brought about by the 2012 Health and Social Care Act have meant that Local Authorities are responsible for substance use services and Clinical Commissioning Groups look after mental health.
This fragmentation poses a risk as commissioners and staff may decide that someone is not their responsibility if they also have issues not directly related to their service.
People with co-occurring mental illness and substance use are often actively excluded from services. You will hear many excuses; “too intoxicated to assess”, “suffering from drug-induced psychosis” or “too complex for our drug-rehab”.
Those who are able to access services may find that they are treated based on what is considered their primary need, be that alcohol use, mental ill health or offending rather than as a set of related and interconnected issues.
We hope that the new guidance will encourage closer collaboration between both sets of commissioners and providers to improve the experiences of service users”.
We will be gathering examples of good practice and sharing these online. If you think your local area is developing or delivering something worth sharing, we would be delighted to hear from you. Please contact emma.christie@phe.gov.uk.
