Scottish Government

MIND THE GAPS
Meeting the needs of people with co-occurring substance misuse and mental health problems

ANNEX C
MODEL OF SERVICE PROVISION IN AYRSHIRE AND ARRAN

In 1995 it was apparent that a large patient group consisting of those suffering from concurrent mental health and substance related problems were not accessing the range of services that met their needs. Numbers were growing, presenting equally to addiction and mental health services and both staff and users were frustrated by 'gaps'. There was a similar problem for local authority social work services. Despite inherent dangers (more boundaries, mismatch between demand and capacity) of creating a specialised service, it was felt that there was an immediate need for service development.

The community service

The aims of the service are threefold:

• to create a small, skilled and willing staff group to provide a direct service to this unpopular and challenging group;

• to provide advocacy, liaison and shared care with both addiction and mental health workers in order to progress the client back into mainstream services; and

• to allow staff on both sides of 'the divide' to work through their concerns and to raise their levels of skill and confidence; and to provide appropriate training.

A community service, established initially with a full time CPN and a part time consultant psychiatrist, was therefore given the task of addressing these needs. The Community Service has now grown to the equivalent of 2.5 full time consultant psychiatrists, 5 CPNs, an occupational therapist and a social worker. The team is now large enough to allow for a named link worker for each of the six main addiction agencies and for each of the 6 community mental health teams (CMHTs). Similar relationships are now being made with the prison, A & E, primary care teams, Housing, Richmond Fellowship, family support projects and community schools. To date other organisations are less willing to be involved, preferring to continue making blanket referrals to either addiction services or mental health services.

The characteristics of the community service are as follows.

• The criteria for the service are based on inclusion so that people with diagnoses such as personality disorder and chaotic users are no longer excluded from treatment. Interventions are negotiated with the mainstream services which allows it to feel comfortable in continuing treatment so that the patient is not lost to services.

• Care is not planned in terms of primary or secondary diagnoses but is based on a pragmatic analysis of presenting problems along with a thorough assessment of attendant risk.

• A patient plan is drawn up which clearly prioritises the sequence and ownership of actions to be undertaken (in full consultation with the patient and presented in a way that makes sense to them).

• Subsequent care is rarely provided solely by the dual diagnosis team and usually involves others. Liaison and the sharing of care with other organisations (often more than one) is the key to success and is always started by joint assessment with the referring partner.

• To meet need better the team has developed skills in three specific areas, namely sexual abuse interventions, care of post-traumatic stress and cognitive behavioural interventions in psychosis.

• To maintain a constructive dialogue with all those organisations that might interact with the service. This includes LHCCs, the Courts, the local A & E department and the local prison, but mainly the various addiction services and Community Mental Health Teams.

Residential support unit

Three years ago there was an opportunity to convert a 12 bedded alcohol rehabilitation unit into a residential support unit for people with dual diagnosis problems. This unit is staffed by nurses and an occupational therapist with regular input from social work, physiotherapy, debt counsellor, housing, pharmacy, and a reiki therapist. Although many had wished originally for a unit catering for the most chaotic and problematic members of this client group, the unit was deliberately designed as a rehabilitative/step-down unit on pragmatic grounds. Severe episodes of mental illness and severe episodes of withdrawal or other drug related problems are best dealt with in IPCU and detoxification beds respectively. The Unit provides a series of cognitive-behavioural packages designed to fit into the 'stages of change' model and directed at a variety of mental health problems ranging from anxiety to psychosis. These tend to be symptom and problem based rather than diagnosis based.

The unit has liaison and shared care roles. 'Inreach' is provided to the acute psychiatric wards and, in conjunction with the general hospital psychiatric liaison service, to general medical and surgical wards. A clear path from acute inpatient care to dual diagnosis has now been established. It starts with a joint assessment and staff providing medium to long-term preparatory input on the wards prior to admission. This has been the arena where the relationships with housing, benefits and family support has been most fruitfully developed and from which the community service has considerably benefited.

For some time there had been a desire to develop a joint project with the Scottish Association for Mental Health (SAMH) for those facing similar problems. A number of projects had been mooted. Transitional housing benefit and the accompanying capital grants have been the catalyst for setting up the service. The common problems shared with SAMH revolved around the difficulty of providing adequate community support for those with enduring mental health needs and co-existing drug or alcohol problems. Two of the 3 relevant local authorities and the NHSBoard have sponsored the development of 75 hours per week of intensive community support in each authority area for people who, after community care assessment and dual diagnosis assessment, addressed as requiring intense community support. This has been invaluable in providing options to hospital admission or in facilitating successful discharge from hospital. As the project is now self-funding, the nature of transitional housing benefit is such as to hopefully allow it to grow as needed. To date 11 clients have been supported in this way.

Statistics from the two services are as follows:

Costs

The normal total cost of both services is approximately 400,000 per annum