Background
The research project investigated the nature, scope and impact of existing service provision in Scotland for people with co-existing mental health and substance misuse problems. The study was commissioned by the Scottish Executive in 2003 to extend current international evidence regarding co-morbidity, address perceived gaps in information on the quality of the provision of care for this client group and help inform the development of the co-morbidity agenda in Scotland. The research fits within the wider strategic context in the UK, complementing other initiatives or strategies.
Aims and objectives
The main aim of the study was to identify the broad range of health and social care needs of people with co-morbid mental health and substance misuse issues in Scotland. Key issues included the quality of current provision and organisation of health, social care and the voluntary and independent sectors in addressing these needs, common factors that might impede this provision, the interrelation of different services and examples of good practice.
Methods
The researchers interviewed commissioners, service providers and service users to obtain a range of perspectives on these issues.
As decision makers and future planners, the commissioners helped to establish local strategic and bureaucratic contexts. Interviews explored issues relating to co-morbidity and examined specific features of relevant policy and practice.
Focus group discussions, held with service providers from the independent, voluntary and statutory sectors, gave the research an operational perspective. Focus group topics included issues around practice and policy, assessment, treatment interventions and wider organisational issues.
Interviews with service users centred on their experiences and perceptions of service provision in relation to their mental health and/or substance misuse problems. Their views on the services utilised, their expectations and experiences provided valuable new insights and made a unique contribution to the project.
Findings
Accessibility and availability
- Signposting: The degree to which services were advertised and the level of knowledge regarding the nature, remit and limitations of services were insufficient to guide the service user either to or through the service maze. In the absence of a 'live' and regularly updated directory of service remit and availability, providers were likely to continue to rely on historical links to services rather than on what was actually available.
- Structural obstacles: The structure of existing services and their service philosophies were considered by many as creating barriers for co-morbid service users who might need input from a number of different service providers. Reports suggested that traditional trajectories rather than client-centred thinking often influenced decision-making about approaches to service users. As a result, there were debates between services as to who should take responsibility for service users with different presenting problems.
- Management of mild to moderate mental health problems in substance misusers: Individuals with substance misuse-related issues often did not have sufficiently severe mental health problems to be eligible for attention from community mental health teams which prioritised severe and enduring mental illness. This sometimes led to inappropriate management by substance misuse agencies or by primary care services.
- Management of mild to moderate substance misuse problems in those with mental health problems: Similarly, individuals who used substances such as cannabis that were commonly thought to be relatively innocuous often did not qualify for eligibility to substance misuse services. This service configuration created obvious gaps in provision for people who needed help for both substance use and mental health issues.
Particular tensions:
- Accommodation: Positive experiences were reported in relation to supported accommodation, though the availability of such living arrangements was scarce and often restricted to those who did not use substances.
- Contentions between drugs misuse and alcohol: Many of the respondents, commissioners and providers included, were concerned over the ways in which more resources were made available for drug misuse compared to alcohol.
- Specialist provision: Frustrations were expressed at the difficulty experienced in accessing specialist help in a crisis. The responsiveness of the 'system' to the needs of a group of people with multiple needs was challenging for all concerned.
Service Characteristics
- The need for flexibility and consistency: The research highlighted the contrast between the inflexibility of services and the chaotic characteristics of co-morbid service users' lives. Services set up to support people living with mental health and substance misuse problems were not sufficiently flexible or appropriate to their needs, concentrating largely on 'diagnosis' and ignoring the wider picture.
- The need for responsiveness and continuity: Providers and users alike reported that when service users asked for help they needed it immediately. They did not want to be placed on a waiting list and told to come back later. It was also felt that service users were often isolated and cut off from appropriate services after formal treatment had ended. There was a clear need for case managers or co-ordinators.
- The need for strengthening psychotherapeutic approaches: Participants agreed that the most effective interventions took the form of warm, friendly, empowering services usually provided by one individual on a continuous basis. Concern was expressed at the relative lack of psychotherapeutic interventions available and the consequent lack of opportunity to develop trusting, therapeutic relationships with one person.
- The need for holistic care: While there were examples of good practice and many positive experiences of different therapeutic relations, service users, commissioners and providers alike commented with regret that several services did not treat problems holistically and in a joined-up manner. They continued to consider mental health and substance misuse issues in relative isolation from one another and to deal with them sequentially.
Service organisation
- The need for specialists: There was a lack of dedicated co-morbidity specialists who appreciated the interaction of substance misuse and mental health problems and had the expertise and the resources to undertake this work.
- The need for training to underpin provision: Service providers stated that they needed specific training and support to help them deal with the complexities co-morbid individuals brought to the services.
- Multi-agency partnerships: In many parts of Scotland, health services and local authorities were working together and shared funds, yet evidence of joint working remained patchy. Where it did exist, experiences were positive.
- Shared assessment protocols and development of care pathways: As a result of patchy joint working arrangements, shared assessments and the creation of care pathways for co-morbid individuals were lacking or under-developed in several locations. Discussions with commissioners indicated that the requirement for joint-funding approval in creating a care package could help to bring about closer collaborative efforts between health and social care.
- Bureaucratic quagmire: Providers and commissioners voiced concern over the expediency of policy and directional changes and associated changes in remit, despite the consistency of the joint planning, joint commissioning and joint delivery messages for mental health and other needs over the past decade. These structural and procedural modifications were believed to act as barriers to developing functional and successful collaborative efforts and providing consistency in care and support.
- Exclusion: Service users felt excluded from decisions about their care and wanted greater involvement and empowerment. Although user involvement was acknowledged by some to be important, others considered that service users were not necessarily best placed or informed to direct and advise on service provision and practice. Service users interviewed also stressed their need for peer support groups.
- Stigma and inclusion: All participants spoke of aspects of wider cultural and social problems that needed to be addressed. Stigma was an enduring feature of mental health and substance misuse problems alike. Since the late 1990s, a marked policy shift towards recognising the importance of social inclusion had taken place and good progress was being made in Scotland on challenging stigma around mental ill-health. Although the structures within which care and support were provided had changed for many, the language of the various professional silos and the theory that underpinned them frequently remained the same.
Conclusions and implications
The picture that emerged from this study was one of a group of people who struggled daily with the realities of living with co-morbid mental health and substance misuse problems and for whom existing support services were often inappropriate, inadequate and which could further undermine their already fragile self esteem and coping strategies. In other cases there was a lack of awareness of available services. The lives of service users were characterised by a series of loss: loss of a routine life, loss of social networks, including loss of friends and family, loss or inability to obtain employment and loss of financial security. Service users were generally considered by providers to lead 'chaotic' lives with a multiplicity of problems jostling for attention.
Services for co-morbidity were varied in number and quality across the different research localities. With notable exceptions, the care that services provided was unsatisfactory and inadequate. Exceptionally, key individuals established a therapeutic relationship with service users within a holistic framework, regardless of the primary 'diagnosis' or 'diagnoses'. This applied to both statutory and non-statutory service provision.
There were examples of good practice. However, the themes identified were lack of awareness of available help, lack of clarity about pathways for help, and a lack of ongoing support. How professional roles and responsibilities within a particular socio-cultural context impinged on responses to the co-morbid client were still poorly understood, as were the reasons, causes, consequences and evidence-based treatment interventions for this group. What was clear was that there were considerable training needs across all professional groups and agencies.
Training, information and awareness raising was required for service users, carers, service providers, commissioners and the general public to contribute to a greater understanding of co-morbidity issues and to engender attitude change.
Commissioners and service providers agreed unanimously that specialist staff should be based within mainstream mental health and/or substance misuse services and not necessarily reside in stand-alone specialist co-morbidity teams. The demand was for specialist mental health and substance misuse competencies provided by a number of practitioners and greater general awareness for all staff working in these services.
The human and economic cost to people with substance problems and mental health difficulties, to the wider community and to health and social services is difficult to quantify. A planned prioritised response, however, can augment clinical, service, training and research agenda.
Please refer to the full report, Co-morbid Mental Health and Substance Misuse in Scotland, for a list of recommendations arising from this research project.