Paul Foreman www.mindmapinspiration.co.uk

Report Contents

Setting the scene (literature)

Concept Mapping

Data sources & definitions

Patterns of DD in the NW

Population segmentation

Planning and Commissioning in the NW

Survey of providers

Conclusions

Dual Diagnosis – Alcohol & Mental Illness

Definitions & Sources of data

Inpatients

NI39

MHMDS

(admission, CPA, OP,

community services)

NATMS Population

Wellbeing

Lifestyle Survey &

Big Drink Debate

What it

Records:

All hospital

admissions

(NHS treatments)

People with severe and

enduring mental health

People in

treatment for

alcohol related

problems

Sample survey Sample survey

Definitions

Mental

health

ICD-10 Diagnosis –

F codes (primary v secondary)

HoNOS

(worst & best)

Enhanced CPA = more

complex cases

Dual Diagnosis

Psychological

health status

WEMWBS - positive

mental health

EQ-5D

Life satisfaction

& others

Unvalidated

questions on

attitudes to alcohol

& life

Alcohol ICD-10 Diagnosis –

Alc attributable (primary v secondary)

ICD-10 Diagnosis

(if recorded)

Units of alcohol &

drinking days

Harmful

(Higher risk)

Harmful

(Higher risk)

Dual

diagnosis

F10 (& all Alc attributable

with a MH diagnosis)

Diagnosis - F10

HoNOS - Problem

drinking or drug-taking

Dual Diagnosis

Low WEMWBS,

extreme anxiety,

dissatisfied +

Harmful drinking

Statements on

‘low’ esteem +

Harmful drinking

Access?

Why the North West ?

� Rates of admission are consistently 1.3 times higher in

the North West compared with the England average

� Total of 183,000 alcohol-attributable admissions in the

North West, which is 108,000 persons

�Rates in 2009/10 vary by 1.8 times across PCTs in the

region

Dual Diagnosis admissions in the North West, 2009/10

� The total number of admissions for F10 was 39,000 in 2009/10 = 26,000 people

� Rates of F10 admission vary by 3 times across PCTs in the North West

� AND ... the proportion of all alcohol-related admissions that are F10 varies from 15 %

in North Lancs to 32% in Liverpool

Dual Diagnosis admissions by Deprivation

� Both the rate of F10 admissions

and the % of all ARA are strongly

related to average deprivation

� Within PCT inequalities are even

greater – with up to 11 times higher

rates of admission in the most

deprived areas compared with the

most affluent

� Over the region, 6 times more

F10 admissions are from the most

deprived areas

Dual Diagnosis admissions – North West in context

Dual Diagnosis admissions - Population SegmentationBy P2 People and Places ©

Beacon Dodsworth www.beacon-dodsworth.co.uk/

Estimated costs in North West = £61 - £85 million

in England = £261 - £376 million

SMI - Mental Health Minimum Dataset (MHMDS)

� A total of 177,000 persons with severe and enduring mental illness were resident in the

North West in 2009/10

� Around 17% are estimated to have dual diagnosis (ICD-10 of F10) = ~30,000 persons who

had 378,000 contacts with community mental health teams (CPN, psychiatrist, social worker etc)

� Estimated cost of £21 million (PSSRU - Unit Costs of Health and Social Care 2010) ; 1/3 - 1/4 inpatient cost

National Alcohol Treatment monitoring (NATMS)

� A total of 14,500 people in the North West were in alcohol treatment services in

2009/10; 15% (about 2,000 people*) were recorded with a dual diagnosis

� Rates of recorded dual diagnosis varied by over 20 -fold across PCTs ... BUT this

needs to be taken in context with data quality and the amount of missing data

* Assuming that missing records had the same proportion with dual diagnosis as those where it was recorded

Communities at risk – Lifestyle surveys

Males Females

Harmful (higher risk) drinkers*

* Derived from combined Lifestyle Surveys & Big Drink Debate – N = 64,548

� There are 5.5 million people aged 16+ living in the

North West region (mid-2009 population estimates)

� From the above, it is estimated that 241,000 of

these drink at harmful levels

� In the NW, around 25% of these might have below

average wellbeing or drink to forget their problems =

57,000 – 60,000 people

� The inequalities gradient is not as great for harmful

consumption/low wellbeing as for alcohol-related harm

Gap Analysis

The proportion of the estimated population with ‘dual diagnosis’ who

are in contact with various NHS services for PCTs in the North West

Planning and Commissioning

Across the North West patch:

• Warrington

• Manchester

• Lancashire DAAT area

• Cumbria

• Bolton

5 proposed Beacon areas assessed

Commissioning structures

� All five have some form of structure in place to commission

services and initiatives for those with a dual diagnosis

� Some have dual diagnosis prevalence data contained within

their Joint Strategic Needs Assessment

o however none had dual diagnosis as a priority in their

Commissioning Strategy Plan, the high level plan of the PCT

�Sharing of dual diagnosis data between alcohol/substance

misuse commissioners is not happening routinely in all areas

o this may lead to a fracture in understanding between the two

commissioning areas of what the current needs are

Treatment models

� There are a number of models used for the delivery of

treatment in the 5 areas:

� Liaison � Parallel � Integrated

� The liaison model has been lauded as being successful but

there has been no formal evaluation to substantiate this.

o A robust evaluation of this model of intervention is

recommended to share findings with the other Beacon sites

� The joint signing off of service specifications by substance

misuse commissioners and mental health commissioners is not

commonplace

o although joint membership on Partnership boards that

oversee the delivery is more common

Partnership working

�Partnership working is variable

o Partnership arrangements in place between Mental

Health and Substance Misuse services (Manchester)

o Some work under development to improve DD

Partnership working via DD Commissioning Group

(Bolton)

o Protocols in place between Police and Mental Health

Services (Warrington)

o Need more evidence of Partnership working, i.e

protocols, pathways etc

Emergency Departments

� Good coverage of Psychiatric Liaison and Alcohol

Health Workers in Emergency Departments

� These services are largely commissioned

separately and no specific shared targets in

service specifications

� Little evidence of inreach into certain clinics (such as

the gastroenterology and fracture clinics) for picking up low

threshold mental health and alcohol misuse issues

Health/Criminal Justice Interface

�Interface with Criminal Justice is generally good

o Assistant Chief Probation Officer on Joint

Commissioning Group for Substance Misuse

(Bolton)

o Probation staff trained to deliver IBA (Warrington

and Manchester)

o More evidence required of effective interface

between Health and Criminal Justice

Beacons

� Based on a successful pilot in London

� To establish 5 PCT areas in the North West to

be beacons of best practice around the

planning and commissioning of DD

� Improvement/support plans will be an

output of the review with an implementation

champion identified for each area

Service Provider Response

�Two methods of data collection:

o Electronic survey

o Workshop at Stakeholder event

�All services providing mental health or alcohol

treatment

�20 emails with link to survey sent to service leads

�12 responses returned

�Response rate of 60%

Survey

� One large third sector organisation did not take part

so respondents mainly from statutory sector

� Mixed definitions of dual diagnosis- some all

inclusive, some focused on serious mental health only

� Range of services offered but most

comprehensive services offered by NHS

� Training and supervision was mostly offered in

NHS mental health

Issues raised

�Access and barriers to serviceso Some areas had open access; others felt DD was a barrier to

accessing services

�Workforceo In some areas training and supervision was well-established, but in

some places this was lacking.

o Staff values and attitudes seen as important and needed to be tackled

�Organisational sign-upo Having agencies in local area signed up to working with this group

o Agreed pathways and protocols

o Co-location and integration suggested to aid this process and reduce duplication

o Importance of local champions to drive change

�Treatmento Right treatment not always available e.g. lack of suitable service for

detox for someone with mental health and alcohol

Report Recommendations

� Commissioning:

o understanding of the definition of

dual diagnosis

o effective treatment for dual diagnosis

o integrated pathways

� Economics:

o economic reviews and audit of

outcomes

o use of the PBRs for alcohol and

mental health

o tariffs and personal health budget

� Intelligence:

o agree dual diagnosis data-sets and

indicators

o comprehensive JSNA

� Leadership:

o Beacon sites as sub-regional

leaders

� Workforce:

o workforce and training needs

review

o University programmes review

� Criminal Justice:

o examine services for offenders

with alcohol misuse and mental

health problems

� Research:

o develop an NIHR bid

Paul Foreman www.mindmapinspiration.co.uk

Contact:

Karen Tocque – k.tocque@btinternet.com

John Currie – john.currie233@gmail.com

Liz Hughes – elizabeth.hughes@york.ac.uk

Charlie Brooker – cbrooker@lincoln.ac.uk