Document name:
Clinical Management of Service
Users with Dual Diagnosis (mental
health and substance use)
Document type:
Policy
Staff group to whom it
applies:
All staff within the Trust
Distribution:
The whole of the Trust
How to access:
Intranet
Issue date:
October 2012
Next review:
October 2015
Approved by:
Trust Board
Developed by:
Director leads:
The Dual Diagnosis and Substance
Misuse Advisory Group a sub group
of the Drug and Therapeutics sub
Committee
Tim Breedon
Contact for advice:
Integrated Governance Manager
1
SOUTH WEST YORKSHIRE PARTNERSHIP FOUNDATION NHS TRUST
Policy for the Clinical Management of Service Users with Dual Diagnosis
1
Introduction
1.1
Provision of good quality services for people with a dual diagnosis (coexisting mental health and substance misuse disorders) should be central to
modern mental health care (University of Manchester 2006). Evidence
indicates that 30-50% of people in contact with mental health services have
co-existing substance misuse problems and in some clinical areas the
prevalence is much higher. Around 75% of people in contact with drug and
alcohol services have co-existing mental health problems ( Weaver et al
2002, Strathdee 2002) and there is an increasing emphasis on incorporating
assessment and treatment of mental health problems into substance misuse
treatment (DH et al 2007). Addressing dual diagnosis, however, presents
significant challenges to service providers (DH 2004). Mental health services
locally are developing on an integrated basis; in partnership with the four
local authorities. All references within the policy to trust services and staff
imply involvement of local authority staff and services.
1.2
Although the term ‘dual diagnosis’ has been widely adopted it has been
criticised as it implies just two diagnoses whereas people may have multiple
diagnoses and a range of associated physical, psychological and social
needs.
1.3
People with a dual diagnosis have often found it difficult to access treatment
due to the separation of mental health and substance misuse services and
their differing care/treatment philosophies. Furthermore, the range and
complexity of needs often experienced eg housing, physical health,
financial, frequently requires multiple service providers to collaborate if
comprehensive care is to be provided.
1.4
To date, dual diagnosis developments, nationally and locally, have largely
focussed on adults of working age. Dual diagnosis is, however, an issue
which crosses the life span.
1.5
DH (2002) guidance advocates an integrated approach to service provision
whereby both mental health and substance misuse problems are addressed
at the same time, in one setting, by one team. The DH guidance sets out a
broad framework for identifying which services are likely to be best placed to
meet the needs of different groups of service users. Each local area is
required to build upon this framework, to comply with NICE guidance (2010,
2011a, 2011b), and ensure that care pathways are in place to facilitate
transitions between services.
1.6
As well as the risk which dual diagnosis service users have of falling
between services, when they are in treatment, the co-existing problem is
often not detected or overlooked (eg Noordsy 2003, Barnby et al 2003).
This can result in misdiagnosis and inappropriate treatment (Carey and
Page 2
Correia 1998). In substance misuse services lack of attention to mental
health issues can adversely affect treatment outcomes and retention in
services (DH et al 2007).
1.7
More specific risks associated with co-morbidity of mental and substance
misuse disorders include: violence; self-harm; suicide; self-neglect; abuse
and exploitation; accidental injury; unstable accommodation/homelessness;
a range of physical health problems including hepatitis B and C and HIV;
poor compliance with medication; worsening of psychiatric symptoms;
increased use of institutional services; poorer social outcomes, contact with
the criminal justice system, disengagement from services and social
exclusion (see for example Banerjee et al 2002, DH 2002, University of
Manchester 2006, DH et al 2007).
1.8
People with a dual diagnosis may be particularly vulnerable to being socially
excluded as they face the double impact of mental illness and problematic
substance use.
1.9
The risks associated with dual diagnosis are likely to have a significant
impact on the carers/family and children of services users. Addressing the
needs of these groups should also be a priority for services. The welfare of
children is paramount and this policy should be read in conjunction with the
policy and procedures on the protection, safeguarding and promoting the
welfare of children.
1.10
The evidence base regarding which treatment models and interventions are
most effective when working with this group is limited (Cleary et al 2008),
however, research and national guidance provide some indicators of the
required components (eg Drake et al 2001, DH 2002). These include taking
an approach which is comprehensive, assertive, staged (linking
interventions to the person’s readiness to change), and focused on
motivation and long term goals.
1.11
To equip staff to work effectively with this group national guidance has
consistently identified the need for staff training (eg for mental health staffHAS 2001, DH 2002, NIMHE 2003, DH 2004, DH 2006a, DH 2006b, NICE
2010, 2011a, 2011b, University of Manchester 2006 eg for substance
misuse staff – HAS 2001, DH 2006c, DH 2006d, DH et al 2007. Training
should be available to all staff (qualified and unqualified) and at basic and
advanced levels, according to need. All staff in this service area need to be
aware of Local Authority policies and developments within social care eg
Direct Payments and Personalisation.
1.12
The Dual Diagnosis Capability Framework (Hughes 2006) identifies
capabilities for working with this group at three levels (1 ‘core’, 2 ‘generalist’,
3 ‘specialist) and provides a framework against which training can be
mapped. The capabilities are matched against the Ten Essential Shared
Capabilities, Knowledge and Skills Framework, Drug and Alcohol National
Occupational Standards and Mental Health National Occupational
Standards. Clinical staff working in mental health services should have level
Page 3
2 capabilities. Those in dual diagnosis specialist roles would be expected to
operate at level 3.
1.13
Guidance highlights the need for training to be followed up with practice
development and supervision as training in isolation will have limited
benefits.
1.14
The template below, derived from Department of Health (2002) guidance,
outlines which service providers are generally best placed to lead care and
treatment delivery for different groups so that care is delivered in line with
the integrated model. The diagram below sets out a more detailed
framework to inform local care pathway development.
severe
Substance misuse lead care delivery
Advice/support from mental
health/dual diagnosis team(s)
Mental health lead care delivery
Advice/support from substance
misuse/dual diagnosis
team(s)
Mild
severe
severity of mental illness
Primary care provide care/treatment
Advice/support from mental health
and/or substance misuse
and/or dual diagnosis
team(s)
Mental health lead care delivery
Advice/support from substance
misuse/dual diagnosis
team(s)
mild
severity of substance use
Page 4
2
Purpose of Policy
2.1
This policy identifies the Trust’s expectations regarding the management of
people with a dual diagnosis – co-morbid mental health and substance
misuse problems. More specifically it sets out requirements for minimising
the range of risks which can be associated with this group.
2.2
This policy should be read in conjunction with the Practical guidance on the
management of illicit substances for the South West Yorkshire Partnership
NHS Foundation Trust which deals with specific issues associated with
minimising the use of drugs and alcohol on Trust premises and managing the
situation when this does occur.
2.3
Other Trust policies and guidance which should be read in conjunction with
this policy are:
Medicines Code
Controlled drug procedures
Patient and Public Involvement Policy
Medicines Management Strategy
Physical Healthcare Policy
Adult Abuse Protection Policies
Framework for the Management of Illicit Substances on Inpatient Wards
Confidentiality Policy
Care programme approach policy and procedures
Policy and procedures on the protection, safeguarding and promoting the
welfare of the children
The Maudsley Prescribing Guidelines are also a valuable resource,
providing information on clinical assessment of substance use, setting out
good practice in relation to implementing pharmacological interventions, and
highlighting potential interactions between prescribed and nonprescribed/illicit drugs and alcohol.
3
Development of policy
3.1
This policy builds on work which has been developing in Wakefield to meet
clinical need and national guidance and the developing services within
Calderdale, Kirklees and Barnsley.
4
Scope
4.1
This policy relates to all clinical services including Adults of Working Age,
People with a Learning Disability, Older Peoples Services and Forensic
4.2
Dual diagnosis is defined as the co-existence of mental health and
substance misuse problems. This broad definition is intended to be
inclusive so that the needs of the wide range of people with co-existing
conditions coming into contact with the Trust are considered regardless of
the severity of their mental illness (including personality disorder) and/or
their substance misuse problem. Beneath this broad heading specific
Page 5
definitions are in place across the areas of Wakefield, Calderdale, Kirklees
and Barnsley.
Page 6
5
Duties
5.1
The policy will be signed off by the Executive Management Team of South
West Yorkshire Partnership Foundation NHS Trust.
5.2
The Adults of Working Age Service Line of the Business Delivery Unit is
responsible for overseeing implementation and monitoring of the policy as it
relates to our own area and work with partner agencies.
5.3
Within the Dual Diagnosis Service Meeting (Wakefield), Dual Diagnosis
Implementation Group (Kirklees), Calderdale meeting and Barnsley Dual
Diagnosis meeting the dual diagnosis leads are responsible for supporting
implementation and monitoring.
5.4
The Dual Diagnosis and Substance Misuse Advisory Group is responsible
for reviewing and updating the policy every three years; supporting area
dual diagnosis leads and strategic groups in developing local strategies,
implementation plans and monitoring processes.
5.5
Team managers are responsible for implementation of the policy within their
services.
5.6
Team managers are responsible for ensuring their staff have attained dual
diagnosis competencies at the appropriate level for their role.
5.7
The training department is supportive of this arrangement providing the
necessary infrastructure within the areas of Wakefield, Kirklees, Calderdale
and Barnsley; local groups exist to facilitate and coordinate the delivery of
relevant training.
5.8
All clinical staff are responsible for being familiar with the policy and
associated policies and complying with them.
6
Addressing the needs of service users with a dual diagnosis
6.1
For the Trust to deliver high quality clinical care to people with a dual
diagnosis, the needs of this group should be considered in the development
of all clinical work streams.
6.2
People with a ‘dual diagnosis’ often experience a range of complex needs
associated with their mental health and substance misuse eg physical
health, financial, housing, childcare, criminal justice. To provide effective
care and treatment it is essential to work collaboratively with service users
themselves; their carers, family and friends; and partner agencies.
6.3
In line with DH (2002) guidance the Trust supports delivery of an integrated
treatment model whereby service users have both their mental health and
substance misuse needs addressed at the same time. As commissioning
priorities and service configurations are different in each PCT area they will
need to develop plans with the Trust for delivering services within this
Page 7
model. The districts of Kirklees, Calderdale, Wakefield and Barnsley have
developed their own unique arrangements as follows: Kirklees has
developed a service which includes a part time Consultant Psychiatrist and
Advanced Practitioner who provide an integrated response, providing a
comprehensive mental health and substance misuse problems and
appropriate initiation of evidence based treatment plans. They engage
individuals with mental health problems into substance misuse services by
collaborative working with Lifeline and support those individuals in Lifeline
access to appropriate mental health services. Wakefield has developed the
Wakefield Integrated Substance Misuse Service (WISMS). The model is
delivered by Turning Point, Spectrum and South West Yorkshire Partnership
Foundation Trust (SWYPFT) with Dual Diagnosis Practitioners supported by
the Nurse Consultant ensuring an effective evidenced based approach.
Calderdale shares the part time Consultant Psychiatrist with Kirklees who
works closely with Calderdale Substance Misuse Service and wider mental
health services across SWYPFT. In Barnsley there is a part time Advanced
Practitioner role supporting developments within the wider mental health
services and a specialist assessment clinic for dual diagnosis takes place
within the Barnsley substance misuse services; which are provided in
collaboration between SWYPFT and Phoenix Futures. The commissioned
Barnsley Substance Misuse Service is led by a Consultant in Substance
Misuse.
7
Internal and external joint working arrangements
7.1
To ensure effective communication within and between SWYPFT each area
(Wakefield, Calderdale, Kirklees and Barnsley) should have a strategic dual
diagnosis group which includes stakeholders from partner agencies and
service user representation. In Kirklees it is called the Kirklees Dual
Diagnosis Steering Group; Wakefield has the Dual Diagnosis Service
Meeting and Dialogue Groups and Calderdale has the Dual Diagnosis
Steering Group and Barnsley has the Dual Diagnosis Steering Group. It
oversees the operation of any dual diagnosis team, and details of training
provision and arrangements for assessing service users’ experiences of
service provision. Strategies must be reviewed every three years. All
strategies and their associated documentation should be available on the
Trust intranet.
7.2
The dual diagnosis leads will support implementation and monitoring of their
local strategies. S/he should be able to influence strategically within the
locality, have good relationships with key stakeholders within and outside
the Trust, and, ideally, working towards capabilities at level 3 in the dual
diagnosis capability framework.
7.3.1.1 The strategic dual diagnosis group will be responsible for the development
of the local strategy, guide future developments in line with national policy
and standards, and monitor and review progress against this policy and
the local strategy.
Page 8
7.4 Governance Structure
Drug and Therapeutics Sub-Committee
Dual Diagnosis and Substance Misuse
Advisory Group
Local Dual Diagnosis Strategy groups
Barnsley
Calderdale
Kirklees
Wakefield
7.4
On occasions there will be differences of opinion regarding which service(s)
is best placed to lead the care delivery of an individual and/or the
appropriate contribution of specific services to the care package. If, following
initial discussion between staff directly involved in a particular case,
differences of opinion are not resolved, a multi-professional meeting should
be arranged. The dual diagnosis leads are well placed to convene this. The
meeting should include the individuals GP, staff directly involved with the
case, the team managers and consultant psychiatrists of the relevant teams,
a social care perspective, as well as any dual diagnosis
practitioner/champion involved. The consensus view should be documented
and reviewed through the care programme approach.
7.5
The dual diagnosis leads in each area should systematically collate
information regarding these challenging cases. This information might
include teams/individuals involved, diagnosis, type and severity of
substance use, service gaps. Cases should be reviewed over the previous
six months involving the Psychiatrists in Substance Misuse, Nurse
Consultant and Advanced Practitioners within the AWA Service Line of the
Business Delivery Units so that common themes can be identified, areas of
unmet need highlighted and pathways adapted with recommendations to the
strategic dual diagnosis groups. It will remain a regular item for discussion at
the Dual Diagnosis and Substance Misuse Advisory Group; a sub group of
the Drug and Therapeutics Sub Committee.
7.6
When a referral is received into mental health services, requesting an
assessment of a service user who has mental health needs and is using
alcohol or drugs, an appropriate assessment will be offered. The decision
NOT to provide care for an individual can only be made following an
assessment. In line with CPA policy and guidance (DH 2008), when a
mental health team is not going to provide care within the CPA framework
Page 9
for someone with a dual diagnosis a rationale for this decision will be
documented within the healthcare record.
7.7
Some people with a dual diagnosis have short periods of contact with
services but tend not to maintain this despite having needs and being
potentially at risk of self-harm, self-neglect, physical health problems,
accidents, suicide and violence to others. They are often people with mild to
moderate mental health problems who do not meet criteria for secondary
mental health care and are unwilling or unable to access substance misuse
services. Services need to work together to consider the needs of each
individual, ensure that risk is carefully assessed, information shared
(including with the person’s GP) and a flexible and timely response taken
when risk escalates or there are opportunities for engagement.
7.8
Regardless of local commissioning and service configurations the Trust
expects adherence to the standards set out in the following sections which
are recognised as core components of good quality care for people with a
dual diagnosis and essential for identifying and managing risk.
Page 10
8
Assessment

Assessment of current and recent substance use should be an integral
component of mental health assessment (for inpatient wards this should be
conducted on admission, or, if this is not possible due to the disturbed
mental state of the person, as soon after as is feasible) (DH 2002, 2006,
2008, AIMS.). If the person does not use any drugs or alcohol this should
also be recorded. This is now recorded on RiO as a part of the
comprehensive assessment.

Risk assessment must identify the risks associated with mental health,
substance use and the interaction of the two, and include risks posed to
service users, their family and carers, children, staff (both on Trust premises
and in users homes) and others in the wider community. Risk assessment
should therefore include determining the potential impact of different types
of substance on violence, self harm, suicide, self-neglect, abuse and
exploitation, and accidental injury as well as risks specifically associated
with substance use such as withdrawal seizures, delirium tremens,
dangerous injecting practices, blood borne viruses, accidental overdose.
The potential risks associated with the interaction of prescribed medication
and non-prescribed, and/or illicit drugs, and/or alcohol, should be
considered. The risk to children with whom the service user is in contact
must also be assessed (Hidden Harm, 2003,).

Where initial assessment indicates present or past substance use a
substance use history should be taken. The drug and alcohol history
section on Sainsbury Risk Assessment outlines the main components of
such an assessment.

The impact of substance use on other assessment domains eg
relationships, accommodation, education/employment, finances, forensic
should be considered and, where relevant, documented.

Substance use, and the lifestyle which may be associated with it, can have a
significant impact on physical health (including sexual health). This should
be assessed and documented and the appropriate physical investigations
conducted eg liver function tests, hepatitis B and C testing and HIV where
commissioned.

The person’s reasons for, and perceptions of, use and motivation for change
should be assessed. This will inform subsequent interventions.

As well as service users themselves, carers, families and other service
providers involved in the person’s care should be invited to contribute to the
assessment process.

When a formal diagnosis of mental or behavioural disorder due to
substances has been made, in line with ICD10 criteria, this should be
recorded.
Page 11
8.1.1
Care planning and treatment intervention

Care planning must be a collaborative process with the service user and
where appropriate, his/her carers.

All service users with problematic substance use must have a care plan(s)
which addresses substance use. This may include one or more of the
following: risk management plan, mental health care plan, physical health
care plan, CPA plan, and crisis plan.

Service users must be offered a copy of their care plan(s).

In accordance with our workforce strategy we are working towards all
practitioners delivering treatment interventions matched to the individual’s
stage of change in line with the cycle of change (Prochaska and DiClemente
1986) and the four staged treatment model (Osher and Kofoed 1989)

While abstinence from substances would usually be the preferred goal for
people with mental health problems many will be unwilling or unable to
attain this. An approach based on engagement, harm reduction (to the
person themselves, those with whom they have contact, and the wider
community) and motivational enhancement is therefore an appropriate initial
goal (DH 2002, 2006).

A key component of harm reduction is health education. All clinical staff
should be able to offer access to health education on the potential impact of
substances on physical and mental health (Hughes 2006) in line with best
practice guidance (eg NICE 2007, Alcohol Effectiveness Review). Each
Trust site should have health promotion information. These should be
offered to service users and carers and could be used as a basis for
discussions during individual work and as a resource in groups.

Where computer terminals are available for the use of service users,
websites which provide information, advice and self-help regarding
substance use should be bookmarked as ‘favourites’ so that they can be
easily accessed.

All mental health services should have information available about local
substance misuse services, what they offer and their referral criteria.

Addiction services either provided by the third sector or by SWYPFT should
have information about local mental health services and how they can be
accessed and should be aware of services provided by Local Authorities
and voluntary and private organisations.

When pharmacological interventions are indicated prescribing must be in
line with best practice guidance (eg Maudsley Prescribing Guidelines, NICE
guidance (NICE 2007 a) b) c)) and Guidelines on the Clinical Management
Page 12
of Drug Dependence (DH England and the devolved administrations 2007)
and the Trust Framework for the Management of Illicit Substances on
Psychiatric Inpatient Wards.

As there are likely to be several agencies involved in care delivery, care
plans must clearly document each person/agencies contribution to the
overall care plan.

For people subject to CPA, substance use must be routinely considered in
CPA reviews.

When service users are being transferred within, or referred on from, Trust
services plans must include provision for continued care/treatment of their
substance use (for those in mental health services) or their mental health
issues (for those in addiction services). When service users have provided
consent, copies of care plans must be forwarded to partner agencies and
carers .We will commit to an audit of this practice

When people with opiate problems are being discharged from inpatient
services they must be informed about the risk of overdose.

When service users are being discharged from inpatient wards a clear plan
must be in place to ensure that a 7 day follow up takes place. It is the
responsibility of the inpatient service to notify the substance misuse service
to ensure prescribing is in place.
8.1.2
Support of carers/families
The families and carers of people with a dual diagnosis can be important
partners in care delivery. They will require information and support to help
them fulfil this role. Even in situations where service users do not consent to
the active involvement of family/carers Trust staffs still have a statutory
responsibility to consider their needs and a carer’s assessment should
always be offered.

Substance use issues should be considered in all carer’s assessments.
Particular attention should be given to the needs of young carers.

Carers should be offered information about the range of carers’ agencies
that can provide them with support (those with a mental health focus and
those with a substance misuse focus). Information resources about these
should be held in each team base.

Carers should be offered information about substances, their effects and
complications, impact on physical and mental health, and potentially
dangerous interactions with prescribed medication.

Carers can be at significant risk of harm from service users with dual
diagnosis problems and should be made aware of who/which services to
contact in case of an emergency.
Page 13

Some carers will have substance use problems of their own. Where
appropriate information about local substance misuse service provision
should be offered.
8.2
Partnership working and information sharing
8.2.1
Underpinning safe and effective care delivery is robust documentation and
information sharing with all partners involved in care/treatment provision.
Given the range of agencies likely to be involved sharing information in a
timely manner is essential.
8.2.2
RIO provides a system that facilitates information sharing across teams in
the Trust including Barnsley BDU from 2013.
8.2.3
It is good practice to obtain written consent before information is disclosed.
Most service users will provide consent if they understand the importance of
information sharing in promoting good care delivery.
8.2.4
Careful consideration of what information is passed on to which
organisations is required. Information is shared on a ‘need to know’ basis.
A minimum requirement would usually be information about the nature of
mental health and substance use problems and an assessment of risk. It is
good practice to discuss with service users what information will be shared
and in what format this will be. Often service users can share in the
preparation of such information.
8.2.5
Some service users pose significant risks to others. Staff have a
responsibility to share such information with other services involved in their
care in line with the Multi agency Information Sharing Policy/Confidentiality
Policy.
8.2.6
In some circumstances it will be necessary to break confidentiality. This
decision should be made by the multi-disciplinary team, including the team
leader and consultant psychiatrist. The rationale for the breach should be
discussed with the Caldicott Guardian who can provide further advice. The
service user should be made aware of actions being taken unless there are
clear reasons for not doing so. The reasons for breaking confidentiality,
and, if the service user is not being informed, the reasons for this, should be
documented. Where children are involved the welfare of the child is
paramount and concerns can be shared without consent if necessary in line
with Safeguarding Children Procedures. Where a person has been
assessed as lacking capacity to make a decision regarding consent to
sharing information, a decision should be made using section 4 of the
Mental Capacity Act to determine if sharing information is in the person’s
best interests. This will include consultation with others who are interested in
the person’s welfare.
Page 14
8.2.7
During treatment (when consent has been given), as a minimum, external
‘agencies’ (including carers) should be invited to CPA meetings and given
copies of care plans. However, it is good practice to maintain regular
dialogue with all parties involved in care delivery. Partner agencies should
always be informed of significant changes in the service users’
circumstances.
9.
Learning from Incidents
9.1
All incidents related to substance use should be reported in line with the
Incident Reporting and Management Policy and Procedures. A record
should be made in the risk event history. The incident reporting system
(DATIX) captures incidents where substance use is a focus and has the
potential to highlight those where substance use has been a contributory
factor to other incidents (eg intoxication with alcohol contributing to
violence).Findings from the reports should be reviewed at least annually.
9.2
Patient safety communications relating to risks associated with substances
(eg contaminated heroin supplies) must be circulated across the whole Trust
via the Chief Pharmacist/Accountable Officer for controlled drugs to the Dual
Diagnosis and Substance Misuse Advisory Group to cascade through
services so that all service users who are using substances and their family
and carers can be alerted. Such information originates from a variety of
sources (eg police, local substance misuse services, Drug and Alcohol
Action Teams). A summary of the information should be posted in waiting
areas and on wards. All staff should pass on details to service users and
carers who may be directly at risk.
9.3
When Serious Untoward Incidents have a substance use component dual
diagnosis leads should be consulted as part of the investigation and review
process to ensure that dual diagnosis perspectives are fully considered as
substance use, particularly alcohol, can be a significant factor in suicides
(With reference to the Investigations Policy).
10
Training
In line with the Trust’s training needs analysis (TNA), any staff members
identified as requiring dual diagnosis training will undertake the e-learning
Dual Diagnosis module as a one off event. It is the individual staff member’s
responsibility supported by their team manager to maintain and update their
skills and knowledge base as appropriate. Trust staff with a specific remit in
their job description will be expected to undertake individual study leave with
an appropriate external provider. This could include modules from Leeds
Addiction Unit. Information regarding further courses can be sought from the
Dual Diagnosis and Substance Misuse Advisory Group. (Contact details for
Wakefield: sean.mcdaid@swyt.nhs.uk; Kirklees: Svyet.finch2@swyt.nhs.uk;
Calderdale: adam.barrett@swyt.nhs.uk; Barnsley: Alison.hill@swyt.nhs.uk )
Page 15
11
Policy standards
Policy Standards
Key:
MH mental health SM substance misuse DD dual diagnosis
Standard
Target
Responsibility
Evidence
Strategic
Calderdale,
Kirklees,
Wakefield
and
Barnsley
Each area to have
100%
AWA Service
Membership list
strategic DD
Line of the
Minutes of
group with
Business
meetings
representation
Delivery Units
from key
stakeholders
Each area to have
100%
AWA Service
Strategy
DD strategy to
Line of the
document
include:
Business
- local care
Delivery Units
pathways
- outline of what
each service
provides
- arrangements
for
accessing
specialist DD
advice
- identification of
local DD lead
- description of
operation of DD
service elements
- details of local
training provision
- arrangements for
assessing
service users
experiences of
service provision
- local action plan
Progress towards
policy targets to
be reviewed
annually
Annual review of
‘difference of
opinion’ cases
100%
100%
AWA Service
Line of the
Business
Delivery Units
AWA Service
Line of the
Business
Process
Minutes of
meetings
Review in
strategic
group
Record of
cases.
Minutes of
Review in
strategic
group
Page 16
Substance use
incident reports to
be reviewed
annually in AWA
Business
Development Unit
and safer
medicines practice
group. Where
controlled drugs
are involved, the
local accountable
officer Lynn
Haygarth will be
involved alongside
the local
intelligence
network
Substance use
incident reports to
be reviewed
annually Trust
wide
Annual review of
SUIs where DD a
factor in
directorates
Annual review of
SUIs where DD a
factor Trust wide
Effective
communication re
drug alerts
Staff attend
training required in
Training Needs
Analysis including
Dual Diagnosis elearning as a one
off event.
Clinical
MH assessments
to include
substance misuse
assessment (MH
services)
Where SM/MH
100%
100%
Delivery Units
AWA Service
Line of the
Business
Delivery Units
meetings
Minutes of
meetings/
reports
AWA Service
Line of the
Business
Delivery Units
Minutes of
meetings/
reports
AWA Service
Line of the
Business
Delivery Units
AWA Service
Line of the
Business
Delivery Units
Lynn Haygarth
D&T TAG
Minutes of
meetings/reports
Review in
appropriate
local
forums
eg police
liaison,
governance
Minutes of
meetings/reports
100%
Team Managers Training dept
collate data
100%
Team manager
Audit of RiO
100%
Team manager
Audit of RiO
Page 17
identified care
plan(s) to be in
place
CPA reviews to
include
consideration of
SM
Partner agencies
invited to CPA and
given copies of
care plan
All Trust sites
have SM health
promotion material
All Trust sites
have information
about local SM
services
Prescribing to be
in line with
Framework for the
Management of
Illicit Substances
on Psychiatric
Inpatient Wards
Risk assessments
to include impact
of SM and risk
management plan
to be in place
When SM
identified SM
history to be taken
Assessment of
reasons for, and
perceptions of,
use and
motivation to
change.
Interventions
offered
appropriate to
service users
readiness to
change
Transfer/discharge
plans include
provision for
ongoing SM/MH
input.
100%
Team leaders
Care
coordinators
Audit of RiO
100%
Care
coordinators
Audit CPA
documentation
100%
Team managers Audit
100%
Team managers Audit
100%
Chief
Pharmacist
check with Lynn
Haygarth
Audit of
prescriptions
Pharmacy
Team managers Audit of RiO
All practitioners
100%
Team leader
RiO
CPA
All practitioners
RiO
CPA
Team managers Audit discharge
care plans
Page 18
Computer
terminals for
service users have
SM self-help sites
as ‘favourites’
Overdose risks
are discussed with
opiate users being
discharged from
inpatient care.
Leaflet available
from pharmacy
department.
Carers needs re
the SM of their
relative/friend are
identified and
acted upon
100%
100%
Audit
DD senior
practitioners
Audit of RiO
Care
RiO
coordinators/key Carers
worker
assessments
Care plans
Page 19
12
Implementation plan
12.1
The policy will be received by Tim Breedon District Service Director as the
sponsor of the policy. It will be added to the policy intranet page and
awareness raised as part of a role out plan.
12.2
General Managers, Heads of Service and dual diagnosis leads will have a
key role in ensuring information about the policy is disseminated widely and
groups and individuals are aware of their responsibilities.
12.3
It is recommended that each team identifies someone with a special interest
in dual diagnosis who can act as a dual diagnosis ’champion’ (DH 2006).
The responsibilities of this person are likely to vary but might include:
maintaining a resource folder, ensuring supplies of leaflets and information
resources are maintained, raising awareness of training, monitoring
substance use incidents, conducting audits.
12.4
Supervision and appraisal processes should be used to ensure that staff are
attaining the competencies required for their roles in line with the capability
framework and KSF.
13
Monitoring compliance/effectiveness
13.1
At Trust level the Business Development Units will review progress in
implementing the policy and will monitor Trust-wide targets set in the policy
standards (above). Links will be made with other work streams where these
can help drive up standards and promote compliance.
13.2.1 Adults of Working Age Business Delivery Units will develop robust systems
within their local governance structures to ensure compliance with policy
standards, including the policy standards above on an annual basis.
We will undertake an audit to ascertain whether service users care plans
have been appropriately shared between agencies.
13.2.2 Dual Diagnosis leads will provide quarterly reports on activity of dual
diagnosis teams to commissioners and to local strategic dual diagnosis
groups.
13.2.3 Supervisors/managers will monitor compliance with training attendance and
development of required staff capabilities in appraisals using the KSF
framework.
13.2.4 Training department will monitor training attendance.
Page 20
14
References
Banerjee, S, Clancy, C and Crome, I (eds) (2002) Co-existing Problems of Mental
Disorder and Substance Misuse (dual diagnosis): An information manual Royal
College of Psychiatrists Research Unit, London
Carey, K B and Correia C J (1998) Severe mental illness and addictions:
assessment considerations. Addictive Behaviours 23 (6): 735-748
Department of Health (1999) National Service Framework for Mental Health.
Department of Health, London
Department of Health (2001) Safety First: Five Year Report of the National
Confidential Inquiry into Suicide and Homicide by People with Mental
Illness, London
Department of Health (2002) National Suicide Prevention Strategy for England,
DH, London
Department of Health (2002) Mental Health Policy Implementation Guide: Dual
Diagnosis Good Practice Guide DH, London
Department of Health/NTA (2002) Models of Care for Adult Drug Treatment. NTA,
London
Department of Health (2004) The National Service Framework – Five years On DH,
London
Department of Health (2004) The NHS Knowledge and Skills Framework and the
Development Review Process DH, London
Department of Health (2004) Standards for Better Health DH, London
Department of Health (2006) From Values to Action: The Chief Nursing Officer’s
review of mental health nursing DH, London
Department of Health (2006) Best Practice Competencies and Capabilities for Preregistration Mental Health Nurses in England: The Chief Nursing Officer’s Review of
Mental Health Nursing Department of Health, London
Department of Health/NTA (2006) Models of Care for Alcohol. DH, London
Department of Health (2006) Dual diagnosis in mental health inpatient and day
hospital settings Guidance on the assessment and management of patients in
mental health inpatient and day hospital settings who have mental ill-health and
substance use problems. London
Department of Health (2006) Essential Shared Capabilities, DH, London.
Available from www.skillsforhealth.org.uk/mentalhealth/esc.php
Page 21
Department of Health (England) and the devolved administrations (2007) Drug
Misuse and Dependence: UK Guidelines on Clinical Management Department of
Health (England) the Scottish Government, Welsh Assembly Government and
Northern Ireland Executive, London
Department of Health (2007) Best Practice in Managing Risk. Principles and
evidence for best practice in the assessment and management of risk to self and
others in mental health services national Mental Health Risk management
programme. London, DH.
Department of Health (2008) Refocusing the CPA: Policy and Positive Practice
Guidance DH, London
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid
ance/DH_083647
Drake, R., Essock, S., Shaner, A. et al. (2001) Implementing dual diagnosis services
for clients with severe mental illness, Psychiatric Services 52: 469–76.
Health Advisory Service (2001) Substance Misuse and Mental Health Co-Morbidity
(Dual Diagnosis) Standards for Mental Health Services. London: HAS
Hughes E (2006) Closing The Gap: A capability framework for working effectively
with combined mental health and substance use problems (dual diagnosis) Centre
for Clinical and Workforce Innovation, University of Lincoln, Mansfield
NICE (2007) TA114 Drug misuse – methadone and buprenorphine
NICE (2007) TA115 Drug misuse – naltrexone
NICE 2010 CG 110 Alcohol use disorder: physical complications
NICE 2011 CG115 Alcohol dependence and harmful alcohol use
NICE 2011 CG120 Psychosis with co-existing substance misuse
Noordsy, D L, McQuade, D V, Mueser, K (2003) Assessment considerations In
Graham, H L, Copello A, Birchwood M J, Mueser, K T (2003) Substance Misuse in
Psychosis: Approaches to Treatment and Service Delivery, Wiley, Chichester
Strathdee, G, Manning, V, Best, D et al (2002) Dual Diagnosis in a Primary Care
Group: A step-by-step epidemiological needs assessment and design of a training
and service response model DH/NTA, London
University of Manchester (2006) Avoidable Deaths: Five year report of the national
confidential inquiry into suicide and homicide by people with mental illness National
Confidential Inquiry into Suicide and Homicide by People with Mental Illness,
Manchester
Weaver, T, Charles, V, Madden P, Renton, A (2002) Co-morbidity of Substance
Misuse and Mental Illness Collaborative Study (COSMIC): A study of the prevalence
Page 22
and management of co-morbidity amongst adult substance misuse and mental
health treatment populations DH/NTA, London
Page 23
Appendix A
Template for policies and procedural documents
Policies and procedural documents should include the following sections:
1. Introduction
2. Purpose and scope of the policy (why is the policy needed and what will it
cover)
3. Duties
- who is responsible for developing and implementing the policy
- who in the organisation is required to do what
- who is responsible for communicating the policy
- who is responsible for consultation with stakeholders
- who is responsible for approving the policy/procedure
4. Equality Impact Assessment
5. Dissemination and implementation arrangements (including training)
6. Process for monitoring compliance and effectiveness – including standards
and key performance indicators
7. Review and revision arrangements (including archiving)
8. References
9. Associated documents
10. Appendices
Page 24
Appendix B - Equality Impact Assessment Tool
To be completed and attached to any policy document when submitted to the Executive Management
Team for consideration and approval.
Equality Impact
Assessment Questions:
Evidence based Answers & Actions:
1
Name of the policy that you
are Equality Impact Assessing
Policy for the clinical management of service users
with dual diagnosis
2
Describe the overall aim of
your policy and context?
The overall aim of the policy is to describe the Trust’s
approach to the delivery of good quality services for
people with a dual diagnosis.
All staff and service users/carers.
Who will benefit from this
policy?
3
Who is the overall lead for this
assessment?
District Director of Wakefield Business Delivery Unit
4
Who else was involved in
conducting this assessment?
Integrated Governance Manager
5
Have you involved and
consulted service users,
carers, and staff in developing
this policy?
During the writing of the original policy there was
extensive service user/carer engagement alongside
commissioners and other local and national experts.
What did you find out and how
have you used this
information?
The policy was seen as a national example of good
practice and has been recently refreshed due to on
going improvements in practice and additional
professionals employed across the trust.
6
What equality data have you
used to inform this equality
impact assessment?
7
What does this data say?
8
Have you considered the
potential for unlawful direct or
indirect discrimination in
relation to this policy?
9
Taking into account the Where Negative impact has been identified please
explain what action you will take to mitigate this.
information gathered.
Does this policy affect one
group less or more favourably If no action is to be taken please explain your
Yes
reasoning.
Page 25
than another on the basis of:
YES
NO
Race
N
Disability
N
Gender
N
Age
N
Sexual Orientation
N
Religion or Belief
N
Transgender
N
10
What measures are you
implementing or already have
in place to ensure that this
policy:
 promotes equality of
opportunity,
 promotes good
relations between
different equality
groups,
 eliminates harassment
and discrimination
This policy aims to standardise the approach to the
care delivered for individuals across the trust to ensure
that all their needs are identified and care planned by
being addressed at the same time, in one setting, by
one team.
11
Have you developed an Action
Plan arising from this
assessment?
N/A
If yes, then please attach any
plans at the back of this
template
12
Who will approve this
Trust Board
assessment and when will you
publish this assessment.
If you have identified a potential discriminatory impact of this policy, please refer it to the Director of
Corporate Development or Head of Involvement and Inclusion together with any suggestions as to the
action required to avoid/reduce this impact.
For advice in respect of answering the above questions, please contact the Director of Corporate
Development or Head of Involvement and Inclusion.
Page 26
Appendix C - Checklist for the Review and Approval of Procedural Document
To be completed and attached to any policy document when submitted to EMT for consideration and
approval.
Title of document being reviewed:
1.
2.
4.
5.
6.
Comments
Title
Is the title clear and unambiguous?
YES
Is it clear whether the document is a guideline,
policy, protocol or standard?
YES
Is it clear in the introduction whether this
document replaces or supersedes a previous
document?
YES
Rationale
Are reasons for development of the document
stated?
3.
Yes/No/
Unsure
YES
Development Process
Is the method described in brief?
YES
Are people involved in the development
identified?
YES
Do you feel a reasonable attempt has been
made to ensure relevant expertise has been
used?
YES
Is there evidence of consultation with
stakeholders and users?
YES
Content
Is the objective of the document clear?
YES
Is the target population clear and
unambiguous?
YES
Are the intended outcomes described?
YES
Are the statements clear and unambiguous?
YES
Evidence Base
Is the type of evidence to support the
document identified explicitly?
YES
Are key references cited?
YES
Are the references cited in full?
YES
Are supporting documents referenced?
YES
Approval
Does the document identify which
committee/group will approve it?
YES
If appropriate have the joint Human
Resources/staff side committee (or equivalent)
N/A
Page 27
Title of document being reviewed:
Yes/No/
Unsure
Comments
approved the document?
7.
8.
9.
10.
11.
Dissemination and Implementation
Is there an outline/plan to identify how this will
be done?
YES
Does the plan include the necessary
training/support to ensure compliance?
YES
Document Control
Does the document identify where it will be
held?
YES
Have archiving arrangements for superseded
documents been addressed?
YES
Process to Monitor Compliance and
Effectiveness
Are there measurable standards or KPIs to
support the monitoring of compliance with and
effectiveness of the document?
YES
Is there a plan to review or audit compliance
with the document?
YES
Review Date
Is the review date identified?
YES
Is the frequency of review identified? If so is it
acceptable?
YES
Overall Responsibility for the Document
Is it clear who will be responsible
implementation and review of the document?
YES
Page 28
Appendix D - Version Control Sheet
This sheet should provide a history of previous versions of the policy and changes made
Version
Date
Author
Status
Comment / changes
1
October
2008
Sean McDaid
Final
Final version approved by Trust Board
2
August
2010
Sean McDaid, Dr
Fariha Kamal, Syvet
Finch and Ros Dellar
Final
Draft
Changes made to ensure the policy
reflects the changes in service delivery for
Dual Diagnosis across the organisation
3
July
2012
Dual Diagnosis and
Substance Misuse
Advisory Group
4
October
2012
Dual Diagnosis and
Substance Misuse
Advisory Group
Changes to ensure the policy reflects
practice across all of the organisation
including Barnsley
Page 29 of 29