paul foreman
TRANSCRIPT
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 – [email protected]
John Currie – [email protected]
Liz Hughes – [email protected]
Charlie Brooker – [email protected]