For a person with co-occurring conditions, the “which came first” debate is irrelevant
With Integrated Care Systems recently gaining a legal footing, local Combatting Drugs Partnership forming and the Department of Health and Social Care developing a new mental health and wellbeing plan, could the time be right to examine the perennial challenge presented by co-existing mental illness and substance misuse and what we can do about it?
This blog draws on Collective Voice’s response to the recent Department of Health and Social Care (DHSC) consultation on mental health and wellbeing.
A well-recognised challenge
Co-occurring mental health and drug and alcohol conditions, or “dual diagnosis”, are a well-recognised challenge that continues to undermine our health and care system’s ability to help some of the most vulnerable people in society. The close relationship between drugs/alcohol and mental health needs no labouring for anyone struggling with them, their families or practitioners working to help them. Twenty years ago clear evidence was noted in the British Journal of Psychiatry, with the Department of Health describing it as “one of the biggest challenges facing frontline mental health services”.
“Which came first?”
The way that co-occurring mental ill health and substance misuse manifest can be complex. A psychiatric illness could precipitate drug or alcohol use as a way to cope, but substance misuse or dependence could also lead to psychological distress or illness, or at least to exacerbate it.
Attempting to disentangle this relationship will be almost impossible. For that person, the “which came first” debate is irrelevant, and it will make very little sense to treat them differently, through different systems.
Stigma and capacity
Some of the problems around co-occurring conditions are structural, for example mental health services having specific illness and risk-related acceptance criteria, or differing commissioning cultures inadvertently embedding public service responses into unhelpful siloes. But other challenges speak of a broader system malaise around responsibility for providing care for the most marginalised. A deep societal stigma has underpinned the lack of attention and funding. When investment has arrived it’s been time-limited and politically vulnerable. The effects of this have left services lacking capacity and confidence to provide the trauma-informed care necessary to deal with a person’s full range of circumstances, rather than focussing on risk management and treating illness.
Green shoots for treatment and recovery?
Sadly, many of the challenges identified by the DHSC twenty years ago remain. However, last year’s Drug Strategy and funding have begun to right the wrongs of the recent past, with political interest and investment climbing to highest levels in a decade. Add the drive to integrate health and social care embodied in Integrated Care Systems (ICS) and an increased focus on health inequalities and could we perhaps have the makings of the fertile environment needed for getting to grips with this issue?
So where are the green shoots?
Well, the Drug Strategy recognises a lack of focus by NHS and mental health services on people with co-occurring conditions and the paucity of links with substance misuse treatment, and promises that government will work with the NHS to improve pathways into care, integration of services and workforce skills.
Another of the Strategy’s commitments (and Dame Carol Black recommendation) is the workforce development transformation programme currently led by the Office of Health Improvement and Disparities and Health Education England, with a national workforce strategy developed by the latter at its heart. This ‘stocktake’ process is a welcome sign of the maturation of our field and provide a vital snapshot of what has historically been a varied and changing workforce. It must recognise the multi-disciplinary teams and full range of skills needed by services to support people with complex needs.
The wider canvas of health policy is focused on two things which could offer opportunity: health inequalities and integration. The Core20PLUS5 approach is focused on reducing inequalities in the most deprived 20% of the population and picks out both “drug and alcohol dependence” and “people with multi-morbidities” as target groups. ICSs could unlock better integration between treatment and recovery services with community mental health and acute health services. They also have a statutory duty to reduce health inequalities and with a focus on place could harness the power of community building to reach people struggling with co-existing conditions.
As ever much of the good work is done close to the ground and dependent on strong relationship building – see examples here from Leeds and Hull. The Making Every Adult Matter coalition has recently produced a set of recommendations on this issue, focussing on accountability, commissioning and local partnerships, including the suggestion that ICSs actually recognise co-occurring conditions as a health inequality.
The opportunity for change is real, and that change is now an imperative. Last year, Mind found a significant worsening of mental health because of Covid-19 among people already struggling, with young people particularly affected. Concerns for the nation’s mental health will only increase in light of the cost of living crisis, with a shocking increase in food poverty and hunger amongst people accessing help for their drug and alcohol use already noted. As the country continues its recovery from the effects of the pandemic while dealing with the rising tide of economic crisis, services that support people with co-occurring conditions will be more necessary than ever.
Read our submission The Advisory Council on the Misuse of Drugs (ACMD) has issued a call for evidence around drug use in ethnic minority groups.
National Audit Office report highlights need to build upon the Drug Strategy and develop a long term, funded plan for full delivery.
Read the report “The government will only achieve value for money if it builds on the initial momentum of the new strategy and develops a