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“2020health is an important and thoughtful contributor to the health debate”

Dr Sarah Wollaston MP, Chairman, Health Select Committee


Dual Diagnosis with David Burrowes MP

Dec 08. till Nov 24.

2020health Expert Roundtable on Dual Diagnosis with David Burrowes MP

Roundtable on Dual diagnosis: Mental Illness associated with Drug and Alcohol addiction

December 8, 20102010-12-08T12:30:00 - November 24, 2010 2010-11-24T07:30:00
12:30 PM 2010-12-08T12:30:00 - 7:30 PM 2010-11-24T07:30:00
Westminster, London

Challenges and Opportunities


Scale of the problem
70% of young people entering mental health services have a drug or alcohol problem. Those patients in mental health services may not be using levels of the drug which would normally be deemed problematic, but due to their mental health issues a small amount of the drug can have a significant impact.

Different populations
There are two agendas in dual diagnosis services; as well as those in the mental health services with drug and alcohol problems, there are those in the drug services (the bigger population) who need their mental health issues addressing, although their problems are not yet severe enough for them to be in secondary care.

Those with personality disorders still fall through the gap, even in standard mental health services, as well as dual diagnosis. More support could be provided through payment by results.

To enter the dual diagnosis pathway, need to have a ‘psychotic illness’ – we also need to deal with other types of mental illness. Maybe we should have 2 dual diagnosis tariff streams – one for those with psychotic illness and one for those with other mental health problems.

Quantification of results
How do we measure recovery – it takes a long time for those with dual diagnosis to get to a stage where complete abstinence is possible. Sometimes just a small change can be positive. This will be a problem for Payment by Results.

Resistance to change
People at the top still sometimes think that drug and alcohol problems in mental health patients should only be dealt with by drug and alcohol specialists. Commissioners need mental health experience and an understanding of the real needs.

There is a resistance within secondary care generic teams to developing the necessary skills – people are worried about getting skilled to deal with addiction problems. A further problem is that high-level consultants now leave a lot of the standard patient interaction to other members of their team, not getting involved with looking at how services can be developed.

Problem of funding: people saying “I’m not funded to do that” when confronted with dealing with drug and alcohol issues.

Current reorganisation and need for savings
The current reorganisation of the NHS is distracting staff from more subtle issues, such as identifying the chaotic nature of people’s minds.

The failure to deal with the dual diagnosis problem is actually costing more money as mental health patients where the drug/alcohol aspect is not recognized initially, will stay in the system longer.  The black population are often a group which are not identified as they do not self-refer into the system.

There is a worry about the number of discreet PbR initiatives. However David Burrowes assured us that this will not be a problem and that the way PbR payments are set up will require services to work together. Whilst pilots are deliberately built around discrete programmes, to test efficacy, the final solution will be driven by outcomes and it will be necessary for services to integrate as there won’t be enough money to do things individually.

Funding derived from generic teams could be used to enable all teams to receive ‘compass’-type input in the form of training and supervision, or a trained dual diagnosis therapis within each team.

There is very little undergraduate and pre-registration training in this area. There is a worry that cuts in staff will stop available further training being taken up, as trusts are disallowing any training other than that which is mandatory. Protection and development is needed of specialist dual diagnosis roles.

It may be possible to force staff to receive the necessary training through commissioning, by only commissioning services if staff have been trained in dual diagnosis.

What to treat first
‘Compass’ aim to break down the barriers of ‘what to treat first’, and other barriers for example, within the crisis team of being unable to assess a patient who is under the influence of drugs or alcohol. An assessment can be made in any state, and then reviewed later.

Safe sanctuary
There is a need for a ‘safe sanctuary’ for these people – affordable residential day-care settings. Beds have been reduced so that those left are always in use. This means these are not available as a safe area for dual diagnosis patients.

Community budgets may allow local teams to work together better. Compass are now working with Birmingham prison and local Drug and Alcohol teams, although would like to work more with other organisations. They act as a bridge between services, keeping people involved in the service

Areas of Good Practice


PROGRESS nurses are sharing best practice, general membership of this group is open via LinkedIn.

Some LAs (for example Greenwich) are merging DAAT and mental health commissioning into one commissioning team.

The Compass programme in Birmingham, is providing training in dual diagnosis to all mental health and substance misuse staff at Birmingham and Solihull Mental Health Trust to enable them to provide integrated treatment for dual diagnosis. Dual diagnosis should be seen as everybody’s responsibility and everyone who comes into the trust with alcohol, drug or mental health problems should have a comprehensive assessment of their needs so that they can be supported appropriately.

The dual diagnosis policy is geared towards training.
Level 1 training is mandatory for all staff
Level 2 covers more comprehensive assessments and brief interventions
Level 3 covers more in depth interventions, trying to establish goals for the patient

In Enfield, 2 weeks ago, a ‘Good Samaritan network’ was established, which amongst other things, enables the community to champion recovery. There will be an awards ceremony for ‘recovery champions’. The network highlights gaps in provision locally and aims to provide solutions.

There are good examples of where services have worked in the independent sector, giving patients the motivation to think about their drug problems, and then take motivated patients out to a new area, so that they are not contaminated by the chaotic group.


  • The expectation and ambition for recovery needs to be much greater.
  • The scale of the NHS reforms mean that funding streams are changing; there is little space to work out how to improve care – in fact some existing teams will disappear.
  • We may be able to force the necessary training through commissioning, by only commissioning services if staff have been trained in dual diagnosis. GPs need to be made aware of this – and we already know they lack confidence about commissioning mental health.
  • There will be a Mental Health tariff but it has to cover complexities – some think therefore this will need to be commissioned by NHS Commissioning Board.
  • Health and Wellbeing boards should be a key driver of integration.
  • The government needs to give a strong message about what needs to happen. This message, together with local budgets can then drive projects at a local level.



This event has now passed. For future events please see upcoming events.

Please note that this is an invitation only event, 2020health always retains the right to refuse admittance.