Agenda for Overview & Scrutiny Commission Ad-Hoc Panel on Dual Diagnosis - Completed on Friday, 7th March, 2008, 10.00am
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Agenda and minutes
Venue: Council Chamber, Hove Town Hall. View directions
Contact: Giles Rossington, Senior Scrutiny Officer
7A Declarations of Substitutes
7.1 Substitutes are not permitted on ad-hoc Scrutiny Panels.
7B Declarations of Interest
7.2 There were none.
7C Exclusion of Press and Public
7.3 The Committee considered whether the press and public should be excluded from the meeting during the consideration of any items contained in the agenda, having regard to the nature of the business to be transacted and the nature of the proceedings and the likelihood as to whether, if members of the press and public were present, there would be disclosure to them of confidential or exempt information as defined in Schedule 12A, Part 5A, Section 100A(4) or 100 1 of the Local Government Act 1972 (as amended).
7.4 RESOLVED - That the press and public be not excluded from the meeting.
Minutes of the Previous Meeting
8.1 That the minutes of the meeting held on 29.02.08 be approved.
9.1 The Chairman welcomed the witnesses giving evidence at this meeting.
Evidence from Witnesses: introduction
10.1 Witnesses at this session were: Steve Bulbeck, Head of Single Homelessness and Social Inclusion, Brighton & Hove City Council; David Allerton, Mental Health Placement Officer, Sussex Partnership NHS Trust; Mike Byrne, Manager, The West Pier Project.
Evidence from David Allerton
11.1 Mr Allerton explained to the Panel that he is a Mental Health Placement Officer, employed by the Sussex Partnership NHS Trust, but based at Bartholomew House, so as to be co-located with Brighton & Hove City Council Housing Options officers. Mr Allerton seeks to find appropriate accommodation to people with mental health problems referred from Housing services (either referred by Housing Options or directly from another Housing Officer).
11.2 Panel members were told that there were limited referral options for clients with a Dual Diagnosis (of mental health and substance misuse problems) within the Mental Health Pathway, as only a minority of providers offered accommodation for this client group.
11.3 There is supported housing available for people with a Dual Diagnosis at a relatively low level of support (provided by Brighton Housing Trust), at an intermediate support level (provided via the “Route 1” initiative, also run by Brighton Housing Trust), and at a high level (provided by the West Pier Project). However, places are limited, and some of these services may be restricted to clients who have agreed to abstain from the use of drugs or alcohol.
11.4 Mr Allerton told Panel members that the majority of clients he referred had relatively minor substance misuse issues if any at all. These clients tended to be considerably easier to place in accommodation than people with severe Dual Diagnoses.
11.5 Information on clients referred to the Mental Health Placement Officer was variable, but there was generally enough detail about people’s history of substance use to make an accurate referral. People who had been in the system a long time tended to have very detailed records, but were often rather hard to place (as they might have a history of being unable to cope with certain types of supported living). Clients new to Brighton & Hove services were generally easier to place.
11.6 Clients willing to engage with Mental Health and Substance Misuse services are typically easier to place than those who are more reluctant to engage. Those who tend not to engage are at much greater risk of “falling between the gaps” of the statutory services.
11.7 Mr Allerton told Panel members that more supported housing was required for people with Dual Diagnosis who were unwilling or unable to abstain from substance use. Such housing should probably be on a relatively small scale (with units having no more than five residents), as there could be significant problems associated with housing a number of clients with Dual Diagnosis together. There is a current lack of such accommodation in Brighton & Hove.
11.8 Mr Allerton noted that some clients might require very long term support at high levels, although this depended on the degree to which people engaged with support and treatment, so it was impossible to speak generally. Supported Housing provision was not necessarily formally “stepped”, with clients automatically moved on to a less intensively supported environment once they were deemed to no longer require a high level of support.
11.9 Mr Allerton told Panel members that it was difficult to estimate the gender split of people with Dual Diagnosis without having a precise definition of Dual Diagnosis itself (i.e at what level a co-morbidity of mental health and substance misuse issues would be termed “Dual Diagnosis”). Mr Allerton also noted that he might not be in the best position to make such an estimate in any case, as those clients he encountered would generally have presented as homeless, and it may be the case that there is a gender imbalance in terms of those presenting to homelessness services (with men more likely to present), which would mean that this client group should not be considered as accurately representing the entirety of the group of people with a Dual Diagnosis.
Mike Byrne, of the West Pier Project, told members that, in his experience, the gender split of people with Dual Diagnosis was approximately 80/20 men to women (but again, with no guarantee that the type of client he encountered was typical of people with a Dual Diagnosis).
11.10 Mr Allerton noted that different providers varied in their definitions of abstinence. However, some providers (including Brighton Housing Trust) would not house clients who were prescribed methadone as a heroin substitute.
11.11 In response to members’ queries regarding care assessments, Mr Allerton agreed that assessments and care plans might be better coordinated so that there were fewer assessments for each client. However, there were very significant problems to be faced in any attempt to create a unified assessment, as different services have significantly different needs, even if these needs are not entirely discrete. Thus, mental health services, for obvious reasons, require assessments focused upon clinical matters. Such material may not be useful to or easily understood by other agencies, so it is hard to see how an easily accessible integrated assessment could readily be created.
Evidence from Mike Byrne
12.1 Mr Byrne told the Panel that he was the manager of the West Pier Project, a Brighton & Hove City Council initiative providing 39 supported housing places. 11 places at the Project are reserved for referrals from the Community Mental Health Teams; the other places are referred into from the Council’s Rough Sleeper’s Team.
12.2 Most clients at the West Pier Project have some substance misuse issues (often featuring a combination of substances). Clients also frequently have underlying mental health problems, although these may be undiagnosed when they are referred to the project.
12.3 The West Pier Project does not require residents to be abstinent: it could not effectively engage with its clients if abstinence was required. Residents are required to minimise the risk to themselves and others when they do take substances, by, for instance, being open about their intravenous use of drugs (so that safe disposal of used needles can be arranged). Residents are not permitted to use in communal areas within the Project, nor may they use in the immediate vicinity of the Project.
12.4 Mr Byrne told Panel Members that any expansion of the West Pier Project within its current premises was unlikely to be feasible, as the Project is based in converted nineteenth century housing that already poses some major problems which would only be exacerbated by enlargement. (Problems include an inability to cater for people with serious mobility issues as the current premises cannot be adapted. Also, the layout of the current accommodation makes surveillance very difficult.)
12.5 Mr Byrne told the Panel that the location of a service such as the West Pier Project was not necessarily vital, but what was very important was ensuring that the service was responsible to the local community, minimising the disruption that residents with often very challenging behaviours could cause. The West Pier Project had been very effective in this area.
12.6 There is no absolute optimum size for such a service as clients vary greatly in terms of the kind of environment they thrive in. Some residents respond positively to a busy environment; others would find this overwhelming and are better suited to much smaller services. Therefore the city needs a range of projects to best cater for all service users.
12.7 Places at the West Pier Project funded by Supporting People grants are limited to two year’s duration. Mental Health placements are not similarly restricted, but a maximum of two years stay is probably the optimum in most instances. However, some clients do stay longer when it is in their best interest to do so.
12.8 Many residents of the Project are evicted rather than leaving voluntarily. This is inevitable given the problems which the majority of clients have, and is not necessarily indicative of a failure in any part of the system. Evicted clients are always made aware of their other housing options, and the Community Mental Health Teams are alerted to the potential eviction of clients whom they are supporting well in advance of any actual eviction.
12.9 Mr Byrne told Panel members that he thought care plans were usually reasonably effective, with good co-working between healthcare providers, substance misuse services and the criminal justice system. If a care plan was inadequate, this was usually readily apparent at an early stage.
12.10Mr Byrne informed the Panel that working with 11 Dual Diagnosis residents at any one time (the number referred into the West Pier Project by Community Mental Health Teams) could be very challenging, but that this depended to a great degree on the individual circumstances of the residents, since some clients required far more attention than others. For instance, clients with alcohol misuse issues could be particularly challenging (particularly if a number of residents had drink problems). Clients who refused to take their medication (for mental health problems) could also pose particular difficulties.
In certain instances, the West Pier Project might decline a referral if that referral was likely to lead to an unsustainable client-mix or to exacerbate a current problem. However, this would depend on the mix of other residents; there were no particular conditions which would lead the Project to reject any potential client without reference to the stability of the Project as a whole.
Evidence from Steve Bulbeck
13.1 Mr Bulbeck informed the Panel that he is the Council’s strategic lead officer in terms of dealing with the problem of single homelessness and in co-ordinating the various non-statutory services operating in Brighton & Hove. He also oversees some of Brighton & Hove City Council’s supported housing services.
13.2 The Council is committed to taking a preventative approach to homelessness. There is a Vulnerable Adults team which operates out of Housing Options where it can link effectively with the Mental Health Placement Officer. Since April 2007 the team has worked with 239 people deemed to be vulnerable due to mental health problems and/or drugs or alcohol issues. In around 80% of cases, homelessness has been avoided, either by enabling clients to maintain their current tenancy or by helping them to find a new tenancy.
13.3 The Council has also tried to minimise the use of inappropriate “Bed & Breakfast” accommodation for housing clients with mental health and/or substance misuse problems. This has included procuring private sector rental accommodation which has been offered as a resource to mental health services so that they have less need to refer into the general private rental sector themselves. Some clients are still placed in inappropriate private sector accommodation, but these are generally people such as failed asylum seekers, with no recourse to public funds to defray housing costs.
13.4 Mr Bulbeck told Panel members that there was a clear need to establish a formal pathway for the “stepping down” of housing support services for people with mental health problems (including Dual Diagnosis clients), so as to ensure that people received an appropriate level of support rather than continuing to receive the level they were first diagnosed as requiring, even if their circumstances have changed for the better.
David Allerton noted that step down of support did happen, but not in a formal way.
13.5 Mr Bulbeck noted that co-working with substance misuse services was not as far advanced as co-working with mental health services. The co-location of the Mental Health Placement Officer with the Housing Options Team had been instrumental in creating an effective partnership.
13.6 In response to questions about care plans and assessments, Mr Bulbeck told the Panel that work on a Single Assessment Process had been ongoing for more than two years. The aim of this process was to combine the assessments of all the statutory services. Mr Bulbeck advised the Panel that it should seek expert advice from someone actively engaged with this process.
13.7 Mr Bulbeck told the Panel that the places at the West Pier Project referred into by the Rough Sleepers’ Team were funded via Supporting People. The Mental Health beds were funded via the Community care budget. All clients at the West Pier Project were also eligible for Housing Benefit.
13.8 Mr Bulbeck noted that recently announced cuts in the Supporting People budget might impact upon city services, particularly as some local providers have had to cope with a number of funding cuts in the past few years, meaning that few of them may have any remaining contingency to draw upon short of actually closing services.
13.9 Mr Bulbeck noted that health services should take the lead on supporting people with a Dual Diagnosis: this is clear from national guidance. However, this does not always happen, and more needs to be done to ensure that all city partners act as they should in dealing with this issue.
14.1 The meeting had to be adjourned at this point due to a fire alarm sounded in the building. There is a meeting arranged for March 28 (at 10am, Hove Town Hall), and members will make arrangements for further meetings in the near future.