Agenda for Overview & Scrutiny Commission Ad-Hoc Panel on Dual Diagnosis - Completed on Friday, 25th April, 2008, 10.00am
navigation and tools
You are here - Home : Council and Democracy : Councillors and Committees : Agenda and minutes
Agenda and minutes
Venue: Council Chamber, Hove Town Hall. View directions
Contact: Giles Rossington, Senior Scrutiny Officer
25A Declarations of Substitutes
25.1 Substitutes are not permitted on ad-hoc Scrutiny Panels.
25B Declarations of Interest
25.2 There were none.
25C Exclusion of Press and Public
25.3 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).
25.4 RESOLVED - That the press and public be not excluded from the meeting.
Minutes of the Previous Meeting
26.1 That the minutes of the meeting held on 07.03.08 be approved.
27.1 The Chairman welcomed the witnesses giving evidence at this meeting.
Evidence from Children and Young People's Trust and Sussex Partnership Trust
28.1 Witnesses at this session were: Sally Wadsworth (Commissioning Manager, Child and Adolescent Mental Health Services - CAMHS); Anna Gianfrancesco (ru-ok Service Manager); Maggie Gairdner (Associate Director, Children’s Services and Substance Misuse, Sussex Partnership Trust); Rebecca Hills (Associate Director, Acute Care, Sussex Partnership Trust); Sue Baumgardt (parent of someone with a Dual Diagnosis).
28.2 As a number of witnesses represented services for children and young people, it was decided to take their evidence jointly rather than interviewing each witness sequentially. The evidence provided by Sue Baumgardt was taken separately.
28.3 Evidence from Anna Gianfranceso, Sally Wadsworth, Maggie Gairdner and Rebecca Hills.
28.4 Sally Wadsworth (SW) explained to the Panel that there are two types of Children and Adolescent Mental Health Services (CAMHS) operating in the city: a “Tier 3” service run by Sussex Partnership Trust, and a “Tier 2” service hosted by the Children and Young People’s Trust. There is a good deal of work currently taking place to ensure that these services are effectively integrated.
28.5 SW noted that CAMHS services for clients with a Dual Diagnosis had some historical weaknesses, notably in terms of the provision of effective nursing support for detoxification and for general, rather than mental, health needs. There was also a need to ensure that young people with a Dual Diagnosis were able to access a wide range of CAMHS services, rather than just being treated within the Dual Diagnosis team. SW was able to assure members that work was ongoing in all of these areas.
28.6 In response to a question concerning the environment in which CAMHS services were delivered, Maggie Gairdner (MG) told Panel members that services were provided in a youth-friendly environment by clinicians who specialised in children’s health.
Anna Gianfranceso (AG) noted that young clients would typically be seen at one of the CAMHS facilities by visiting clinicians; clients would only be required to attend adult Substance Misuse Services (SMS) in an emergency situation.
28.7 In answer to questions concerning how these services were currently delivered, the Panel was told that services were either available at centres in Hove and Brighton or via outreach, work in schools etc. There is ongoing work aimed at making access to CAMHS services easier and more inclusive. This may include effectively integrating the services rather than having partially discrete Tier 2 and Tier 3 provision.
28.8 In response to a query regarding the definition of Dual Diagnosis,members were told that assessing younger people was often very difficult, as they frequently evinced highly chaotic behaviour and could be very tricky to engage with. In consequence, diagnoses of a co-morbidity of mental health and substances misuse problems could often not be made until clients were in their mid twenties.
28.9 In answer to a question regarding the success of the Children and Young People’s Trust (CYPT), members were informed that CYPT had facilitated much improved co-working between disciplines, both at strategic/management levels and at the “front line” where services are delivered.
28.10 Councillor Pat Hawkes stressed that it was very important that Brighton & Hove City Council analysed the performance of CYPT so that other Council services could benefit from this good practice.
28.11 AG acknowledged that CYPT services were often considerably more effective than equivalent adult services, and that this could be very problematic when clients needed to transfer across. The feasibility of increasing the upper age range covered by CAMHS to 25 was being considered, as such an extension of the service might ameliorate some of the problems caused by any relative incompatibility between child and adult services.
28.12 MG noted, that, although CAMHS was, in some ways, better integrated than adult mental health and SMS, this did not mean that adult services were necessarily poorly integrated. On the contrary, there was a good deal of effective co-working in adult services in terms of initial assessment of clients, in terms of discharge, and throughout treatment. There was also a history of effective partnership between SMS and Community Mental Health services, particularly the Assertive Outreach Team. A nurse consultant would shortly be recruited to co-ordinate this partnership working.
However, there were considerable challenges to more closely integrating services, including incompatible IT systems.
28.13 In response to a question regarding the involvement of the legal system in CYPT work, AG told members that ru-ok has a worker in the Youth Offending Team. Young people who have offended and have been identified as having substance misuse problems, or who committed crimes involving substances, will be assessed by ru-ok to see if they would benefit from intervention.
ru-ok also works with the Community Safety Team to identify young people who use substances problematically before they come to the attention of the courts.
28.14 In response to a query regarding the types of substances commonly misused by young people, AG told members that a wide range of substances were encountered, although misuse of solvents was not as prevalent as it had once been.
MG noted that problematic alcohol use was on the rise, and that services relating to this were generally under-funded. This was a particular concern, particularly because of the serious physical problems (liver disease etc.) associated with long-term misuse of alcohol.
SW noted that alcohol related problems were not always accorded the priority that they should be. Although the commissioners were now beginning to direct significant funds into adult drink services, there had to date been relatively little funding for younger people’s services.
AG told the Panel that it was very difficult to assess the extent of alcohol related problems, as the recording of this data was often incomplete. This was particularly the case in terms of attendances at hospital Accident & Emergency (A&E) departments; A&E did not typically code attendances as being drink related, and the high turnover of A&E staff made it very difficult for ru-ok to develop effective working relationships with A&E. Current work is ongoing to develop a Care Pathway for A&E referrals to ru-ok (with targets for numbers of referrals).
MG noted that there were similar problems encountered in trying to get A&E staff to identify and record A&E attendees who might have mental health or substance misuse problems, although it was recognised that the pressures of A&E work were considerable.
28.15 In response to a question from a member of the public concerning Out Of Hours (OOH) psychiatric cover at the Royal Sussex County Hospital (RSCH) A&E department, Rebecca Hills (RH) told members that Mill View hospital provides 24/7 OOH cover for the RSCH. In addition, improved Mental Health and SMS resources at the RSCH A&E are currently being developed.
28.16 In answer to questions about the crossover between children’s and adult services, members were told that this was a nationally recognised problem. The notion of “transition” services (covering an age range of 14-25) is being actively considered. (Some services, such as services for Special Needs and for Pregnant Teenagers, already vary their provision on this basis.)
Evidence from Sue Baumgardt
29.1 Ms Baumgardt introduced herself: her son Yannick had a Dual Diagnosis and died in November 2005 as a result of heroin poisoning. Ms Baumgardt has subsequently been involved in campaigning on issues relating to provision for the treatment and support of people with a Dual Diagnosis.
29.2 Ms Baumgardt explained that Yannick had begun displaying psychotic behaviour in his teens (although the family only recognised this in hindsight). He was first detained (under a section of the Mental Health Act) in his early twenties, and was subsequently “sectioned” on several occasions.
29.3 Yannick also developed problems with substances. These included heroin, prescription medicines (amphetamines and benzodiazepines) and alcohol. Yannick refused to acknowledge that he had mental health problems, and may have misused these substances in order to “self-medicate”, seeking to ameliorate the effects of his illness with these drugs rather than prescribed psychiatric ones.
29.4 Ms Baumgardt explained how she had encountered major difficulties in persuading healthcare professionals that, on occasion, Yannick needed detaining (under a section of the Mental Health Act) for his own safety and the safety of others. Ms Baumgardt described how healthcare professionals were slow to attend in emergency situations, and how they advised her to call the police if she became concerned about Yannick’s behaviour. Ms Baumgardt feels that this was unrealistic advice which threatened to place her family at risk of harm.
29.5 Ms Baumgardt also described problems she had encountered with services at Mill View hospital on occasions when Yannick was “sectioned”. These included:
· a lack of security at Mill View (whilst supposedly detained on a locked ward, Yannick was able to access local shops to buy alcohol);
· no detoxification services offered to Yannick;
· insufficient Occupational Therapy on offer to people in Pavilion Ward;
· the effective unavailability of Cognitive Behavioural Therapy (CBT) for people in Yannick’s position;
· inappropriate granting of leave to sectioned patients;
· an inappropriately “laissez faire” attitude evinced by ward staff (not encouraging patients to engage with therapies, to be active, to maintain their own appearance etc). Ms Baumgardt recounted visiting Yannick at 3pm to find him still in bed, surrounded by half eaten food, dirty crockery etc. Ms Baumgardt feels that Yannick should have had more positive. intervention to care for him/enable him to care for himself.
29.6 Ms Baumgardt also felt that her son’s discharge from hospital was poorly handled, with Yannick initially being placed in inappropriate Bed & Breakfast (B&B) with no cooking facilities.
29.7 Yannick was then transferred to accommodation in the Royal Promenade Hotel, Percival Terrace, Brighton, which Ms Baumgardt thinks was equally unsuitable, as it was situated in an area where drugs use was prevalent. Ms Baumgardt also considers that hotel staff were insufficiently briefed on the people they were required to house, having neither detailed knowledge of Yannick’s medical history, nor his Next Of Kin contacts.
29.8 After discharge, Yannick was supported by the Assertive Outreach Team. Ms Baumgardt feels that this support was inadequate; when she called the team with worries about her son’s state, their response was inappropriately slow. Ms Baumgardt recognises that the Assertive Outreach Team needs to act so as to gain the confidence of its clients, which may necessitate building relationships slowly; but she feels that the Team ought to be prepared to intervene far more swiftly when necessary, particularly when acting on the advice of people with intimate knowledge of a person’s behaviour such as family members/ carers.
After Yannick died, Ms Baumgardt told Panel members that hotel staff were only able to contact Next Of Kin after the Assertive Outreach Team had called Yannick’s mobile phone, some two days after his death.
29.9 Ms Baumgardt was asked to suggest how she thought services for people with a Dual Diagnosis might be improved. She suggested that:
· Appropriate supported housing was a priority. People discharged after being detained under a section should never be placed in B&B accommodation. There should instead be some kind of temporary supported housing provision, so as to allow extremely vulnerable people to live in a safe and appropriate environment whilst suitable long term accommodation was found for them. This might even save money in the long term, as it could reduce the frequency with which people discharged from a section were quickly re-sectioned because they were unable to cope with inappropriate temporary housing.
· People detained under a section of the Mental Health Act should receive much more encouragement to engage with therapeutic activities whilst in hospital, and should also be encouraged to be active, clean themselves etc.
· People under a section should be compelled to take appropriate psychiatric medication.
· Sussex Partnership Trust officers should re-think their response to families/carers of people with a Dual Diagnosis who contact the trust with severe concerns about their relations’ behaviour. Telling people to call the police is inappropriate advice as police officers are not well placed to determine the mental state of someone with a Dual Diagnosis, who may well present as quite rational. Should police officers attend at the behest of families/carers and choose not to intervene (by arresting the person with a Dual Diagnosis/detaining them under Section 136 of the Mental Health Act), the people who called the police may find themselves at risk of attack. A more appropriate response would be for mental health staff to attend in a timely fashion to assess patients.
· Rehabilitation services should be located outside the city, preferably in a rural environment with ready access to therapeutic interventions, arts, gardening etc. Such facilities could well be Sussex wide rather than dedicated to Brighton & Hove patients.
29.10 The Chairman thanked Ms Baumgardt for her evidence.