Hampshire County Council Adult Services response

1. How available are early identification services at present and how are agencies

co-operating to improve on this?

There are no specific services within Adult Services to address this issue. There are Early Intervention in Psychosis teams across Hampshire, managed through Hampshire Partnership NHS Trust and Surrey and Borders Partnership NHS Trust, but their remit is to work with people aged 14 to 35 who have or are suspected of having a psychotic illness. There may be some of those young people for whom alcohol also poses a problem and staff in those teams are likely to recognise the issues and know whom to contact.

Information collected from operational services would indicate that the alcohol issues they identify with clients are long standing. However, it was noted that if there were ways of identifying issues early and working with people, the impact on Adult Services later might reduce.

The lack of preventative, lower level services for people abusing alcohol was identified as an issue.

2. What multi agency workforce development is in place and what are the

workforce planning arrangements for the future?

2.1 There are limited opportunities to develop the non specialist workforce in relation to alcohol issues. Hampshire Learning Centre provide 1 course - Mental Health, Substance Misuse and Child Protection - which would provide information on alcohol and drug problems. This course is recommended for staff in Children's Services, Mental Health Service (both Health and Social Care employees), Youth Offending Teams, Connexions and Probation. Staff in Older Persons, Learning Disability and Physical Disability teams would not normally attend this course unless they were preparing for Approved Social Worker training.

A difficulty in accessing residential and domiciliary care packages for older people or those with a physical disability, which is exacerbated by alcohol misuse suggests that there needs to be training of staff in the private and third sector. I am not aware of any training of volunteers and informal carers.

2.2 Multi-agency courses and workshops are run by the DAAT to which staff from Adult Services have access and do attend. However, the need for more awareness raising training in Older Persons, Physical Disability and Reception and Assessment teams has been suggested.

Individual teams within Adult Services do know of the services commissioned for people misusing substances; an example of joint working being a training day with Spencer House and the Physical Disability team in Winchester.

There are staff employed by Adult Services present in all the Tier 3 Substance Misuse teams across the County, but only totalling 11.63 FTE, several of whom are in DAAT funded posts.

3. What improvements could be made to deliver effective support and treatment

to the most vulnerable people, including those with mental health problems?

3.2 A current initiative underway from Safeguarding Adults is work with the Substance Misuse teams within the Mental Health Trusts to raise the awareness of abuse and to ensure that at least 1 person in each team has undertaken the 3 day Adult Protection training. The 3 new Safeguarding Co-ordinators in Adult Services, when they come into post on 31.10.07, will be visiting the substance misuse teams to progress this work.

3.3 Responsibility for dual diagnosis work (mental health and substance misuse) is given to adult mental health services rather than substance misuse services. There is only 1 worker, in a Community Mental Health Team (CMHT) in Farnborough, who works with people with alcohol misuse (as opposed to drugs misuse) and mental health, but due to a period of sickness there is no current data available.

The DAAT is about to review the work and effectiveness of dual diagnosis workers based in CMHTs, but their remit is drugs misuse and mental health. If this approach was assessed as being effective, an extension to include work with people who misuse alcohol could be considered, but there would be funding implications.

Adult Services substance misuse budget is small, £410K in total across Hampshire for staffing and care purchasing, covering drug and alcohol misuse, which limits the numbers of people who can receive support and rehabilitation care packages. These packages are designed on an individual basis according to the needs of each person and vary considerably in cost. They tend to be purchased only when clear motivation is indicated or the risks to the health, well being and safety of the individual or their children are severe. Additional money is occasionally made available by the DAAT for purchasing, but is ring-fenced for drug misuse care packages only.

The biggest barrier to improvement is the lack of finance to support work with people who have mental health and alcohol problems. Additionally, there are no performance indicators to drive an expansion of work in this field.

4. Are there any other matters that you would like to draw to the attention of the

review group?

The main issue raised by staff in Adult Services has been people over 65, who misuse alcohol in addition to their other needs. Staff spoke of people whose personal care and health was compromised by incontinence and poor eating caused by an underlying long standing alcohol misuse problem. Figures taken from the draft Older Persons Mental Health Strategy, based on The Health of the Nation 1997 indicate that 1-3.5% of older people are adversely affected by dependency on alcohol. In Hampshire that translates to 4,967 people currently, rising to 5,774 in 2013. 1 Care Manager in a Reception and Assessment team said that 8% of her current caseload, also had alcohol problems. There was a feeling that Tier 3 services did not always recognise this age group.

There was considered a difficulty in finding appropriate residential or domiciliary care packages for older people due to the existence of alcohol misuse, which might result in challenging behaviour and inability to cope by providers not trained to deal with the effects of the alcohol problem. Alcohol appears to be an increasing issue for Physical Disability teams too, both in terms of increased referrals due to people not meeting the criteria for entry into Tier 3 substance misuse services and in terms of disabilities caused by alcohol leading to falls and liver damage.

The issue of eligibility for services was also raised for people referred to Reception and Assessments teams. Separately the physical disability, older person or substance misuse issues may not meet Adult Services eligibility criteria, but the combination nevertheless made the individual vulnerable.

Staff described difficulties in improving the outcomes for people they were working with, who also abused alcohol, but did not recognise the problem, refused to engage with substance misuse services or who were not motivated to change; the chaotic lifestyles that people may have mitigating against effective delivery of care.

All these problems at times result in vulnerable people losing touch with services or falling between services.

A specific issue was raised about the difficulties encountered by deaf people who misuse substances in accessing substance misuse services, although the extent of the problem was not quantified. Another question to ask would be whether an underlying or developing alcohol problem for a person with learning disabilities would be picked up in primary care or adequately dealt with in substance misuse services.

Liz McGill

Mental Health Commissioning Manager