This project began in 2015 to update our Trust’s Dual Diagnosis tool, and was led by the Substance Use Mental Health Operations group, which works across the Trust to promote better care for mental health service users who use alcohol or drugs. This is not an alternative to addiction services, nor the sole mental health service for people with substance use issues.
Development of NICE guideline NG58 “Coexisting Severe Mental Illness & Substance Misuse: Community Health & Social Care Services” began during our project and it was resolved that our tool and related protocol would comply with the new guidance. NICE CG120 for “Co-existing severe mental illness (psychosis) and substance misuse” was also considered.
Recommendations from both CG120 (Recommendation 4) and NG58 (Section 1.1 & Recommendation 1) highlight the importance of including drug and alcohol use in initial interviews; to explore the prevalence of substance use among mental health service users and better identify risks for individuals.
- Coexisting severe mental illness and substance misuse: community health and social care services (NG58)
- Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings (CG120)
- Drug misuse in over 16s: opioid detoxification (CG52)
- Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115)
Aims and objectives
- To audit reporting of substance use on the Trust’s electronic record system. Using standard protocols from the substance use and mental health (SUMH) guidelines and key performance indicators.
- To identify the incidence of alcohol and drugs use among mental health service users.
- To inform training and education programmes for non-specialist mental health workers, in order to improve the care given to those service users.
- To improve the tools used for reporting and recording this information.
- To recognise trends such as increasing use of novel psychoactive drugs.
Reasons for implementing your project
CNWL’s Dual Diagnosis policy covers the assessment of substance use for those engaged in the Trust’s mental health services, education of staff and their responsibilities to provide advice, referral and some interventions when alcohol or drug use impacts a service user’s health. The previous version was due to be reviewed in 2016, but was held until 2017 to coincide with the publication of new NICE guidelines and Public Health England’s “Better Care for people with co-occurring mental health and alcohol/drug use conditions”.
A substance use screening form, known as the Bromley Screening Tool was implemented within CNWL mental health services around 2010 as part of the Trust’s new patient information system (JADE). It was intended to provide a simple screening tool for mental health staff who did not have specialist addictions knowledge. By recording service users’ substance use in a consistent manner, it was hoped to better identify and provide support for people with hazardous or dependent use.
Bromley had six of the ten questions from the Alcohol Use Disorders Identification Tool (AUDIT); followed by a list of commonly used illicit drugs; and then a series of questions about the subject’s contact with local drug and alcohol services. We were told by colleagues that Bromley tool followed work by Strathdee et al (2005) and New Horizons (DH 2009), but records of development meetings are no longer available.
Two key factors lead to the decision in 2015 to develop a new Dual Diagnosis policy and a Substance Use in Mental Health screening tool. Firstly, there was a general feeling amongst staff that the current tool did not relate to risk assessment processes, and among service users that it led to some repetitive lines of questioning during assessment. Secondly, a serious incident involving a novel psychoactive substance demonstrated the form did not account for newer substances (except in an open section “other”) and staff were not aware of the serious risks of newer substances being used.
The project group included dual diagnosis workers from four of the five London boroughs where CNWL provides mental health services. This included two service user representatives alongside frontline staff from in-patient and out-patient psychiatric services.
How did you implement the project
Since 2014, the SUMH team has checked completion of the Bromley tool on our Trust patient information system (JADE) with an annual snapshot audit of admissions to adult mental health wards from five sectors (Westminster, Kensington & Chelsea, Brent, Harrow & Hillingdon).
We selected 100 cases - the first 20 people admitted to each sector in May each year - and audited their electronic records for details of their substance use. This included the following information:
- Bromley Tool: Was it fully completed? Was it positive or negative? What was the alcohol score? (adapted from A.U.D.I.T.)
- Risk Assessment: Any mention of substance related risk?
- Initial Assessment: Any mention of substance use?
- Urine Drug Screen (UDS): Was this carried out? How did positive tests inform care?
- Further qualitative information was taken from text notes.
It should be noted that all wards were required to complete a drug and alcohol screening tool on admission to hospital, under local key performance indicators.
No attempt was made to correlate cases against local populations, nor to adjust for complexity of admissions. Where the audit tool was refined each year, retrospective data was re-audited. Although the tool was shared around the trust at key events, it was difficult to engage all key people via circulating by email.
People who were admitted for less than 24 hours were not excluded, as it is not always appropriate to complete assessment during that time.
Developing the SUMH tool:
During the most recent audit year, we worked on the tool which has replaced Bromley. This originally included smoking information, but that was kept in a physical assessment form also being implemented across the Trust.
Alcohol screening was reverted to AUDIT-C, three question shortened from AUDIT-10.
Drug screening was replaced with an updated list of commonly used drugs from three main data sources; National Treatment Agency (drugs services), Mental Health reports, crime reports and reference to the ‘Mixmag’ annual survey of recreational drug use.
These questions include prompts about frequency, amount and route, plus the service user view of their risk and intentions on reducing use.
The tool was discussed in the steering group with stakeholders from around the trust including CMHT and ward staff, nursing and psychiatry, and service user representatives. The initial version was piloted in two wards in one of the boroughs. Changes were made based on feedback and details added to record urine drug screen results, brief interventions and referrals.
The steering group named the tool SUFARI – an acronym for Substance Use Frequency, Amount, Risk Identification.
Most boroughs had met targets for completion of screening prior to 2017, but a significant proportion of cases had incomplete or contradictory information on the forms.
Urine screen only
No substance use recorded
Although there appears to be a fall in 2017, this is mostly explained as transition from key performance indicators to National CQUIN (Commissioning for Quality and Innovation) relating to alcohol screening and tobacco use.
The introduction of SUFARI in two boroughs gives a screening rate of 77.5% (31/40) for 2017, while the others show 40% (24/60) compliance with Bromley tool. With a longer period of implementation we expect further improvement to be shown in all five boroughs.
Overall completion of data did not improve, but several key parts of the form were improved - such as quantity and frequency of use, plans for interventions about alcohol and drugs, and service user’s opinions about their substance use.
Data to be published shows that risk assessment suggests 50% of in-patients are at “severe risk” from substance use, but this is often contradicted in the notes.
Conclusions of the audit cycle – 2014 to 2017
The current system for screening and documenting substance use on JADE is too complicated, with questions repeated several times in different contexts.
Conflicting records were found in admissions notes, such as one person whose Bromley tool said they “used no drugs”, the risk assessment form reported ‘use of skunk that they did not consider a problem’ however; the interview with them said they ‘had been trying to stop’.
Substance use issues are often not included in care plans and risk assessment forms and new patterns of use, including abstinence, are not taken into account when previous data is carried forward from old forms.
Some substances are frequently reported in ways that suggests staff are not familiar enough with them to make clinical judgments - especially novel psychoactive drugs (see below).
The Bromley tool did not provide enough focus on clinically useful information and patient risks. Nor does the JADE version allow easy reporting on which drugs are commonly being used.
Next steps: We will re-audit in May 2018, but for 2017, alcohol screening is reported as part of a national CQUIN, which has replaced the KPIs. This will allow us to analyse differences between wards more closely.
Key learning points
The screening of alcohol and drugs use can be facilitated by standard forms and is easily collected when incorporated in electronic systems.
Tools should be flexible to update as trends for new substances arise and should include service user and staff input, where possible.
The way in which information is structured should enhance the knowledge and understanding of staff who are not specialists in substance use.
Where possible, these forms and risk assessment forms should have linked fields to avoid repetition or inconsistency and to ensure that any risks highlighted form part of a clear care plan.
The current physical health risk CQUIN requires screening for alcohol use and tobacco use, plus delivery of brief interventions and/or onward referral. Any forms used should allow recording of risk as perceived by mental health workers and service users. Ideally any interventions or referral should be recorded on the same form.
Claudine Pisani, Substance Use in Mental Health Lead, Brent & Clinical Educator, Central and North West London NHS Foundation Trust,
Eloise Tabernacle, Care Manager/Trainer, RBKC Dual Diagnosis Team, Royal Borough of Kensington & Chelsea, firstname.lastname@example.org
Participants in this project were from all SUMH teams, which included colleagues from Royal Borough of Kensington & Chelsea Social Services. This collaboration will be extended to locally commissioned alcohol and drug recovery service.