Hostname: page-component-7c8c6479df-7qhmt Total loading time: 0 Render date: 2024-03-28T02:00:41.326Z Has data issue: false hasContentIssue false

‘From glorious to infamous’: the life span of (addiction) specialists in psychiatry

Published online by Cambridge University Press:  02 January 2018

Sandra Swatkins
Affiliation:
Dudley & Walsall Mental Health Partnership Trust
Romina Lopez Gaston*
Affiliation:
Dudley & Walsall Mental Health Partnership Trust
Mahnaz Hashmi
Affiliation:
Birmingham & Solihull Mental Health Foundation Trust
David Thomas
Affiliation:
Dudley & Walsall Mental Health Partnership Trust
*
Romina Lopez Gaston (romina.gaston@dwmh.nhs.uk)
Rights & Permissions [Opens in a new window]

Summary

In this editorial we look at the implications of organisational changes to the National Health Service and financial constraints on addiction psychiatrists, and how creativity and adaptability could be the key to fostering survival and sustainability of subspecialties in danger of extinction.

Type
Editorial
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © Royal College of Psychiatrists, 2011

They came first for the Communists, and I didn't speak up because I wasn't a Communist.

Then they came for the trade unionists, and I didn't speak up because I wasn't a trade unionist.

Then they came for the Jews, and I didn't speak up because I wasn't a Jew.

Then they came for me and by that time no one was left to speak up.

Pastor Martin Niemöller (1892-1984) Reference Niemöller, Bloomberg and Barrett1

The metamorphosis of addiction services

They came first for the Communists, and I didn't speak up because I wasn't a Communist.

The National Health Service's (NHS) reorganisation that started with the Darzi report Reference Darzi2 is shaping up with the most recent White Paper Liberating the NHS. 3 This is taking place in the light of a constrained financial climate. The interaction between these translates into the ongoing metamorphosis of services, aiming to provide the best care at competitive costs. Over the past couple of years, the working landscape of addiction psychiatry has been witnessing gradual reshaping with an increased risk of extinction. Reference Finch4 This prospect continues to grow and has become even more real with the recent Coalition's announcement 5 involving the dissolution of the National Treatment Agency (NTA, an NHS special health authority established to improve the availability, capacity and effectiveness of drug treatment in England) alongside the merging of addiction monies within the ring-fenced public health budget. 6 During its lifespan - and in the context of an implicit exclusion of funding for people with alcohol dependency - the ethos of the NTA has been based on raising the involvement of primary care physicians in the provision of services for drug addicts. The model indulged patients in the evidence-based victories of a methadone or buprenorphine prescription as the end-point of their treatment. 7-Reference O'Hara9 The emphasis on harm reduction is swiftly shifting towards the broader concept of ‘recovery’ that decentralises the medical model aiming to foster reintegration of addicts in society with abstinence as the prime goal. 7,10,11

The ‘ownership’ of addiction services has become blurred with decommissioning and retendering being the ruling processes of redesign in a financially drained NHS. Reference Finch4,Reference Wolstenholme12-Reference Pollock, Murphy and Sugarman14 According to an interim report of a survey performed by the Specialist Clinical Addiction Network (SCAN, www.scan.uk.net/) in 2009, 45 services were involved in the process of retendering in England and Wales. Reference Wolstenholme12 In total, 31 of those services completed the retendering process and only 16% were regained by the NHS, 42% went to non-statutory agencies and 13% to a partnership between both. The report also highlighted inconsistencies in the bidding process, lack of clarity when awarding bids and perceived poor rationale in the decommissioning of innovative and well-functioning services. Reference Wolstenholme12

Driving competition to achieve excellence at lower costs is leading to a combination of partnerships between the NHS, non-statutory services and the private sector that more often than not tend to re-evaluate the need to employ ‘expensive’ consultant psychiatrists, favouring general practitioners (GPs) or senior nurses with a special interest in the area. Reference Finch4 As is the case for many other subspecialists, we now have to redesign our future and ‘charm’ commissioners trying to attract investments. Reference Butterworth15 This is the current cost-effective NHS in which we can only make ourselves financially worthwhile as long as we can differentiate what we do from cheaper options. Reference Butterworth15

Then they came for the trade unionists, and I didn't speak up because I wasn't a trade unionist.

General adult psychiatrists have not been immune to ongoing reshaping of services with functionalisation being the upcoming controversy. Reference Burns16 Furthermore, challenges raised around the model of functionalisation against the status quo Reference Burns16 have resembled those affecting retendering of addiction services, for instance: threats to continuity of care, staff uncertainties, low morale and animosity among providers, with patients falling into precarious interfaces. Reference Finch4,Reference Wolstenholme12,Reference Butterworth15 There is recognition that weaknesses associated with these transitional models will undoubtedly impact on the training of developing professionals Reference Finch4,Reference Drummond13 and there are questions as to whether their objectives will be ultimately achieved (lower costs with better services). Reference Drummond13,Reference Burns16,Reference Drummond17

Resuscitating old classics and reinventing new ones

Mental illness combined with substance misuse: working with the departed

The current trend underpinned by costs and the functionalisation of services is leading to narrowed gaps between primary and secondary care. People addicted to drugs and alcohol without comorbid conditions or within the mild-to-moderate spectrum of mental illness have been increasingly embraced by GPs. Reference Strathdee, Manning, Best, Keaney, Bhui and Witton18,19 General psychiatrists are absorbing those with additional risks intertwined with more complex mental disorders, with addiction specialists losing ground in the wider equation. 19,Reference Weaver, Madden, Charles, Stimson, Renton and Tyrer20

In this context, working on existing fractures in the system may offer sustainable opportunities. Areas that merit consideration are individuals with dual diagnosis in the ‘new functionalised world’, as well as their care - and that of non-mentally ill addicts - at the interface between the acute and mental health trusts, 19,Reference Weaver, Madden, Charles, Stimson, Renton and Tyrer20 particularly given the high rates of comorbidity, poor identification and inadequate treatment of this dually diagnosed population. Reference Weaver, Madden, Charles, Stimson, Renton and Tyrer20

According to the Comorbidity of Substance Misuse and Mental Illness Collaborative (COSMIC) Reference Weaver, Madden, Charles, Stimson, Renton and Tyrer20 study, a sizeable proportion of individuals using drug (74.5%) and alcohol (85.5%) services experience mental health problems, with almost 44% of those utilising mental health services reporting drug use or alcohol misuse in the previous year. Historically, people with dual diagnosis have been in receipt of poor access to specialist services, Reference Weaver, Madden, Charles, Stimson, Renton and Tyrer20,Reference Crome, Chambers, Frisher, Bloor and Roberts21 and although a national strategy was launched in 2002, 22 reports still show regional inconsistency and variability of resources throughout England. 23 National inquiries into suicides and homicides by people with mental illness 24-Reference Scott, Johnson, Menezes, Thornicroft, Marshall and Bindman26 continue to stress the enhanced risks associated with the harmful use/dependence on substances in this population. Mindful of this situation, the National Institute for Health and Clinical Excellence is drawing up national guidelines 27 to streamline service provision, with the acknowledgment that 40% of people with psychosis will develop substance misuse in their lifetime. The complex nature of mental illness in these individuals, Reference Crome, Chambers, Frisher, Bloor and Roberts21,28 associated with potential risks, 24,25 poor engagement with services, multiple admissions to hospital and an overall poor prognosis Reference Hunt, Bergen and Bashir29,Reference Carey, Carey and Meisler30 with reutilisation of services Reference Hunt, Bergen and Bashir29,Reference Hoff and Rosenheck31 still constitute an ideal opportunity for addiction consultants. By leading consultation and liaison dual diagnosis teams with peripatetic input we might offer the desperately sought integrated and continuous care required by this overlooked population, in future functionalised partnerships. 19,28

Making alcoholism NICE

Another area of participation involves the detrimental impact on public health resulting from the harmful use/dependence on alcohol that has been the ‘elephant in the room’ across the NHS for many years. Almost 1.6 million people are alcohol dependent in the UK and the estimated cost of alcohol misuse (including health, loss of productivity and crime) is £18-25 billion a year; for the NHS alone the financial burden of the harmful use of alcohol is around £2.7 billion. 11 Recently, the World Health Organization reached a consensus for the first time about implementing a global strategy with ten target areas aiming to confront this problem. 32 The National Institute for Health and Clinical Excellence has published two 33,34 out of three planned national guidelines aiming to offer these individuals what they have long deserved: the right for recognition through a comprehensive and standardised package of care. This has been reinforced by the newly released drug strategy that embraces alcoholism as well as drug-related problems. 11 This acknowledgment underpinned by financial support would allow addiction specialists to offer a myriad of expertise associated with recognised neuropsychiatric complications of alcoholism, bridging gaps between primary care and the acute and mental health trusts.

Innovative pilot schemes Reference Butterworth15,35 with combined liaison psychiatry and addictions expertise are already developing to enhance patient care at the front door of the NHS. Such models, based on a multidisciplinary mental health rapid assessment interface and discharge (RAID) approach are starting to demonstrate how effectively a responsive integrated service can help acute general hospitals comply with national target outcomes and quality standards (reduce waiting times, length of in-patient admissions and re-attendance rates). 36 With 40% of accident and emergency attendees having alcohol issues complicating their care, rising to 70% at peak times, Reference Drummond37 embedding substance misuse specialists into the fabric of general hospitals via established liaison psychiatry services can enable addiction experts to play a vital role in addressing the complex interplay between physical health, mental health and substance misuse.

Primum non nocere

Then they came for the Jews, and I didn't speak up because I wasn't a Jew.

Although the number of substance misuse consultants in the UK is limited to 361 (Royal College of Psychiatrists’ Addiction Faculty personal communication, 2011), the issues they face are as complex as in any other subspecialty. They lead rich, rounded quality services with a uniquely wide range of high-level skills to manage the most severe cases. 19 They foster a supportive and therapeutic setting that offers liaison with other professionals from primary and secondary care. They provide training to expand the provision of high-quality services and there is a commitment to research and innovation to improve effectiveness and efficiency. 38,Reference Craddock, Kerr and Thapar39

This combination of leadership and expertise is presently being threatened by the current ethos of the NHS reorganisation. There is a consensus of concern about price competition damaging healthcare quality. Reference Hawkes40 Besides, the monetarisation of the transitional process in which redesign is implemented by the retendering of services is likely to see many casualties among highly qualified professionals. Reference Godlee41 Service providers should be mindful to apply the principle of Primum non nocere to professionals as well as patients, in particular because of the need for personal integrity to be the riding force leading quality, enhancing outcomes and absorbing accountability in a cost-effective and creative way.

Then they came for me and by that time no one was left to speak up.

Footnotes

Declaration of interest

None.

References

1 Niemöller, M. They came for the communists. In The Jewish Holocaust (eds Bloomberg, M, Barrett, BB). Wildside Press, 2006.Google Scholar
2 Darzi, A. High Quality Care for All: NHS Next Stage Review. Final Report. Department of Health, 2008 (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825).Google Scholar
3 Department of Health. Equality and Excellence: Liberating the NHS. White Paper. Department of Health, 2010 (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353).Google Scholar
4 Finch, E. Who can you work for? SCANbites 2010; 7 (winter): 1.Google Scholar
5 Civil Service World. DH Publishes Quango Plans. Civil Service Live Network, 2010 (http://network.civilservicelive.com/pg/pages/view/373558/).Google Scholar
6 Department of Health. Healthy Lives, Healthy People: Our Strategy for Public Health in England. Department of Health, 2010.Google Scholar
7 The Centre for Social Justice. Green Paper on Criminal Justice and Addiction. The Centre for Social Justice, 2010 (http://www.centreforsocialjustice.org.uk).Google Scholar
8 National Treatment Agency. Models of Care for Treatment of Adult Drug Misusers: Update 2006. National Treatment Agency, 2006 (http://www.nta.nhs.uk/uploads/nta_modelsofcare_update_2006_moc3.pdf)Google Scholar
9 O'Hara, M. Keep taking the medicine. The Guardian 2008; 18 June (http://www.guardian.co.uk/society/2008/jun/18/drugsandalcohol).Google Scholar
10 National Treatment Agency for Substance Misuse. Drug Treatment, Reintegration and Recovery in the Community and Prisons. NTA, 2009 (http://www.nta.nhs.uk/uploads/treatment_plan_guidance_2010_11.pdf).Google Scholar
11 HM Government. Drug Strategy 2010: Reducing Demand, Restricting Supply and Building Recovery. Supporting People to Live a Drug Free Life. HM Government, 2010 (http://www.homeoffice.gov.uk/drugs/drug-strategy-2010/).Google Scholar
12 Wolstenholme, A. Retendering of addiction services revealed by SCAN survey. SCANbites 2009; 6 (summer): 12.Google Scholar
13 Drummond, C. Tenderisation of addiction treatment. SCANbites 2009; 6 (summer): 3.Google Scholar
14 Pollock, A, Murphy, E, Sugarman, P. Should NHS mental health services fear the private services? BMJ 2010; 341: 760–1.Google Scholar
15 Butterworth, M. Retendering: one person's experience. SCANbites 2010; 7 (winter): 23.Google Scholar
16 Burns, T. The dog that failed to bark. Psychiatrist 2010; 34: 361–3.Google Scholar
17 Drummond, C. Change happenz. SCANbites 2010; 7 (autumn): 1.Google Scholar
18 Strathdee, G, Manning, V, Best, D, Keaney, F, Bhui, K, Witton, J, et al. Dual diagnosis in a primary care group, (100, 000 population locality): a step-by step epidemiological needs assessment and design of a training and service response model'. Executive summary. Drugs, Educ, Preven Policy 2005; 12: 119–23.Google Scholar
19 Royal College of Psychiatrists. New Report Emphasises Vital Role of Addiction Psychiatrists in Preventing and Treating Growing Substance Misuse Problems in UK. Royal College of Psychiatrists, 2002 (http://www.rcpsych.ac.uk/press/pressreleasearchive/pr332.aspx).Google Scholar
20 Weaver, T, Madden, P, Charles, V, Stimson, G, Renton, A, Tyrer, P, et al. Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. Br J Psychiatry 2003; 183: 304–13.Google Scholar
21 Crome, I, Chambers, P, Frisher, M, Bloor, R, Roberts, D. The Relationship between Dual Diagnosis, Substance Misuse and Dealing with Mental Health Issues. Research Briefing 30. Social Care Institute for Excellence, 2009.Google Scholar
22 Department of Health. Dual Diagnosis – Good Practice Guidance. Department of Health, 2002.Google Scholar
23 Care Services Improvement Partnership. Themed Review Report 07: Dual Diagnosis. National Service Framework for Mental Health. Department of Health/Care Services Improvement Partnership, 2007 (http://www.nmhdu.org.uk/silo/files/dual-diagosis-themed-review-report-2007.pdf).Google Scholar
24 Department of Health. Safety First: Five Year Report of the National Confidential Enquiry into Suicide and Homicide by people with Mental Illness. Department of Health, 2001 (http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4058243.pdf).Google Scholar
25 University of Manchester. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness: Annual Report England and Wales. University of Manchester, 2010 (http://www.medicine.manchester.ac.uk/psychiatry/research/suicide/prevention/nci/inquiryannualreports/AnnualReportJuly2010.pdf).Google Scholar
26 Scott, H, Johnson, S, Menezes, P, Thornicroft, G, Marshall, J, Bindman, J, et al. Substance misuse and risk of aggression and offending among the severely mentally ill. Br J Psychiatry 1998; 172: 345–50.Google Scholar
27 National Institute for Health and Clinical Excellence. Psychosis and Substance Misuse: Assessment and Management in Adults and Young People. Draft Consultation Guidelines. NICE, 2010 (http://www.nice.org.uk/nicemedia/live/11815/50217/50217.pdf).Google Scholar
28 Turning Point. Dual Diagnosis: Good Practice Handbook. Turning Point, 2007 (http://www.turning-point.co.uk/inthenews/Documents/DualDiagnosisGoodPracticeHandbook.pdf).Google Scholar
29 Hunt, GE, Bergen, J, Bashir, M. Medication compliance and comorbid substance abuse in schizophrenia: impact on community survival 4 years after a relapse. Schizophr Res 2002; 54: 253–64.Google Scholar
30 Carey, MP, Carey, KB, Meisler, AW. Psychiatric symptoms in mentally ill chemical abusers. J Nerv Ment Dis 1991; 179: 136–8.Google Scholar
31 Hoff, RA, Rosenheck, RA. The cost of treating substance abuse patients with and without comorbid psychiatric disorders. Psychiatr Serv 1999; 50; 1309–15.Google Scholar
32 World Health Organization. Draft Global Strategy to Reduce the Harmful Use of Alcohol. Revised Version based on the Outcomes of WHO Executive Board 126th session, Geneva 18th–23rd Jan 2010. WHO, 2010 (http://www.who.int/substance_abuse/alcstrategyaftereb.pdf).Google Scholar
33 National Clinical Guidance Centre. Alcohol Use Disorders Diagnosis and Clinical Management of Alcohol Related Physical Complications. National Clinical Guidance Centre, 2010 (http://www.nice.org.uk/nicemedia/live/12995/48989/48989.pdf).Google Scholar
34 National Institute for Health and Clinical Excellence. Alcohol Dependence and Harmful Alcohol Use. NICE, 2011 (http://guidance.nice.org.uk/CG11S).Google Scholar
35 Trust Talk. BSMHT Launch unique Mental Health Service at City Hospital. Trust Talk 2010; Feb/March: 3 (http://www.bsmhft.nhs.uk/publications/trust-talk/?assetesctl52320=4368).Google Scholar
36 Anon. Innovation in Mental Health. Health Service Journal Awards Supplement, 2010; 23 December: (http://www.hsj.co.uk/Journals/2/Files/2010/12/1/HSJ%20AWARDS%202011.pdf).Google Scholar
37 Drummond, C. Alcohol Needs Assessment Research Project: The 2004 National Alcohol Needs Assessment for England. Alcohol Needs Assessment Research Project, 2005 (http://www.nwph.net/alcohol/reports/anarp%20alcohol%20concern%201-11-05.pdf).Google Scholar
38 Faculty of Substance Misuse. Role for Consultants with Responsibility in Substance Misuse. (Council Report CI97). Royal College of Psychiatrists, 2010.Google Scholar
39 Craddock, N, Kerr, M, Thapar, A. What is the core expertise of the psychiatrist. Psychiatrist 2010; 34: 457–60.Google Scholar
40 Hawkes, N. Unions Attack plan to allow providers to offer cut price services. BMJ 2011; 342: D331.Google Scholar
41 Godlee, F. NHS reforms – why now. BMJ 2011; 342: d552.Google Scholar
Submit a response

eLetters

No eLetters have been published for this article.