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Coexisting severe mental illness and substance misuse: assessment and management in healthcare settings

About

What is covered

This interactive flowchart covers assessment and management of psychosis with coexisting substance misuse in adults and young people.
The term psychosis is used to describe a group of severe mental health disorders characterised by the presence of delusions and hallucinations that disrupt a person's perception, thoughts, emotions and behaviour. The main forms of psychosis are schizophrenia, bipolar disorder or other affective psychosis.
Substance misuse (in these recommendations) is a broad term encompassing the harmful use of any psychotropic substance, including alcohol and either legal or illicit drugs. Such use is usually, but not always, regarded as a problem if there is evidence of dependence. However, substance misuse can be harmful without dependence, especially among people with coexisting psychosis.
Approximately 40% of people with psychosis misuse substances at some point in their lifetime, at least double the rate seen in the general population. Substance misuse among individuals with psychiatric disorders is associated with significantly poorer outcomes than for individuals with a single disorder.

Updates

Updates to this interactive flowchart

19 August 2019 Coexisting severe mental illness and substance misuse (NICE quality standard 188) added.
29 November 2016 The title of this interactive flowchart was changed.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said about assessing and managing coexisting severe mental illness and substance misuse in healthcare settings in an interactive flowchart

What is covered

This interactive flowchart covers assessment and management of psychosis with coexisting substance misuse in adults and young people.
The term psychosis is used to describe a group of severe mental health disorders characterised by the presence of delusions and hallucinations that disrupt a person's perception, thoughts, emotions and behaviour. The main forms of psychosis are schizophrenia, bipolar disorder or other affective psychosis.
Substance misuse (in these recommendations) is a broad term encompassing the harmful use of any psychotropic substance, including alcohol and either legal or illicit drugs. Such use is usually, but not always, regarded as a problem if there is evidence of dependence. However, substance misuse can be harmful without dependence, especially among people with coexisting psychosis.
Approximately 40% of people with psychosis misuse substances at some point in their lifetime, at least double the rate seen in the general population. Substance misuse among individuals with psychiatric disorders is associated with significantly poorer outcomes than for individuals with a single disorder.

Updates

Updates to this interactive flowchart

19 August 2019 Coexisting severe mental illness and substance misuse (NICE quality standard 188) added.
29 November 2016 The title of this interactive flowchart was changed.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Structural neuroimaging in first-episode psychosis (2008) NICE technology appraisal guidance 136

Quality standards

Coexisting severe mental illness and substance misuse

These quality statements are taken from the coexisting severe mental illness and substance misuse quality standard. The quality standard defines clinical best practice for coexisting severe mental illness and substance misuse and should be read in full.

Quality statements

Initial identification of coexisting substance misuse

This quality statement is taken from the coexisting severe mental illness and substance misuse quality standard. The quality standard defines clinical best practice for coexisting severe mental illness and substance misuse and should be read in full.

Quality statement

People aged 14 and over with suspected or confirmed severe mental illness are asked about their use of alcohol and drugs.

Rationale

People who have severe mental illness and substance misuse have significantly poorer outcomes than people who have either severe mental illness or substance misuse alone. Identifying substance misuse as soon as possible, by asking people about it when they attend services, such as child and adolescent mental health services (CAMHS), mental health services, emergency departments, general practice and services within the criminal justice system, gives a better chance of tailored care and treatment plans being effective. Initial identification and subsequent comprehensive assessment also help to reduce the risk of worsening psychiatric symptoms and homelessness, to reduce contact with the criminal justice system and to improve physical health.

Quality measures

Structure
Evidence of local arrangements to ensure that people aged 14 and over with suspected or confirmed severe mental illness are routinely asked about substance misuse.
Data source: Local data collection, for example, written clinical protocols to ensure people aged 14 and over with suspected or confirmed severe mental illness are asked routinely, and at least every 12 months, about substance misuse.
Process
a) Proportion of people aged 14 and over with suspected severe mental illness who are asked about their use of alcohol and drugs.
Numerator – the number in the denominator who are asked about their use of alcohol and drugs.
Denominator – the number of people aged 14 and over with suspected severe mental illness.
Data source: Local data collection, for example, audits of patient records.
b) Proportion of people aged 14 and over with confirmed severe mental illness who are asked about their use of alcohol and drugs.
Numerator – the number in the denominator who are asked about their use of alcohol and drugs.
Denominator – the number of people aged 14 and over with confirmed severe mental illness.
Data source: Local data collection, for example, audits of patient records. The number of people with psychosis in the community and in secondary care who had their alcohol and substance misuse recorded in the preceding 12 months for 2017/18 was collected by the National Clinical Audit of Psychosis. The Indicators no longer in Quality Outcomes Framework (INLIQ) extraction for 2019/20 will include the number of people with schizophrenia, bipolar affective disorder and other psychoses who had a record of alcohol consumption in the preceding 12 months (Former Quality Outcomes Framework indicator MH007. Data available for previous years from NHS Digital.)
Outcome
Incidence of people aged 14 and over with severe mental illness newly identified as having coexisting substance misuse.
Data source: Local data collection, for example, audit of patient records and referrals.

What the quality statement means for different audiences

Service providers (such as general practices, emergency departments and mental health services, including CAMHS and services provided within the criminal justice system) ensure that people aged 14 and over with suspected or confirmed severe mental illness are asked about coexisting substance misuse. Services ensure that all staff are trained to discuss this sensitively so that people do not feel judged or stigmatised and can be honest in their responses.
Healthcare practitioners (such as GPs and practice nurses, accident and emergency practitioners and mental health professionals, including those working in CAMHS and services within the criminal justice system) ask people aged 14 and over with suspected or confirmed severe mental illness about substance misuse. The level of the discussion should be appropriate to the setting (for example, a more detailed discussion is likely in a mental health service). Practitioners should be sensitive and bear in mind that people may not wish to divulge all the details of substance use, perhaps because of stigma or the requirements of probation terms.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services in which people aged 14 and over with suspected or confirmed severe mental illness are asked about coexisting substance misuse. They monitor whether the services they commission have effective joint working arrangements to provide care and support for people with coexisting severe mental illness and substance misuse.
People aged 14 and over with suspected or confirmed severe mental illness are asked whether they drink alcohol or use drugs (prescription and non-prescription). If alcohol or drugs are affecting their physical and mental health or relationships, or might do in the future, they are offered help and support.

Source guidance

Definitions of terms used in this quality statement

Severe mental illness
Severe mental illness includes a clinical diagnosis of schizophrenia, schizotypal and delusional disorders, bipolar affective disorder, or severe depressive episodes with or without psychosis.
Asking about use of alcohol and drugs
Healthcare professionals routinely ask people about their use of alcohol and prescribed and non-prescribed (including illicit) drugs (examples of drugs used include illegal drugs such as cannabis, cocaine, crack cocaine and heroin, prescribed drugs that have not been prescribed to the person using them or are not taken in the way that was intended such as diazepam and 'over-the-counter' medicines that can be bought from the chemist such as codeine linctus). People are also asked about their use of new psychoactive substances. The level of detail obtained depends on the setting and how much information the person wishes to provide at that time.
Where possible, the person should be asked about all of the following:
  • particular substance(s) used
  • quantity, frequency and pattern of use
  • route of administration
  • duration of current level of use.
Healthcare professionals should also seek corroborative evidence from families, carers or significant others (a partner, friends or anyone important to the person), where this is possible and permission is given.
[Adapted from NICE’s guideline on coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings, information for the public, recommendation 1.2.1 and expert opinion]
Substance misuse
Substance misuse refers to the use of legal or illicit drugs, including alcohol and medicine, in a way that causes mental or physical damage. This may include low levels of substance use that would not usually be considered harmful or problematic but may have a significant effect on the mental health of people with a mental illness such as psychosis.

Equality and diversity considerations

The symptoms of severe mental illness can be different in young people than in adults. Mental health and substance misuse professionals need to take this into account when working with young people and should be aware that young people may present with quite subtle manifestations of mental illness. Professionals working with young people, for example, in the criminal justice system or substance misuse services, should have access to advice from a CAMHS team.
Coexisting severe mental illness and substance misuse can occur in older people but there are often misconceptions that this is an issue for younger people. Older people should be asked about substance misuse when they present to services.

Exclusion from services

This quality statement is taken from the coexisting severe mental illness and substance misuse quality standard. The quality standard defines clinical best practice for coexisting severe mental illness and substance misuse and should be read in full.

Quality statement

People aged 14 and over are not excluded from mental health services because of coexisting substance misuse or from substance misuse services because of coexisting severe mental illness.

Rationale

People with coexisting severe mental illness and substance misuse need age-appropriate support and expert care for these conditions. Appropriate care and support from mental health and substance misuse services will improve mental and physical health and medication adherence, and will reduce the risk of homelessness and dropout from services.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people aged 14 and over are not excluded from substance misuse services on referral or when they present because of their severe mental illness.
Data source: Local data collection, for example, a local pathway for coexisting severe mental illness and substance misuse, joint working arrangements between mental health and substance misuse services, and service protocols.
b) Evidence of local arrangements to ensure that people aged 14 and over are not excluded from mental health services on referral or when they present because of their substance misuse.
Data source: Local data collection, for example, a local pathway for coexisting severe mental illness and substance misuse, joint working arrangements between mental health and substance misuse services, and service protocols.
Process
a) Proportion of referrals to substance misuse services for people aged 14 and over that are refused because of coexisting severe mental illness.
Numerator – the number in the denominator that are refused because of coexisting severe mental illness.
Denominator – the number of referrals to substance misuse services for people aged 14 and over with coexisting severe mental illness and substance misuse.
Data source: Local data collection, for example, audits of patient and referral records.
b) Proportion of referrals to mental health services for people aged 14 and over that are refused because of coexisting substance misuse.
Numerator – the number in the denominator that are refused because of coexisting substance misuse.
Denominator – the number of referrals to mental health services for people aged 14 and over with coexisting severe mental illness and substance misuse.
Data source: Local data collection, for example, audits of patient and referral records.
c) Proportion of people aged 14 and over presenting to substance misuse services who are not seen because of coexisting severe mental illness.
Numerator – the number in the denominator who are not seen because of coexisting severe mental illness.
Denominator – the number of people aged 14 and over with coexisting severe mental illness and substance misuse presenting to substance misuse services.
Data source: Local data collection, for example, audits of patient and clinic records.
d) Proportion of people aged 14 and over presenting to mental health services who are not seen because of coexisting substance misuse.
Numerator – the number in the denominator who are not seen because of coexisting substance misuse.
Denominator – the number of people aged 14 and over with coexisting severe mental illness and substance misuse presenting to mental health services.
Data source: Local data collection, for example, audits of patient and clinic records.
Outcome
a) Levels of physical health of people aged 14 and over with coexisting severe mental illness and substance misuse.
Data source: Local data collection, for example, audits of patient records. The Quality Outcomes Framework includes indicators on the physical health of people with severe mental illness. MH003 measures the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood pressure in the preceding 12 months. MH006 measures the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of BMI in the preceding 12 months.
b) Rates of medication adherence in people aged 14 and over with coexisting severe mental illness and substance misuse.
Data source: Local data collection, for example, audits of patient records.
c) Proportion of people aged 14 and over with coexisting severe mental illness and substance misuse in stable accommodation.
Numerator – the number in the denominator in stable accommodation.
Denominator – the number of people aged 14 and over with coexisting severe mental illness and substance misuse.
Data source: Local data collection, for example, audits of patient records. Public Health England’s information on severe mental illness public health profile includes data on stable and appropriate accommodation for people on a care programme approach.

What the quality statement means for different audiences

Service providers (community, primary and secondary mental health services, including child and adolescent mental health services [CAMHS], and substance misuse services, including voluntary sector organisations) have policies and training in place to ensure that staff do not exclude people from the service because of severe mental illness or any substance misuse at point of referral or presentation to the service. They support and train staff to work with people with substance misuse and mental illness. They ensure that staff understand that people with coexisting severe mental illness and substance misuse may present with symptoms of severe mental illness or under the influence of alcohol or drugs. Providers ensure that staff know that people should not be excluded from the service because of this.
Mental health and substance misuse practitioners do not exclude people from a service because of severe mental illness or substance misuse. This applies at the point of referral and when people present to the service, even if they are severely intoxicated on presentation. Practitioners work with people with coexisting severe mental illness and substance misuse, and other services as needed, to ensure they provide the care and support required.
Commissioners (clinical commissioning groups, local authorities and NHS England) commission services for severe mental illness and for substance misuse and ensure that they have joint strategic working protocols so that people are not excluded from either service because of their coexisting condition. This applies at the point of referral and when they present to the service.
People aged 14 and over with severe mental illness and substance misuse are not refused care and support from a substance misuse or mental health service because of their mental illness or their drug or alcohol use. This means that they can receive care and support for both conditions at the same time.

Source guidance

Definitions of terms used in this quality statement

Severe mental illness
Severe mental illness includes a clinical diagnosis of schizophrenia, schizotypal and delusional disorders, bipolar affective disorder, or severe depressive episodes with or without psychosis.
Substance misuse
Substance misuse refers to the use of legal or illicit drugs, including alcohol and medicine, in a way that causes mental or physical damage. This may include low levels of substance use that would not usually be considered harmful or problematic but may have a significant effect on the mental health of people with a mental illness such as psychosis.
Exclusion from services
This includes refusal to accept a person for assessment or treatment because of the coexisting condition. This can be at the point of referral or when people attend for treatment. Most people aged 14 and over with coexisting severe mental illness and substance misuse will receive treatment for both conditions by healthcare professionals in secondary care mental health services such as community-based mental health teams, with input from substance misuse services if appropriate.
[Adapted from NICE’s guideline on coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings, recommendation 1.4.5 and expert opinion]

Equality and diversity considerations

The symptoms of severe mental illness can be different in young people than in adults. Mental health and substance misuse professionals need to take this into account when working with young people, and should be aware that young people may present with quite subtle manifestations of mental illness. Professionals working with young people, for example, in the criminal justice system or substance misuse services, should have access to advice from a CAMHS team.

Care coordinators

This quality statement is taken from the coexisting severe mental illness and substance misuse quality standard. The quality standard defines clinical best practice for coexisting severe mental illness and substance misuse and should be read in full.

Quality statement

People aged 14 and over with coexisting severe mental illness and substance misuse have a care coordinator working in mental health services when they are identified as needing treatment from secondary care mental health services.

Rationale

People with coexisting severe mental illness and substance misuse who need treatment from secondary care mental health services may be in contact with several services, including substance misuse, primary and secondary care health, social care, local authorities, housing and employment services. A care coordinator working in mental health services in the community can liaise with the different services and act as a central point of contact for the person, their carers and service providers. This support helps to keep the person engaged with services. It also helps with the development and review of the care plan and ensures that the person is seen by the right service at the right time.

Quality measures

Structure
a) Evidence of a locally agreed specification of the role and functions of the care coordinator working in mental health services.
Data source: Local data collection, for example, descriptions of the role of care coordinator and service specifications.
b) Evidence of local arrangements to ensure that people aged 14 and over with coexisting severe mental illness and substance misuse have a care coordinator working in mental health services when they are identified as needing treatment from secondary mental health services.
Data source: Local data collection, for example, service specifications and joint strategic working protocols.
Process
Proportion of people aged 14 and over with coexisting severe mental illness and substance misuse who have a care coordinator working in mental health services when they are identified as needing treatment from secondary care mental health services.
Numerator – the number in the denominator who have a care coordinator working in mental health services.
Denominator – the number of people aged 14 and over with coexisting severe mental illness and substance misuse identified as needing treatment from secondary care mental health services.
Data source: Local data collection, for example, audits of patient records.
Outcome
Proportion of people aged 14 and over with coexisting severe mental illness and substance misuse receiving care from secondary care mental health services who are satisfied with the support they receive from services.
Numerator – the number in the denominator who are satisfied with the support they receive from services.
Denominator – the number of people aged 14 and over with coexisting severe mental illness and substance misuse receiving care from secondary care mental health services.
Data source: Local data collection, for example, surveys of people aged 14 and over with coexisting severe mental illness and substance misuse.

What the quality statement means for different audiences

Service providers (such as mental health services, including child and adolescent mental health services, health services, substance misuse services, housing services and employment services) ensure that their staff understand the role of the care coordinator for people with coexisting severe mental illness and substance misuse. They ensure that staff work with the care coordinator when developing care plans. Providers ensure that people with coexisting severe mental illness and substance misuse are given a care coordinator working in mental health services in the community when they need treatment from secondary care mental health services.
Care coordinators working in mental health services in the community work with the relevant services to develop a care plan for people with coexisting severe mental illness and substance misuse. They involve the person and work with the services to address the person’s social care, housing, physical and mental health needs, as well as their substance misuse. They provide any other support that may be needed, including coordinated flexible individualised care.
Health and social care practitioners (such as GPs, mental health practitioners, drug and alcohol misuse practitioners, housing officers and employment officers) work with care coordinators when planning care and support for people with coexisting severe mental illness and substance misuse who need treatment from secondary care mental health services.
Commissioners (such as clinical commissioning groups, local authorities and NHS England) ensure that they commission services that work closely, for example, through joint strategic working protocols, with care coordinators working in mental health services in the community to plan and provide care for people with coexisting severe mental illness and substance misuse who need treatment from secondary care mental health services. Clinical commissioning groups commission mental health services that provide care coordinators in the community for people with coexisting severe mental illness and substance misuse who need treatment from secondary mental health services.
People aged 14 and over with severe mental illness and substance misuse have a care coordinator who works in mental health services in the community if they need treatment from secondary care mental health services. The care coordinator is their main point of contact and works with them to support their care plan. The coordinator works with the other services involved in the person’s care (for example, housing and employment services) to make sure they get the support they need.

Source guidance

Definitions of terms used in this quality statement

Severe mental illness
Severe mental illness includes a clinical diagnosis of schizophrenia, schizotypal and delusional disorders, bipolar affective disorder, or severe depressive episodes with or without psychosis.
Substance misuse
Substance misuse refers to the use of legal or illicit drugs, including alcohol and medicine, in a way that causes mental or physical damage. This may include low levels of substance use that would not usually be considered harmful or problematic but may have a significant effect on the mental health of people with a mental illness such as psychosis.
Identified as needing treatment from secondary care mental health services
A person is identified as needing treatment from secondary care mental health services following a comprehensive assessment of their mental health and substance misuse needs. They will receive the ongoing treatment they need from mental health services either based in hospitals, as an inpatient or outpatient, or in the community.
[NICE’s guideline on coexisting severe mental illness and substance misuse: community health and social care services, recommendation 1.2.1 and expert opinion]
Care coordinator
The care coordinator acts as a contact for the person and helps to develop a care plan with them. They work in the community with other services to address the person's social care, housing, physical and mental health needs, as well as substance misuse, and provide any other support the person may need. They work with other organisations (with shared responsibilities and regular communication) when developing or reviewing the person's care plan. This includes substance misuse services, primary and secondary care health, social care, local authorities and organisations such as housing and employment services. They usually arrange annual multi-agency and multidisciplinary case review meetings.
[NICE’s guideline on coexisting severe mental illness and substance misuse: community health and social care services, recommendations 1.2.2, 1.2.3, 1.3.1 and 1.3.9]

Follow-up after any missed appointment

This quality statement is taken from the coexisting severe mental illness and substance misuse quality standard. The quality standard defines clinical best practice for coexisting severe mental illness and substance misuse and should be read in full.

Quality statement

People aged 14 and over with coexisting severe mental illness and substance misuse are followed up if they miss any appointment.

Rationale

Services may find it difficult to engage with people with coexisting severe mental illness and substance misuse and this can lead to people missing appointments. If people are automatically discharged from a service because of non-attendance they can be left without support when they are vulnerable. It is therefore important for them to be promptly and actively followed up, for example, by phoning or visiting them if they miss any appointment, especially after the first missed appointment. This will help to ensure they remain in contact with services or re-engage quickly.

Quality measures

Structure
a) Evidence of local arrangements to identify people aged 14 and over with coexisting severe mental illness and substance misuse who miss any appointment.
Data source: Local data collection, for example, clinic attendance protocols and data-sharing arrangements.
b) Evidence of local arrangements to contact people aged 14 and over with coexisting severe mental illness and substance misuse who miss any appointment.
Data source: Local data collection, for example, service protocols.
c) Evidence of flexibility when arranging appointments for people aged 14 and over with coexisting severe mental illness and substance misuse.
Data source: Local data collection, for example, service protocols for arranging for home visits or meeting at other locations, for example, in a café.
d) Evidence of local arrangements for services to ensure that people aged 14 and over with coexisting severe mental illness and substance misuse are not automatically discharged for missing appointments.
Data source: Local data collection, for example, service protocols and joint strategic working protocols.
Process
a) Proportion of people aged 14 and over with coexisting severe mental illness and substance misuse who are followed up when they miss any appointment.
Numerator – the number in the denominator who are followed up.
Denominator – the number of people aged 14 and over with coexisting severe mental illness and substance misuse who miss any appointment.
Data source: Local data collection, for example, audits of patient records and clinic records.
b) Proportion of people aged 14 and over with coexisting severe mental illness and substance misuse who were not followed up and were discharged from services because of missing any appointment.
Numerator – the number in the denominator who were not followed up.
Denominator – the number of people aged 14 and over with coexisting severe mental illness and substance misuse discharged from services because of missing any appointment.
Data source: Local data collection, for example, audits of patient records and clinic records.
Outcome
a) Proportion of people aged 14 and over receiving treatment for coexisting severe mental illness and substance misuse who re-engage with services after missing an appointment.
Numerator – the number in the denominator who re-engage with services.
Denominator – the number of people aged 14 and over receiving treatment for coexisting severe mental illness and substance misuse who miss any appointment.
Data source: Local data collection, for example, audits of patient records.
b) Proportion of people aged 14 and over with coexisting severe mental illness and substance misuse who complete their planned treatment for substance misuse.
Numerator – the number in the denominator who complete their planned treatment for substance misuse.
Denominator – the number of people aged 14 and over with coexisting severe mental illness and substance misuse who are receiving treatment for substance misuse.
Data source: Local data collection, for example, audits of patient records. Successful completion of drug and alcohol treatment data is available in Public Health England’s crisis care profile.
c) Proportion of people aged 14 and over with coexisting severe mental illness and substance misuse who remain in planned treatment for severe mental illness.
Numerator – the number in the denominator who remain in planned treatment for severe mental illness.
Denominator – the number of people aged 14 and over with coexisting severe mental illness and substance misuse.
Data source: Local data collection, for example, audits of patient records.

What the quality statement means for different audiences

Service providers (community, primary and secondary mental health services, including child and adolescent mental health services [CAMHS], and substance misuse services, including voluntary sector organisations) ensure that they are flexible when arranging appointments for people with coexisting severe mental illness and substance misuse. This may include holding drop in clinics and arranging appointments in locations suited to the person’s needs (for example, in a café). Ensuring people can access services in these ways will help to avoid missed appointments and keep people engaged. Services should have systems in place to identify people who have missed any appointment and contact them, for example, by phone, text or home visit outside of routine hours, to keep them engaged with the service.
Mental health and substance misuse practitioners (such as community, primary and secondary, including CAMHS, mental health practitioners, care coordinators and drug and alcohol misuse practitioners) work with other practitioners and services to help people with severe mental illness and substance misuse to stay engaged with services. They contact people, for example, by phone, text or home visit outside of routine hours, who have missed any appointment and discuss any non-attendance with other practitioners if needed. They provide appointments at times and locations to meet people’s needs where they can. They discuss and agree future care with other practitioners involved before the person is discharged from a service.
Commissioners (clinical commissioning groups, local authorities and NHS England) ensure that the services they commission do not automatically discharge people with coexisting severe mental illness and substance misuse because they miss an appointment. They ensure that the services they commission work together to offer flexibility, for example, with appointment times and locations to meet the specific needs of this group. They ensure that services follow up non-attendance to help people to stay engaged with services.
People aged 14 and over with severe mental illness and substance misuse are contacted if they miss any appointment rather than being automatically discharged from the service. The service works with them to arrange appointments at suitable times and places to help them avoid missing appointments in the future.

Source guidance

Definitions of terms used in this quality statement

Severe mental illness
Severe mental illness includes a clinical diagnosis of schizophrenia, schizotypal and delusional disorders, bipolar affective disorder, or severe depressive episodes with or without psychosis.
Substance misuse
Substance misuse refers to the use of legal or illicit drugs, including alcohol and medicine, in a way that causes mental or physical damage. This may include low levels of substance use that would not usually be considered harmful or problematic but may have a significant effect on the mental health of people with a mental illness such as psychosis.
Follow-up
Non-attendance at any appointment or activity is viewed by all practitioners involved in the person's care as a matter of concern. Follow-up actions could include:
  • contacting the person to rearrange an appointment
  • visiting the person at home
  • contacting any other practitioners involved in the person’s care, or family or carers identified in the person's care plan
  • contacting the person's care coordinator within mental health services immediately if there is a risk of self-harm or suicide, or at least within 24 hours if there are existing concerns.

Equality and diversity considerations

People who are homeless may be difficult to contact if they do not attend an appointment. When people who are homeless first attend services, agreements should be made on how they can be contacted, for example, through friends or relatives or through voluntary services.
People should be provided with information about their appointments that they can easily read and understand. Information should be in a format that suits their needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally and age appropriate. People should have access to an interpreter if needed.
For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

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Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

Child and adolescent mental health services
refers not just to a partner but also to friends and any person the service user considers to be important to them
refers not just to a partner but also to friends and any person the service user considers to be important to them
CAMHS Tier 1 refers to primary care and educational settings
CAMHS Tier 2 refers to primary care
CAMHS Tier 3 refers to community mental health
CAMHS Tier 4 refers to specialist inpatient and regional services

Paths in this pathway

Pathway created: September 2012 Last updated: August 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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