Introduction

Challenges and ways to further grow social action are examined in terms of service provision gaps, resource requirements, stigma and prejudice, procedural challenges, leadership, commissioning and demonstrating impact. The report has been led by submissions received from our call for evidence and we would like to express our sincerest thanks to all the organisations and individuals that submitted evidence and otherwise supported and made our work possible.

The All Party Parliamentary Group (APPG) on Complex Needs and Dual Diagnosis was established in 2007 in recognition of the fact that people seeking help often have a number of over-lapping needs as well as problems accessing support. It is made up of interested MPs and peers and supported by a large membership network, with secretariat support provided by Turning Point. The group aims to ensure that the issues faced by people with complex needs or a dual diagnosis remain on the political agenda. Between April and May 2017, the APPG ran a joint call for evidence with the Office for Civil Society (OCS). This asked how social action can improve outcomes, prevent crisis, support recovery and help develop more responsive services for people with a dual diagnosis or complex needs. Both written and oral evidence was received from a wide range of respondents from VCSE organisations, the NHS, peer-led groups, service providers, academics, public sector professionals and people with lived experience.

• Social action is broadly defined as ‘people coming together to tackle an issue, support others or improve their local area’, by giving time and other resources in forms such as volunteering, community owned services, peer-led groups and community organisation (Office for

Civil Society, 2017)

• Dual diagnosis can be used to describe many combinations of needs, however the APPG defines dual diagnosis in terms of co-existing mental health and substance misuse issues

• Complex needs is a term, which for the APPG describes two or more needs that affect a person’s physical, mental, social or financial wellbeing.

Such needs typically interact with and worsen one another, leading to individuals experiencing several problems at the same time. These needs can also be severe, longstanding and difficult to identify, diagnose or treat (APPG on

Complex Needs and Dual Diagnosis, 2014)

• For the purpose of the call for evidence the APPG was interested in complex needs where one of

For more background information, please see the appendices.

It is estimated that one in four people will experience mental health issues at some point and mental ill health is thought to cost the UK £105 billion each year (Department of Health, 2011). Drug and alcohol misuse affects more than 15 million people (Home Office, 2015; Public Health England, 2016) and is estimated to cost more than £36 billion a year (Public Health England, 2014).

As noted in Turning Point’s Dual Dilemma report (2016), what is less clear is the prevalence of people who experience mental health and substance misuse issues together and the impact of this. It is even more difficult to quantify the numbers of people with wide-ranging complex and multiple needs, however there are some statistics that offer insight:

• More than a quarter of a million people in England have contact with at least two of the following: homelessness services, substance misuse services and the criminal justice system. At least 58,000 people have contact with all three (Lankelly Chase Foundation, 2015)

• The cost to society of those experiencing severe and multiple disadvantages could be in the region of more than £10 billion a year (Lankelly Chase Foundation, 2015)

• Up to 70% of people in drug services and 86% of those in alcohol services have experienced mental health problems (Public Health England, 2014) • Dual diagnosis affects a third of mental health service users, half of substance misuse service users and 70% of prisoners (NHS

Confederation, 2009)

• There are around 300,000 problem gamblers in the UK and this is associated with poor mental health, drug and alcohol problems and social problems (Cowlishaw and

Kessler, 2015).

• People with serious mental health problems have a life expectancy of 15 to 20 years less than the rest of the population. The figure is nine to 17 years less in those who misuse alcohol and drugs (Wahlbeck et al, 2011)

In recent years there has been an increasing focus on addressing mental health, stigma and inequality, more person-centred approaches to services and a focus on community integration and peer support within mental health and substance misuse services.

Government support for social action initiatives has continued to grow. Social action has been encouraged by Government activity including the growth of projects through the Centre for Social Action, empowering communities through the Community Organisers Programme, backing employer-supported volunteering in the workplace, supporting giving, encouraging young people to get involved in social action and recognising and rewarding people’s contributions.

The Five Year Forward View for Mental Health (NHS England, 2016) provides a blueprint for changes that NHS staff, organisations and others can make to improve mental health. Key aims include strengthening communitybased services to reduce demand on the acute sector and moving the commissioning model for in-patient beds in mental health towards a more ‘place-based’ approach so that pathways and incentives are better aligned. Recent NICE guidance (2016) also aims to develop coordinated services that address people’s wider needs and states that people with co-existing severe mental illness and substance misuse issues should be involved in improving existing services. We are yet to see how widely this has been implemented.

The previous No Health Without Mental Health strategy (Department of Health, 2011) identified the need for integrated care pathways which could improve support for those with both mental health and substance misuse issues. The 2012 Health and Social Care Act also brought in greater integration and changes to commissioning, though with the public health remit moving to local authorities the gap between substance misuse and mental health commissioning has arguably widened (Turning Point, 2016).

Numerous efforts to improve services for people with complex needs or a dual diagnosis continue and there are many examples of excellent practice. However, joined up and collaborative services that can respond to people with multiple needs are not yet the norm. It is the APPG’s view that people with complex needs remain at the sharp end of the inverse care law. This means that they often require the most support but tend to receive the least. This can happen because traditional services are difficult for them to access, they are refused referrals and shunted between several different services, or they have fallen through gaps in services due to a lack of integrated provision. This is of course harmful for the individuals and those close to them who suffer as a result. It also means that accident and emergency departments, the police and other frontline services face significant pressure when individuals reach crisis point. In the longer term, public services as a whole continue to face pressure as people’s unmet needs worsen further.

There is both a moral and economic case for making sure that people with complex needs are able to access responsive and appropriate services and achieve recovery in a way that works for them. The evidence suggests that social action has the potential to be a big part of the solution.