Better provision for people with dual needs

Friday, 8 November 2013 - 7:48am

By breaking down barriers between services, we can work together to gain a better understanding of the connection between different needs and issues.

Photograph: J Hayne (Flickr)
Photograph: J Hayne (Flickr)

“The biggest gap (in service provision) is care for both mental health and drugs/alcohol at the same time” – Survey of Needs & Provision 2012.

People experiencing homelessness can often suffer from a range of complex needs, which require the attention of multiple services. Unfortunately, due to a lack of joint-working, they can often be denied access to the services they require. By breaking down barriers between services, we can work together to gain a better understanding of the connection between different needs and issues.


The World Health Organisation defines health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. Significantly, this definition offers a view of health as a multi-faceted condition, comprising of numerous different physical, mental or social elements.

The idea of health as a series of interconnecting factors is also vital to understanding and treating poor health. It is, after all, extremely rare that a particular health concern will exist in isolation, whatever the severity. 

For example, in discussing mental health, the 2010 government drug strategy, ‘Reducing Demand, Restricting Supply, Building Recovery’, identifies ‘a clear association between mental illness and drug and alcohol dependence’ and recognises those ‘experiencing mental ill-health have a higher risk of substance misuse’.

Dual needs

The connection between these two aspects of ill-health is what we’ve come to know as “dual needs”. Given the prevalence of mental illness and substance misuse within the homeless community, it is not surprising that efforts to provide support for clients with a dual diagnosis represent a major challenge for the sector. 

According to the latest CHAIN figures, 69% of all rough sleepers in London have at least one support need around alcohol, drugs and/or mental health. Furthermore, one-in-three rough sleepers will have experience of prison, and one-in-ten will have been in care. However, these are all self-declared figures and so, if anything, are probably erring on the low side. 

Over the past 18 months our Dual Needs project has been funded by the Department of Health to work with five different Innovation Areas across the country to identify the issues that currently exist in supporting and treating homeless people with dual needs.

A report for each Innovation Area was produced containing qualitative and quantitative data on levels of local need and the views of clients and staff on the current state of service provision.

Lack of joint working

One of the major structural concerns highlighted across all of the areas was a lack of effective joint working between services. Problems associated with poor communication, information sharing, inflexible appointment times and overly stringent service entry criteria have all contributed to large numbers of patients being unable to gain access to the services they require. 

The current government strategy, ‘No health without mental health’, makes clear that the ‘provision of fully integrated care’ is vital to treating patients with a dual diagnosis, and that it is keen to actively promote and support improvements in commissioning service provision for this group’.   

In leaving these people untreated, it is likely that they will have little choice but to resort to costly emergency services to receive the help they need. On average, 55% of the people with dual needs surveyed across the five Innovation Areas had been to A&E at least once in the last six months, with a significant proportion visiting multiple times.

Better commissioning

One of the major ways in which the project has attempted to improve joint working is to encourage the Innovation Areas to use the research information contained within their reports to influence their local health commissioning structures.

In basing their commissioning decisions on the needs of those in their local areas, Clinical Commissioning Groups and public health structures need to work in tandem with local service providers to coordinate the commissioning of services for people with dual needs, including housing, health and social care. 

Recent changes to the NHS and local government offer great opportunities, but also present huge challenges. What remains clear, however, is that without a coordinated response from local service providers and wider strategic partners, the needs of a lot of people will remain unmet.