Mainstreaming care provision in mental health support requires a shift in culture

More than one-third of people with severe mental health problems (SMI) have a co-existing alcohol/drug condition: but the evidence base on which to build effective service models and responses is limited.

Across the UK, the integration of service models remains fragmentary. This is despite a consistent policy direction spanning almost two decades to “mainstream” treatment of people with co-occurring severe mental health problems and alcohol/drug use (COSMHAD).

“Mainstreaming” means that all staff in mental health and substance use services should be equipped with the skills, knowledge, and attitudes to deliver care that integrates both the mental health and substance use needs in a holistic package of care. 

An NIHR Health Technology Assessment study (The RECO Study), led by Edinburgh Napier University and working with Liverpool John Moores University (as well as partners from King’s College, London, Northumbria University, South London and Maudsley NHS Trust, and Avon and Wiltshire Partnership NHS Trust), is aiming to identify and describe the contexts and associated mechanisms by which engagement and other health outcomes are achieved.

Published this week in The Lancet, the research team’s first paper provides a realist synthesis of evidence from 132 international studies.

“For the first time, we have been able to identify the key ingredients that are essential in order to meet the challenge of co-occurring disorders,” explains Liz Hughes, Professor of Nursing at Edinburgh Napier University and chief investigator of the RECO study.

“It is clear that there needs to be more integration of mental health and substance use care provision, as well as a change in culture and attitudes. This can only be achieved with dedicated expert leaders who have the support of senior managers.”

Dr Jane Harris of Liverpool John Moores University, lead author, adds: “Services for people with co-existing serious mental health and alcohol/drug conditions are complex systems. Outcomes can be affected by numerous compounding factors, such as the type and severity of the mental health or alcohol/drug condition, the interplay between the two conditions, peoples’ age, gender and ethnicity, as well as previous experiences of seeking help. Applying realist approaches, as the research team has done, offers the potential to describe why interventions or services for COSMHAD are successful or unsuccessful, focusing on ‘what works, for who, and in which circumstances’.”

The research team has developed 11 programme theories from their analysis, to provide insight into what might work and under what conditions. These include making first contact count as a positive experience to increase the likelihood of ongoing engagement.

Other critical success factors include the provision of compassionate care without stigma; and a clearly defined local care pathway to ensure people get the right help. To deliver this, appropriate training (including pre-registration and post-registration training) and supervision is required. But it is not enough to focus on just staff training to deliver effective care.

“What is needed is a cultural shift in compassionate leadership and system delivery to ensure people with COSMHAD receive compassionate, trauma-informed care that meets their needs,” says Professor Hughes.

“Local clinical leadership is vital, as well as support from senior leaders in the local area (and commissioners), as this work needs to span multiple agencies.”


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