Services ‘ill-equipped’ to cope with mental health and substance use conditions

Researchers are urging UK governments to introduce expert clinicians across all health services to co-ordinate better treatment for people with serious mental health illness and substance use problems.

As part of October’s World Mental Health Day, a study involving experts from Northumbria University and led by Professor of Substance Use Research Elizabeth Hughes, from Glasgow Caledonian University, was published by funders the National Institute for Health and Care Research (NIHR).

The study revealed services across the UK remain ill-equipped to meet the needs of people with co- existing serious mental health and substance use conditions. It said change requires joined-up government policy and local integration of health and social care services, with clinical leads supporting the workforce to come together.

However, the study also identified the contexts and components of good practice at a systems and practitioner level to improve the outcomes for people who use the services, and their carers, and job satisfaction for staff who work in mental health and substance use services.

Between 30 and 50 per cent of people with serious mental illness also have co-existing alcohol and drug conditions, which is associated with poor health outcomes and people in areas of deprivation are worst hit.

The impact of serious mental health difficulties can be severe, long-lasting, and can seriously affect peoples' lives over a long period of time. It is common for people who experience serious mental health difficulties to have problems with drinking too much alcohol and/or taking drugs, which can add to the mental health difficulties.

The Realist Evaluation Co-occurring (RECO) began in 2020 when scientists gathered information about existing joined-up services across all health board areas and found none in Scotland, and less than 20 locations in England and Wales where there was a tangible investment in staffing to address this need.

As well as Northumbria and Glasgow Caledonian Universities, the research involved experts from a range of mental health, alcohol and drug organisations, and the Universities of Leeds, King’s College London and Liverpool John Moores, NHS Trusts and the Institute of Population Health.

The team picked five out of the 20 locations in England to study. They talked to service users including women, homeless people and ex-prisoners, carers, staff in mental health, and drug and alcohol services, to find out how local services work together and what works best.

A realist evaluation was used as the underpinning methodological framework for the research. This was led from Northumbria University by Professor of Applied Health and Social Care Research, Sonia Dalkin, with health economics input from Professor Angela Bate. Realist evaluation focuses on understanding if and how interventions work, or not, for who, and in which circumstances. It aims to identify the underlying mechanisms that explain how outcomes were caused, and how context influences these.

Speaking about the study, Professor Dalkin from Northumbria’s Department of Social Work, Education and Community Wellbeing, said: “A realist approach is useful when trying to understand complex interventions or services, such as those designed to help people with co-existing serious mental health and substance use conditions. We know that what works in one NHS Trust or particular area or for a particular type of person, may not work in the same way for another. Therefore, we need to be mindful of what we refer to as ‘context’ and the impact it has on services and their ‘effectiveness’, and thus their cost-effectiveness.

“Despite finding that services across the UK remain ill-equipped to meet the needs of people with co-existing serious mental health and substance use conditions, using a realist approach allowed us to avoid giving a ‘pass or fail’ verdict on these services. Instead, we developed transferable lessons for increasing best practice across the UK, by highlighting how these services could work best, in particular contexts, and through which mechanisms.”

The study provides details on how and in what circumstances integrated care can work better for people with co-occurring severe mental health, and alcohol and drug conditions, and makes a series of recommendations for change.

Professor Hughes, who is based in Glasgow Caledonian’s School of Health and Life Sciences Department of Nursing and Community Health, said: “It's hard to believe that we are in 2024 and people with combined serious mental health illness and alcohol or drug use are being left behind in the system because of the lack of a co-ordinated approach in treatment and services across the whole of the UK.

“There will be people who slip through the net and spiral out of control, or even take their own lives, because they feel there's nowhere for them to go and they keep getting passed from pillar to post.

“We will use all that we have learned from this study to help people who fund and provide health services to improve these services. We will also make sure our findings are shared with people in the department of health who develop policies and guidance that will be used in the future when new services are developed.

“We hope that the results will help service providers to offer people who experience severe mental health difficulties who also use alcohol and/or drugs get the right treatment and support in order to meet their goals.

“We found things work well when there is a dedicated clinical leader who can co-ordinate all these services, who can be a role model to other staff, put on some in-house training, supervision, and broker that relationship between substance use and mental health, which is really divided right now.

“Nothing really happens without somebody on the ground doing those things, because we found in one of our case studies locations that they had a consultant nurse doing that role who retired and hadn't been replaced and nothing worked after that as there was nobody joining the dots.”