Collaboration between mental health and substance misuse services – what could it look like?

Across 2020 South East Fulfilling Lives facilitated conversations with 17 professionals – both specialist and non-specialists – from across mental health and substance misuse services: ranging from clinical psychologists and commissioners, to leaders of organisations, services managers, and frontline workers. The topic being discussed was ‘what does good psychological support look like for people entering formal substance misuse treatment’.

We asked contributors 7 questions over the course of a 1-hour conversation and we have brought together these views into a report called The Perspectives Project . One of those questions was ‘To what extent do you think statutory mental health services and substance misuse services working together is important in aiding someone to access and complete formal substance misuse treatment?’

It is this area we’re are going to look at in a little more detail in this blog and review what contributors had to say in response to this question.


By not working together, are we failing to meet the needs of people who have experienced complex trauma?

All the contributors to our work believed collaboration between support agencies is important, and all agreed it is not happening in practice as well as it could.

Joined up working should be an absolute minimum and was viewed as one of the primary challenges facing services. Operational teams shouldn’t be reliant on building good relationships with other agencies, collaboration and partnership working needs to be built into service design. More on this later!

Different Cultures, Different Structures

Many contributors reflected on how some of the differences between substance misuse services and mental health services have unintentionally created obstacles that slow down and hold back joint working and collaboration.

Professional divisions do exist between mental health and substance misuse services. It isn’t that workers decide not to cooperate with colleagues from other services. It’s that people are trained differently. Workers from both services work in different frameworks and to different professional accreditations.

Contributors to the report reflected that the current systems aren’t set up to be able to cope with a lot of the joint working that we know people with complex issues would benefit from. For example, things like consent and confidentiality, client records and communication are all approached differently within independent service structures. In substance misuse services diagnoses are not really used. You may say that someone is alcohol dependent or they’re non-dependent. But a diagnostic approach is not taken. Whereas, to qualify for lots of CMHT’s [Community Mental Health Team services], you have to have some kind of a diagnostic. And, that’s because anyone can self-refer into substance misuse services. Another key difference.

How services and systems not working effectively together impacts people complex health issues

All contributors reflected on the negative impact of services and systems not working together as effectively as they can to support this group of people.

Have we lost our grip on how to effectively support the most vulnerable complex needs clients? And instead of giving them less, do we need to give them more? More time and more choice.

There was a concern from some contributors that Discussions and conversations that were happening 40 years ago, are the same discussion we’re having today: Has the issue of how to effectively support dual diagnosis clients been cracked? Are we doing good enough by this group of people? We’re certainly working hard. We’re doing the best we can. But, if we’re honest with ourselves, are our current systems failing people?


Commissioning and KPI’s

We can improve collaboration between mental health and substance misuse services – lots of ideas and suggestions were shared in conversations.

An idea favoured by contributors who were working in non-client facing roles was for there to be joint key performance indicators (KPI’s) and joint commissioning of both substance misuse and mental health services. That both services should have to show evidence of communication and partnership building around joint client working. With the best will in the world. Sometimes things only work or only happen if there’s a KPI. Accountability to services to work in a certain way because they’re paid to, it’s a requirement of contract monitoring. Not something that’s aspirational.

Do mental health service and substance misuse services need to start being jointly commissioned? Some contributors felt this would be helpful.

Dual diagnosis teams and co-location of workers

Some contributors reflected that dual diagnosis teams and co-location of workers has improved collaboration.

Having experienced, well-trained complex needs workers who are embedded within services and who can cross those divides or differences that exist between services can be vital. The value of having this type of specific complex needs role cross cutting services needs promoted and spoken about more widely.

Having more support and input from clinical services/staff is very useful. Many contributors shared a view that specialist who can act in a more consultative, advisory way to non-clinical practitioners is something that would be good to develop further. the reality is that If psychologists are carrying out direct client support work, they will always carry small caseloads – there’s only a limited supply of psychologists in services. Thinking about the role of psychologists within the support system is important to widen the impact of their expertise. Clinical specialists supporting non-specialists within a psychological framework to deliver frontline support was felt to be where they could add most value.  That’s people on the desk in a busy service, in a needle exchange, in a pharmacy, and frontline workers supporting some of the most vulnerable people in our communities.

Services should be used for their core expertise.


These conversations enriched and challenged our thinking and we are thankful to all those who contributed to this work. At Fulfilling Lives, we want to take these conversations forward locally to explore how we can test new ways of working informed by the views and ideas shared in the Perspectives Project. Collaboration is vital to supporting the multiple needs faced by those with multiple disadvantage and mechanisms to enhance the sharing of information, expertise and risks are key to this.

You can read the full Perspectives Project report here: Full Report

Pilot evaluation helps share learning and shape future design of local MARAC system

Fulfilling Lives South East has collaborated with East Sussex County Council and Brighton & Hove City Council to evaluate the impact of a pilot trailing a new approach to the local MARAC systems.

The Multi-Agency Risk Assessment Conference (‘MARAC’) is a regular weekly local meeting to discuss how to help victims of domestic abuse at high risk of murder or serious harm. It brings together Representatives from a number of agencies in the local area to discuss the safety, health and wellbeing of people experiencing domestic abuse (and their children) and to agree actions and safety plans in order to reduce risk and keep individuals safe.

In 2019, the Joint Domestic, Sexual Violence & Abuse and VAWG Unit for Brighton & Hove and East Sussex reviewed the MARAC structures and referral pathways. The review highlighted the increasing numbers of referrals into the MARAC locally across Brighton & Hove and East Sussex, as well as highlighting the increasing challenges of safety planning for victims of complex and repeat cases. The MARAC Support Team worked with agencies to shape a new ‘Hub’ model in response to challenges identified in the review. A three-month pilot was launched in January 2020 to trial a new approach and was rolled out across Brighton & Hove and East Sussex.

This report shares the learning of the Brighton & Hove and East Sussex MARAC pilot with a view to informing the future design of the MARAC structures locally. We also hope that these findings and reflections can support other areas in the country who are interested in developing their own local MARAC structures and systems to improve outcomes for high risk victims of domestic abuse.

What the evaluation says

From this evaluation, the data supports that the MARAC meeting now feels safer and more effective than before. Meeting conversations have moved away from having an update-focus to allow for more discussion about safety and planning. The changes that have been made have created strong foundations to continue to develop this important space. The evaluation has shown that this is dependent on effective preparation, smaller number of meeting attendees, productive relationships between agencies, and effective chairing.

You can read the full evaluation report here: MARAC report to learn more about the evaluation findings and recommendations for the future.

IfFulfilling Lives South East has a particular interest in the experiences of people with Multiple and Complex Needs (‘MCN’). 93% of women who work with us have experienced domestic abuse and many are heard at MARAC. Our client-facing work has previously highlighted to us the challenges of discussing complex cases in detail within the previous MARAC structure and we are pleased to see that conversations appear to now be more focussed on risk planning, exploring agency involvement and ensuring accountability of actions. We are also very interested in how the evaluation highlights that complex cases require clearer definition and pathways within future MARAC systems in order to ensure safety planning is completed in the most effective way possible. This is an area that we hope will be included for further consideration and development in the future.

Fulfilling Lives is committed to continue working with partners across the public and voluntary sectors to support in finding new ways of working and testing new ideas to help improve the situation for women who have multiple complex needs and experience domestic abuse and violence. Should you wish to discuss the report further, please contact Rebecca Rieley, Systems Change Lead for FLSE:

Author – Rebecca Rieley

COVID-19 Initial Impact Report

As with the rest of the world, we at Fulfilling Lives have been significantly impacted by the coronavirus outbreak that took hold in March. Our teams have had to rapidly adapt to new ways of working, which has been especially challenging for the client-facing teams. Due to the speed at which the Coronavirus pandemic has escalated, and the degree of uncertainty of its ongoing impact, we have had to act quickly to formulate an appropriate response. Part of our response has been to try and capture client and worker experiences ‘on the ground’, and to gain insight into:

  • The challenges our clients are facing in this difficult time and how they are adapting and coping.
  • The challenges that front-line workers are facing in adapting to new ways of working, often remotely.
  • The ways support systems have changed and the gaps and barriers in service provision that appear to have a disproportionate impact on people with multiple and complex needs.
  • Examples of successes, creative solutions and good practice, as we seek to understand what good or even best practice looks like, in this highly challenging situation.

To begin capturing this data a survey was conducted with all specialist workers and area leads in FL SE (Brighton & Hove, Eastbourne, and Hastings). The initial findings from this survey are summarised in this report and will feed into further research, evaluation, and shared learning

The full report is available to download below: