Title: The RECO study: Realist Evaluation of service models and systems for CO- existing serious mental health and substance use conditions.
Funder: Chief Scientist Office, Scotland

Abstract: 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. Mental health services do not always have the skills or treatment available to help people with their alcohol and/or drug use, and alcohol and drug services are not always skilled to help people if they also have mental health difficulties. When developing new services for those who experience both severe mental health and alcohol and/or drugs difficulties, people look to government policy and guidance to help decide what might work best. However, at the moment we do not have a good understanding about what types of services would be most helpful. Therefore the aim of the research is to find out what is most helpful about the current services aimed at people with severe mental health difficulties and alcohol or drug problems. We would also like to find out what it is about effective services that helps people to stay in contact with their workers, get the right help they need in order to achieve their goals. We are a team of health researchers and people with lived experience who have experience of developing and testing treatments for people who experience severe mental health difficulties and also use drug and/or alcohol. Some of us are also psychologists and nurses who have worked in mental health and drug and alcohol services and one of the team has lived experience of using mental health services. We will work with a group of people who have experience of severe mental health difficulties and alcohol and drug use throughout the study, to ensure that we are asking the questions that are important to them. We will also ask their advice on the best ways to recruit people to take part and to help us understand the findings of the research. We will be collecting information in three stages. Stage one will look at published research studies in order to find out what these tell us about the types of services that might work. Stage two will be a survey of the services in England, so that we can see how many there are, and what those services do to help. Stage 3 will involve stakeholder events in 5 locations. We will talk to service users, their carers and staff in mental health and alcohol and drug services to ask them about how local services works, including what aspects seem to work really well and what aspects not so well. We will also ask whether some services work better for certain types of people, for example some services may not work so well for women, people who are homeless or those who have been in prison. in addition to these events we will recruit and interview 10-15 people who represent groups that often don't have a voice. We will use all that we learn from the three stages of the 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.

Lay abstract: BACKGROUND Around 30-50% of people with serious mental illness also have co-existing alcohol/drug conditions (COSMHAD) and this co-morbidity is associated with poor health outcomes. One of the issues is that there is disjointed care by mental health and alcohol/drug services, and limited evidence on which to base effective services. _x000D_ AIM: In response to the commissioning brief, the aim is generate a programme theory (using realist synthesis of evidence and stakeholder views) that identifies and describes the contexts and associated mechanisms by which engagement and other health outcomes are achieved in service systems for COSMHAD, and for whom these are most effective. _x000D_ RESEARCH QUESTIONS:_x000D_ 1. What does the existing literature suggest ‘works’ (demonstrated by engagement and other health outcomes) in terms of COSMHAD, for whom, and in which circumstances?_x000D_ 2. What are the current range and types of service systems that currently operate in the UK that aim to improve engagement and health outcomes for people with COSMHAD? _x000D_ 3. What are the specific contexts and mechanisms that make COSMHAD models successful (or not), for whom and under what contexts?_x000D_ METHOD: The overarching method will be Realist Methodology. _x000D_ SETTING any service (primary or secondly services) that has specifically funded posts for COSMHAD; or provides some form of formalised care pathway or integrated package of care, or interventions specifically aimed at people with COSMHAD. This includes NHS mental health and substance use services , third sector providers, charities and voluntary services, criminal justice, and housing and social care (not exhaustive). _x000D_ POPULATION: people who commission or provide COSMHAD services; those who access the services and their carers _x000D_ HEALTH TECHNOLOGIES BEING ASSESSED: any service model or pathway; any psychosocial intervention or psychological therapy that is aimed at specifically improving engagement and health outcomes for people with serious mental illness and co-existing alcohol/drug conditions. _x000D_ WORKPACKAGES: _x000D_ WP1: realist evidence synthesis of literature_x000D_ WP2:Mapping and auditing of services in the UK. The first phase will be a mapping of COSHMAD services based on web searching, identification via relevant networks and snowballing of local contacts. this first wave will be to simply create a map of known services and a key contact in every place. A survey will be devised to gather more information about the services - will include who commissions; remit, number and types of staff and volunteers, type of service, types of intervention offered, any evaluations been undertaken. A survey will be co-produced with the team and advisors. _x000D_ WP3:Stakeholder focus groups in 5 locations in the UK. The questions will be informed by the realist approach and the findings of WP1 and 2. In addition 10 individual interviews will be undertaken with a purposive sample of people who are harder to reach (such as people who are homeless, women, offenders) in two locations. _x000D_ The data will be synthesised across the three work packages, and a final event will be held with stakeholders to finalise the research priorities (using nominal group technique)._x000D_ OUTPUTS AND DISSEMINATION: We will share findings as they emerge using a website and social media to launch blogs and academic papers. In addition there will be a final report to HTA, conferences, and executive and lay summaries via established networks.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;7.3 MANAGEMENT AND DECISION MAKING;8.1 ORGANISATION AND DELIVERY OF SERVICES;8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE
Health categories: MENTAL HEALTH