It is estimated that 75% of people using drug and addiction services and 85% of people using alcohol services had a psychiatric disorder in the past year. In addition, 44% of patients using community mental health services had problems with drug or alcohol use (Weaver et al, 2003).
In relation to alcohol specifically, morbidity and deaths from alcoholic liver disease have doubled in the last 20 years (Williams, R et al, 2018). People with alcoholic liver disease live with multiple health conditions, including mental health conditions. In this group, people living on lower incomes and who face other health inequalities, are much more likely to become severely ill.
In spite of the high level of comorbidity, few services provide integrated care for both mental health and substance use disorders.
The aim of this Mental Health Implementation Network project is to implement new integrated care protocols for patients with co-occurring severe mental illness and substance abuse, including alcohol misuse.
In supporting the implementation of these new care protocols, we aim to:
Prevention and treatment of alcohol misuse are key priorities for the NHS, local authority public health teams in south London and the Long-Term NHS Plan (2018).
There have been numerous recommendations and guidelines to provide integrated care for comorbidity, including for cooccurring mental health and substance abuse problems, but progress in implementation has been limited (Public Health England, 2017).
To address the aims of this project researchers assessed the implementation of AAOT in three sites in England: Greater Manchester, Hull and South London. Alcohol Assertive Outreach Treatment (AAOT) offers a creative and flexible approach to engaging and treating patients with alcohol dependence and complex needs through regular proactive support at home or in their local neighbourhood, who might otherwise be readmitted to an acute hospital ward. The multidisciplinary team is proactive in developing and maintaining a lasting, supportive and therapeutic relationship with service users and their carers.
The research teams identified what key features make an effective AAOT service and what impact AAOT had on NHS and social care costs. A King’s College London study evaluated the impact of AAOT on admissions to King’s College Hospital in south London. The study found that following implementation of the AAOT programme there was a 23% reduction in overall alcohol admissions to the hospital. Frequent attenders at hospital were targeted to help them find better ways of managing their health in the community. The economic evaluation found that AAOT led to saving of £10,470 per patient per year compared to care as usual.
Research in Manchester and Hull both found that high-quality alcohol assertive outreach treatment lead to reduced emergency hospital admissions. A qualitative evaluation by the University of Hull highlighted the importance of the relationship between the patient and keyworker to deliver effective AAOT. Assertive advocacy was a key feature of successful implementation of AAOT. Assertive advocacy is when the key workers repeatedly and persistently advocate for better care for their service users with other services who are involved in their care.
Patient and public involvement was a successful element of this project which was underpinned by a partnership between academic experts and experts by experience. Patients and the public were involved in co-facilitating workshops, co-authorship of publications, co-facilitation and presenting at commissioner events and disseminating research findings.
Findings and learning from the project have been shared in over nine regional, one national and one international event over the past two years. An Alcohol Assertive Outreach Toolkit is also in development to support implementing and sustaining high-quality AAOT.
In March 2024, the MHIN team held a webinar to disseminate findings of the project: Integrated protocols for substance use, mental and physical health problems. Find out more and watch a recording of the webinar.
Another webinar was held in March 2025 to share learning on implementation and evaluation of Alcohol Assertive Outreach Treatment. Find out more and watch a recording o the webinar.
As part of this project we launched a Community of Practice for people involved in Alcohol Assertive Outreach Services across England. Read a blog on The Health Foundation's Q site from Afra Kelsall, senior advisor at the MHIN, who shares her learning about how valuable the Communities of Practice model can be as a quality improvement tool.
A qualitative exploration of the barriers and facilitators to the implementation of the alcohol assertive outreach model. Alcohol and Alcoholism, Volume 60, Issue 2, March 2025, (Laura H Scoles, Nikolaos Mylonas, Aansha Priyam, Stephen Blood, Amy O’Donnell, Colin Drummond, Karina Lovell, Stephen J Kaar, )
