Trauma-informed care in UK: where are we? A qualitative study of health policies and professional perspectives

Problem

People can experience trauma as a result of violence, abuse, neglect, loss and other emotionally harmful experiences. Mental health consequences of such experiences are common in the general population, with reviews finding a lifetime prevalence of post-traumatic stress disorder (PTSD) of 14-44% in primary care patients. Awareness of patient re-traumatisation in healthcare settings has developed alongside recognition that staff may themselves both have experienced trauma and be at risk of vicarious trauma. The concept of a trauma-informed (TI) approach has gained international interest over the last 20 years. TI approaches recognise the impact of psychological trauma on patients and staff and establish organisational change, promoting recovery and preventing re-traumatisation in healthcare services. TI approaches are represented in major national UK health policy. However, our systematic review of TI approaches in primary and community mental healthcare identified limited evidence for its effectiveness in the UK, despite endorsement in various policies. Aims: This study aimed to address this evidence-policy gap by answering the following questions:• How are TI approaches represented in UK policy? • How are TI approaches understood and implemented in the UK?• Why are TI approaches represented and implemented in this way?

Approach

Qualitative study comprised of 1) a document analysis of UK health policies using the READ approach 2) semi-structured interviews with key informants with direct experience of developing and implementing TI approaches. Qualitative analysis was undertaken according to the framework method and READ approach.

Findings

We analysed 25 documents and interviewed 11 professionals from healthcare organisations and local authorities. Policies at the level of healthcare organisations, local authorities, and Scottish and Welsh governments recommended TI approaches. However, there was no England-wide strategy or leadership. Across the UK, there is inconsistency in the terminology and frameworks used. Despite growing endorsement of TI approaches in policies, positive statements were not supported by legislation, funding, or resource allocation. Documents revealed differing understandings of TI approaches between geographical areas and across services, with disconnected and piecemeal implementation. Interview participants reflected on a lack of: 1. high-level strategy and leadership, 2. adequate funding for evaluation, 3. shared understanding of TI approaches, 4. knowledge about existing frameworks and evidence base. Factors viewed as affecting the implementation of TI approaches included: leadership support, bottom-up and top-down development, presence of systemic thinking, supportive organisational culture, adequate resource allocation, competing priorities, impact of the COVID-19 pandemic. Participants had conflicting views on the future of TI approaches and called for coordination between organisations and regions.

Consequences

A coordinated, centralised national strategy on TI approaches in health systems, improved funding for evaluation, and education through professional networks about evidence-based TI health systems can increase value and reduce waste in research and implementation of TI approaches in the UK.