The System Isn't Broken – It's Working As Designed

October 13, 2025 

Simon Bratt, PhD, Author and Trauma-Informed System Strategist

Tom O'Connor, Publisher

"The System Isn't Broken – It's Working As Designed" is a statement that asserts the observed problems within a system are not due to malfunctions, but rather the logical outcomes of the system's inherent design.

Author Simon Bratt is from Madeley, England, United Kingdom. Simon helps organizations fix the gaps in mental health and addiction care so people are supported, not shut out. For over 20 years, Simon has worked at the frontline of NHS crisis teams, forensic units, and homelessness outreach. He has applied that experience to his doctoral research, designing practical, justice-oriented solutions. 

Simon now leads Layered Care, a consultancy and newsletter that helps services embed trauma-informed, context-driven, and humane practices into everyday operations. From structural reform to frontline training, Simon's work seamlessly blends theory and practice, ensuring that change is both meaningful and actionable.

According to Simon Bratt:

New research, moral injury, and why integrated care keeps failing people who use drugs. When I first began Layered Care, it was to create space for honest conversation—for saying out loud the things many of us feel when we work in systems that are supposed to help but often harm. This emphasis on honest conversation is crucial, as it is through open dialogue that we can begin to address the systemic issues that plague our current care systems. Your input and participation are crucial in this dialogue. Today, I want to share something that brings together years of that experience—both lived and researched—and which, I hope, might spark something useful for you too.

My new, peer-reviewed article has just been published in Substance Abuse Treatment, Prevention, and Policy. It's called "Structural and Cultural Barriers to Integrated Care for Co-Existing Mental Health and Substance Use: A Morphogenetic Analysis."

This paper began, as most honest research does, with a sense of discomfort. I felt uncomfortable with the number of times I'd watched someone fall between services. Discomfort with being told that nothing more could be done because the person didn't fit. Discomfort with the moral gymnastics I'd performed trying to justify a system that couldn't hold the complexity of people who both used drugs and were in pain. Eventually, that discomfort became a question: Why does integrated care remain so elusive for people with co-existing mental health and substance use needs (CEMS)?

To answer that, I combined interviews with frontline professionals—people who knew this discomfort intimately—with Freedom of Information data from 54 mental health trusts. I drew on critical realism and social theory not to abstract the problem but to make it visible in new ways. The findings were difficult, though unsurprising. Services remain siloed not simply due to bad luck or miscommunication but because of deep-rooted structural and cultural logics: risk-driven thresholds, diagnostic boundaries, resource constraints, and a system-wide discomfort with people whose needs don't neatly fit a care pathway.

One participant described it best when they said, "You end up having to choose whether to follow the rules or do the right thing—and sometimes you can't do either." That quote stayed with me. It speaks not just to systemic failure but to moral injury—the emotional toll exacted on those working within fragmented systems that punish complexity and reward compliance. The paper argues that the current configuration of services creates harm not only for those in distress but also for those trying to support them.

However, this is more than a critique. The paper also introduces the Integrated Morphogenetic Care Model (IMCM)—a framework grounded in structural realism and lived expertise. The IMCM is not a theoretical concept, but a practical and implementable care model. It proposes a care model based not on managerial targets or diagnostic purity but on structural flexibility, embedded social determinants, practitioner agency, and a recognition of distress as contextually meaningful, not merely disordered. This model offers a hopeful and practical vision for the future of mental health and substance use care, one that is more honest and inclusive of the complex realities of people's lives and the multifaceted responsibilities we hold as practitioners, researchers, and citizens.

I don't pretend it's a magic fix. However, I believe it's a step toward something more honest—something that makes room for the complex realities of people's lives and the multifaceted responsibilities we hold as practitioners, researchers, and citizens.

So why am I sharing this with you now? Because I don't want it to gather dust in a journal. If you're someone who works in or around services—mental health, housing, substance use, social care—then I believe this paper is for you. I'd be honored if you read it, shared it, and let me know what it stirs up for you. I encourage you to share your thoughts, experiences, and ideas in the comments section or through direct communication. Let's start a conversation about how we can collectively work towards a more inclusive, flexible, and effective care system.

Co-existing mental health and substance use challenges (CEMS) remain a significant barrier to integrated care due to systemic fragmentation, inflexible eligibility criteria, and risk-averse service cultures. Despite policy commitments to coordination, individuals with CEMS face exclusion, crisis-driven interventions, and stigma, which reinforce cycles of disengagement. This study applies Archer's (Being Human: The Problem of Agency, 2004) morphogenetic framework to analyze structural and cultural barriers to integration. Using qualitative methods, it examines Freedom of Information (FOI) data from NHS mental health trusts, along with open interviews with professionals and individuals with lived experience. Findings reveal ongoing service silos, abstinence-based eligibility policies, and professional constraints that sustain morphostasis, preventing reform.

The Integrated Morphogenetic Care Model (IMCM) is proposed as a framework to promote structural flexibility and co-produced service design. Urgent reforms are necessary to ensure person-centered, trauma-informed care for individuals with CEMS. The implications of these findings for policy and practice are significant, as they provide a roadmap for systemic reform and the implementation of more inclusive, flexible care models.

You can read Simon Bratt's full article at Structural and cultural barriers to integrated care for co-existing mental health and substance use: a morphogenetic analysis.

If you enjoyed this article, 

Please forward this to a friend or colleague who might benefit from it!