Nottingham’s new model for a co-occurring needs pathway is transforming local practice, says Apollos Clifton-Brown.
We’ve spent too long nationally treating mental health and substance use needs as a specialist service issue when they are a systems issue. If organisations don’t share responsibility, people inevitably fall through the gaps.
People do not experience their mental health separately from their substance use, or one service at a time. They experience life as a whole. The closer our services reflect that reality, the better the outcomes will be.
When I read the government’s recent Co-occurring mental health and substance use framework, what struck me was how much of the document is actually about organisations rather than clinical guidance – leadership, service design, data sharing, workforce development, commissioning. This is important because, in my experience, people with co-occurring needs are rarely failed by a lack of goodwill or expertise. They’re failed when systems become more important than people.
Time for change
The need for change is clear. Between 2024 and 2025, up to 74 per cent of people starting drug and alcohol treatment had a mental health treatment need, while more than a third of people with mental illness also experience substance use problems. Yet services still operate separately.
Dame Carol Black recently visited our services to see how the partnership between Nottingham Recovery Network (NRN), Framework, Nottinghamshire Healthcare NHS Foundation Trust and Change Grow Live Nottinghamshire have implemented effective joined-up care.
Many of the approaches now promoted nationally were already established in Nottingham and Nottinghamshire because we kept asking a simple question: why are people expected to fit around services, rather than services fitting around people? That gives us a useful perspective on what worked, what didn’t, and what other areas might learn.
Strategic leadership
One of the most important recommendations in the government framework is not to create standalone dual diagnosis services. That reflects a conclusion we first reached following the publication of the NICE guidance on Coexisting severe mental illness and substance misuse in 2016. When services struggle, the instinct is often to create a new team or pathway. But this can often mean new silos with limited interventions available, and poorer outcomes for the people assigned to them.
We quickly realised the challenge wasn’t a lack of services, but how those services worked together. By developing joint working protocols, introducing multidisciplinary case discussions and investing in joint training, staff could stop working in parallel and start collaborating.
One of the most effective changes was embedding specialist practitioners across teams. These roles create direct links between mental health and substance use services, bringing expertise into everyday practice, challenging exclusionary approaches and ensuring that knowledge from one service informs decision making in another. We now have mental health specialists embedded in our substance use service, and substance use specialists embedded in mental health inpatient units, community treatment and crisis teams.
Previously, early opportunities to identify substance use needs on mental health wards were often missed – referrals came late in an admission, creating delays in discharge and avoidable re-admissions. Now, embedded substance use practitioners provide screening, brief interventions and recovery support, as well as continuity from mental health inpatient care into community substance use treatment.
Frontline experience
Too often, people reach crisis point before co-occurring needs are identified. Through closer working relationships, we’ve strengthened how screenings, interventions, signposting and referrals are monitored across pathways. This has increased NRN’s recording of unmet mental health needs, bringing what we record closer to what we already knew from research and frontline experience.
In the last year, 247 people in Nottingham who may not otherwise have been identified were referred into drug and alcohol treatment following assessments by psychiatric hospital liaison teams, crisis services and local mental health teams. We knew there were unmet mental health needs in our treatment population – better recording didn’t create that reality, it simply made it visible.
Our next step is joining a single record system being rolled out across Nottingham and Nottinghamshire. When implemented, substance use services will be able to access key information from hospital, GP and mental health records in one place, saving time, and meaning clients will no longer have to repeat their story every time they encounter a new professional.
Transformative training
Historically, we’ve taught staff to become experts in different parts of a person’s life, then been surprised when services struggle to see the whole person. Joint training has been transformative – staff across services have trained together on trauma-informed care, motivational interviewing, substance use awareness and suicide prevention.
Beyond knowledge, joint training builds relationships and confidence, making practitioners more likely to seek advice and adapt their practice. We’ve created a culture of ongoing learning rather than one-off knowledge transfer, resulting in regular advice clinics, supervision sessions and specialist assessments led by mental health colleagues.
Perhaps the biggest lesson is that workforce development isn’t separate from service transformation. The framework talks about co-occurring needs being everyone’s responsibility. Joint learning is how you turn that into everyday practice.
Built-in partnerships
The guidance rightly recognises that partnership working needs to be built into the system. Our progress has relied on agreed referral pathways, joint risk management arrangements, reciprocal training and clear expectations. Regular strategic meetings chaired by public health ensure that collaboration becomes embedded in day-to-day practice.
We’ve also taken every opportunity to commission posts from each other. Some embedded roles are funded by mental health services to bring substance use expertise into their teams, while substance use services fund roles that bring mental health expertise into treatment settings. This approach recognises the strengths of each partner, builds trust, and supports more integrated care. We also involve people with lived experience in reviewing and shaping services, as they’re often the best judges of whether a pathway feels integrated.
Despite the best intentions, priorities inevitably change and organisations come under pressure. To be maintained, partnership working has to be built into the way services are designed.
What’s next?
Our focus now is on rolling out the single record system and strengthening links with talking therapies and ADHD and autism pathways. Initiatives such as embedded practitioners show what’s possible when services are designed around people’s experiences rather than organisational boundaries.
‘No wrong door’ and ‘everyone’s job’ are simple phrases, but achieving them takes years of relationship building, cultural change and shared commitment. For me, the real value of the framework isn’t that it tells us something new. It’s that it gives permission to challenge some of the assumptions our systems have been built on.
Apollos Clifton-Brown is director of health and social care at Framework