MODEL BEHAVIOUR
W e’ 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.
Nottingham’ s new model for a co-occurring needs pathway is transforming local practice, says Apollos Clifton-Brown
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
Picture credits: Tracey Whitefoot and Forecast Designs
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