Guidance

Co-occurring mental health and substance use delivery framework

Published 10 December 2025

Applies to England

Introduction

Drug, alcohol and mental health problems are often co-occurring rather than separate problems to be addressed independently. People with co-occurring mental health and substance use conditions can find it hard to engage with support, and services too often fail to meet their needs. This must change.

The need for change

Dame Carol Black’s independent review of drugs underlined the complex relationship between mental health and drug and alcohol use. The review identified that too often people are being excluded from mental health services until they resolve their drug problem, while also being excluded from substance use services until their mental health problems have been addressed.

Between 2024 and 2025, 74% of people starting drug and alcohol treatment had a mental health treatment need (for more information, see Substance misuse treatment for adults: statistics 2024 to 2025). Over a third of people with serious mental illness have co-existing drug or alcohol conditions, associated with poor health and social care outcomes (Harris and others, 2023) and people with co-occurring problems who are not in contact with any specialist services are at greatest risk of suicide.

Between 2010 and 2020, 47% of people in contact with mental health services in England who died by suicide had a problem with alcohol use, and 38% had a problem with drug use (National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), 2025). These numbers demonstrate the scale of the problem.

Barriers to quality care

How people experience services is at the heart of many of the issues we’re facing. The Department of Health and Social Care (DHSC) and NHS England have listened to the concerns and experiences of people with complex needs who have attempted to access both drug and alcohol treatment and mental health services. From this engagement, we found that:

• mental health needs, including trauma, and substance use problems are not addressed together by drug and alcohol treatment and mental health services
• people are made to feel like they need to fit services, rather than services meeting people’s needs
• people wait a long time for a diagnosis, and following this are often told they are in the wrong service and need to start the process again

We know that treatment for co-occurring mental health conditions is associated with better retention and engagement in services and ultimately, better outcomes. So, it is vital these issues are addressed. Improving integration of care will have a real effect on peoples’ lives and ensure those in need can access high quality support.

Supporting an NHS fit for the future

Action on co-occurring mental health and substance use issues will help deliver the government’s health mission to build an NHS Fit for the Future by reducing pressure on services and lives lost to both mental health and substance use conditions. This delivery framework directly supports the 10 Year Health Plan for England to:

• shift care from the hospital to the community
• provide co-ordinated, patient-orientated services
• reduce health inequalities

The 10 Year Health Plan aims to ensure that care is no longer split into separate services that are hard to access and unable to meet people’s individual needs. This delivery framework aims to champion integrated care and improve treatment services for all people with co-occurring mental health and substance use needs.

The government is committed to reducing lives lost to suicide and, given the greater risks that exist for suicide when people have co-occurring conditions, it is vital that appropriate and timely support is available for patients. We are making commitments to improve mental health support in the 10 Year Health Plan including:

• investing up to £120 million to develop dedicated mental health emergency departments, to ensure patients get fast, same day access to specialist support in an appropriate setting
• expanding mental health support teams in schools and colleges
• transforming mental health services into neighbourhood care models
• improving assertive outreach care and treatment to ensure 100% national coverage in the next decade, with a focus on narrowing mental health inequalities

We also recognise that people experiencing homelessness are disproportionately affected by co-occurring mental health and substance use conditions. People who are homeless are at increased risk of poor health outcomes, including higher rates of suicide, and are less likely to receive co-ordinated care. We are continuing to invest in drug and alcohol treatment and support services for people who sleep rough, including support to people who have co-occurring mental health and substance use needs.

We are also committed to improving mental health support for children and young people by focusing on prevention and early intervention. While this delivery framework focuses on adult mental health services only, we are aware of the issues facing children and young people’s mental health. We will consider this in the next phase of this work.

The actions in this delivery framework will only make a meaningful difference if there is a concerted effort and commitment across all levels of the healthcare system. We will continue to work with commissioners, service providers, clinicians and staff in both drug and alcohol treatment and mental health services to support and review progress against the ambitions of this framework. We must now maintain momentum and deliver better services for people with co-occurring mental health and substance use needs.

Purpose of this delivery framework

In this delivery framework, we have set out a programme of work to improve and ensure there is integrated high-quality service provision and treatment for people with co-occurring mental health and substance use needs. We have worked with subject matter experts, including:

• people with lived experience
• academics
• clinicians
• service providers

National priorities

This delivery framework sets out the actions needed to improve treatment services for people with co-occurring mental health and substance use. We are taking action at a national level across the following 4 priority areas.

Strategic leadership and service model design

Effective strategic leadership, across all levels of the health system, and quality service model designs are both vital to delivering integrated, patient-centred care.

Data and monitoring

Improving data collection, quality and monitoring is essential to improving services. It enhances our understanding of local population needs, service access and outcomes, as well as informing continuous improvement.

Workforce and training

All staff working with people with co-occurring mental health and substance use conditions should be trained to have the basic competencies needed to provide effective support and respond to people’s needs.

Commissioning and incentives

What commissioners plan, performance manage, include in service specifications and incentivise has a significant impact on the quality and effectiveness of care, as well as guiding the populations and specific needs that services focus on.

Improving services at a local level

To improve services and ensure the needs for people with co-occurring mental health and substance use conditions are met, action is required at national level and at all levels of the health system.

The actions we have committed to take in this delivery framework will help to tackle nation-wide challenges and also make it easier for commissioners, service providers and clinicians to implement change and improve care at a local level.

To further enable improvements, this delivery framework also includes recommended actions that can be collectively taken at local level. Commissioners, service providers and clinicians should use the recommended actions to inform improvements they can make and ensure that the needs of people with co-occurring substance use and mental health needs are better met.

This framework is just one part of a broader programme of work aiming to improve services, and it will only succeed if all parts of the system take responsibility to lead, champion and implement change. We must strive to continually improve, reviewing progress and adapting our approach as we go to ensure success and real transformation.

A summary of all the actions set out in this document is available on the Co-occurring mental health and substance use: delivery framework homepage.

Building on current structures and initiatives

This framework should not be seen as the only mechanism for change but rather a step towards the change we need to see. Other workstreams are also vital to achieve the transformation needed, such as NHS England’s Drug and alcohol treatment and recovery workforce programme.

Further research will play a major role in supporting future practice development. DHSC, through the National Institute for Health and Care Research, has recently commissioned an extensive drug and alcohol research programme. DHSC will keep this research programme under review and commission further research to build on what has already been done, while filling any gaps in our evidence base.

There is also existing guidance available, including:

• National Institute for Health and Care Excellence (NICE) guideline Coexisting severe mental illness and substance misuse (NG58)
• Better care for people with co-occurring mental health, and alcohol and drug use conditions
• NHS England’s Community mental health framework for adults and older adults

The 2 main principles of care for working with people with co-occurring mental health and substance use conditions are as follows.

Everyone’s job: commissioners and providers of mental health and alcohol and drug use services have a joint responsibility to meet the needs of people with co-occurring conditions by working together to treat those with mental health conditions as well as substance use conditions.

No wrong door: providers in alcohol and drug, mental health and other services have an open-door policy for individuals with co-occurring conditions and make every contact count. Treatment for co-occurring conditions is available through every contact point and services should be in seamless partnerships to meet needs.

Compliance with guidance on co-occurring conditions has been limited to date, and this framework aims to improve that.

If the actions in this delivery framework are carried out, they have the potential to reduce the pressure on wider NHS and local authority services, for example, reducing the demand for crisis care (Harris and others, 2023) and freeing up hospital beds.

Transition to one organisation

In March 2025, the government announced that NHS England would be integrated into DHSC.

We recognise it is vital that accountability for this delivery framework is maintained throughout this transition period. So, we have set up an oversight group to begin implementing the commitments. The group has members from both organisations who will manage the structural changes taking place and ensure we implement the actions we have committed to.

Priority area 1: strategic leadership and service model design

Why strategic leadership and service model design are important

Integrated care is essential to improving service provision and access for people with co-occurring substance use and mental health needs. Providing integrated care is the collective responsibility of:

• national organisations
• local commissioners and leaders
• front-line staff delivering services

However, we know that there are barriers to joined-up working. There are frequent challenges which all need to be addressed, including:

• workforce shortages
• skill gaps
• a lack of locally agreed data sharing agreements
• disjointed pathways
• exclusion criteria

Delivering patient-centred care is a core ambition of integrated care systems and the 10 Year Health Plan. Doing this requires a whole-system approach. Effective strategic leadership and quality service model designs are both vital to achieving this.

Everyone, especially leaders, must champion joined-up working to bring about effective change at all levels of the system, across mental health and drug and alcohol services. This includes senior strategic and operational leaders as well as commissioners, managers and clinicians. All leaders have a critical role in sustained meaningful change that translates into improved services and outcomes for people.

Lessons learned through the COVID-19 pandemic need to be implemented to ensure access to good quality and holistic care. The speed and scale of co-ordinated efforts made during the pandemic showed that creative and innovative solutions can be achieved through collaboration and integrated care.

Working together toward common goals allows services to be flexible and efficiently share resources. Working effectively across organisations in multidisciplinary teams enables:

• improved outcomes for individuals
• upskilling of staff
• more efficient use of resources

Actions we are taking nationally

DHSC will produce statutory duty to co-operate guidance issued under the Health and Care Act 2012. This guidance will define how local authorities and NHS bodies should work together to achieve positive health outcomes for people with co-occurring drug and alcohol use and mental health conditions.

The duty to co-operate guidance will be supported by an accompanying quality standard checklist for joint care planning. DHSC will develop the checklist to support implementation of the duty to co-operate guidance when agreeing care plans. This will enable more consistency between mental health services and drug and alcohol services.

DHSC will work with the Care Quality Commission (CQC) to ensure that treatment and care for co-occurring conditions are better embedded in their regulatory frameworks and guidance for inspectors. This will ensure that relevant good practice is a part of CQC’s assessment of mental health and drug and alcohol treatment services.

NHS England will publish a positive practice guide on drug and alcohol use. The guide will outline how talking therapies services and drug and alcohol services should work together more closely to improve outcomes for patients. It will also reflect updated ways of supporting patients with drug and alcohol use problems.

NHS England will establish or use existing national, regional and local networks and groups to share learning and promote effective joint working practices between drug and alcohol and mental health services. This will include promoting the value of trauma-informed person-centred care and workforce roles and models that enable better joined-up working.

Recommended actions for integrated care system leadership

Integrated care system leadership should ensure there is effective strategic collaboration between commissioners and providers of mental health and drug and alcohol treatment services. This collaboration should help deliver high-quality personalised treatment and better outcomes for people with co-occurring substance use and mental health conditions.

Integrated care systems have a leading role in creating better integrated services because they are responsible for commissioning and setting priorities for services. Integrated care boards (ICBs), within integrated care systems, bring together:

• the NHS
• local authorities
• social care providers
• voluntary, community and social enterprises
• many others who play a role in improving the health and wellbeing of local people through education, housing, employment or emergency services

ICBs are vital to providing integrated care. They should lead work to meet the aims of this framework by:

• improving outcomes in population health and healthcare for people with co-occurring conditions
• reducing inequalities in access, outcomes and experience
• improving productivity of the system and increasing value for money by reducing pressure on certain parts of the system (such as emergency departments) through reducing the number of people with co-occurring conditions seeking crisis care
• helping the NHS support broader social and economic development by working with other providers of health and social care, including the voluntary sector

Integrated care systems have the influence needed to bring about local change and encourage joined-up working. These include:

• leading change programmes such as NHS England’s Core20Plus5, which looks at how health inequalities (as highlighted in the index of multiple deprivation) can be reduced at both a national and local level
• helping to align ICBs and local authority commissioning practices through recognising the integrated care needs of people with co-occurring mental health and substance use needs

Recommended actions for clinical and service leadership

Clinical and service leaders should develop, champion and implement a vision and plan for change to improve person-centred care and better joint working between drug and alcohol treatment and mental health services. They should monitor the plan’s implementation and impact, and continually identify areas that need further development.

Clinical and service leaders have a significant role in:

• ensuring that staff provide the highest standard of care
• improving clinical practice
• ensuring services are well designed to meet the need of people with co-occurring conditions

They also have a role in reducing the stigma often associated with mental health and substance use. Reducing stigma is essential to breaking down barriers in accessing care. Clinical and service leaders are well placed to emphasise to staff that substance use conditions are mental health conditions and that working with these should be a core mental health competence.

Clinical and service leaders should take several actions including:

• developing multidisciplinary teams to encourage collaborative case management
• establishing joint working protocols between drug and alcohol services and mental health services
• encouraging and enabling relevant training for the workforce, such as trauma-informed care and motivational interviewing techniques
• establishing and recruiting to roles that lead on co-occurring mental health and substance use, to implement service and practice improvement programmes that better connect drug and alcohol treatment and mental health services
• promoting closer working relationships between mental health and drug and alcohol teams to allow effective communication and better continuity of care for patients between these services
• avoiding focusing on or identifying a primary diagnosis (substance use or mental health conditions) or on a pre-determined sequence of care
• developing practice that is focused on people’s individual needs and their experience of care in a co-ordinated and integrated way
• monitoring access, treatment quality and outcomes for people with co-occurring substance use and mental health needs to identify areas that need to be improved and developed
• emphasising the importance of harm reduction interventions for crisis management and suicide prevention for people using drugs and alcohol

Recommended actions on service model design

All staff, including clinical and service leaders and commissioners should follow and implement the service design principles in existing guidance and this delivery framework, and use the best practice examples to inform implementation.

Patient need is at the heart of good service model design and delivery, and this is reflected in existing guidance. For instance, NICE NG58 specifies that people with co-occurring needs, their families and carers should be involved in improving the design and delivery of services.

NCISH reported that integrated service provision between mental health and substance use services is more efficient and effective at improving treatment outcomes (NCISH, 2013). Dame Carol Black’s independent review of drugs highlighted that having separate services contributed to difficulties in patients accessing them, as well as failing to meet their needs.

NICE NG58 makes the following recommendation:

Adapt existing specialist services to meet both a person’s coexisting severe mental illness and substance use needs and their wider health and social care needs. Do not create a specialist ‘dual diagnosis’ service.

To ensure people with co-occurring substance use and mental health needs have their needs met, all services should build the following core principles into their design:

• clear integrated pathways that are adaptable to meet the holistic needs of individuals
• shared learning, training, and development opportunities for staff in both drug and alcohol treatment and mental health services
• data sharing agreements to ensure that mental health and drug and alcohol services can track cases and provide seamless and integrated care
• co-located services, where appropriate, to enable better communication, collaboration and integrated care
• criteria and policies that ensure services do not exclude people with co-occurring substance use and mental health needs
• opportunities for peer support and staff that are trained in treating co-occurring conditions
• safety assessment, formulation and management, following NHS England’s best practice guidance Staying safe from suicide for potential crisis or suicide to patients when they access services

Services should implement NICE NG58. This guideline highlights the importance of:

• regular reviews of policies and procedures by strategic partners
• ensuring referral pathways across agencies are consistent and that governance arrangements are in place
• joint working practices, including joint risk management and data sharing protocols
• considering the other needs that people with mental health and substance use issues may have, including physical health or housing and employment needs

Priority area 2: data and monitoring

Why data and monitoring are important

Improving data collection, quality and monitoring is essential to improving services. It enhances our understanding of local population needs, service access and outcomes, as well as informing improvement.

National data sets such as the Mental Health Services Data Set (MHSDS) and the National Drug Treatment Monitoring System (NDTMS) should be used by services and commissioners to better monitor access and outcomes for people with co-occurring mental health and substance use needs. It is also important to ensure that services are collecting the right type of data and sharing it with all local partners to support better service planning and delivery.

At a national level, we will use data to track system-wide changes and whether need is being met and positive outcomes are being achieved. Improving commissioners’ access to data and their ability to share it can also improve joint working and the provision of care.

Data can also highlight:

• the number of people being screened and identified as having co-occurring needs
• if integrated care pathways and plans are in place and effective
• the level of unmet need in the local area
• whether commissioning practice is effective at meeting needs of the local population

Improvements in data collection and monitoring will show how commissioning, service delivery and clinical practice is changing in line with the actions and recommendations set out in this framework and relevant guidelines (including NICE NG58 and the forthcoming duty to co-operate guidance).

Standardising the approach to screening

Effective screening can help identify and monitor people with substance use needs and make sure they get appropriate support and treatment. Good use of screening tools enables more efficient communication between services, as well as better data collection and analysis.

Identifying and monitoring drug and alcohol use should form part of routine mental health assessments, along with providing brief advice. Healthcare professionals should make the best use of all contact with patients to support them reduce their substance use to:

• reduce premature mortality and morbidity
• reduce the burden on the NHS
• reduce health inequalities
• improve their health and mental health treatment outcomes

However, in mental health services, the recorded number of drug and alcohol screenings remains low. This indicates a lack of a standardised approach by services to talking about substance use with people who have mental health needs. This lack of consistency was also identified in Dame Carol Black’s independent review of drugs. This not only detrimentally affects individual people’s outcomes but may also lead to increased health inequalities.

We recommend that all services adopt a standardised approach to substance use screening which should include:

• brief interventions
• signposting
• supported referral to treatment and mutual aid

The ASSIST-Lite screening tool is proven to be effective in identifying problem drug use and we are recommending that services across the country use it because it:

• is a comprehensive, validated screening tool screening for alcohol, tobacco, cannabis, stimulants, sedatives, opioids and psychoactive substances
• is adapted and licensed for use in health and social care settings in the UK
• includes the ‘Alcohol use disorders identification test - consumption’ (AUDIT-C) test for identifying health risks from alcohol consumption (available in Alcohol use screening tests), which has been proven to be effective in identifying health risks from alcohol consumption (Reinert and Allen, 2007)
• is included in MHSDS, which allows data to be recorded easily and simply

If mental health services adopt ASSIST-Lite as the standard screening tool for drugs and alcohol, it will help them to provide more streamlined, consistent and effective healthcare. It will also help improve local and national data that can be used to inform service improvements.

Two versions of the ASSIST-Lite forms have been developed. One version is specifically adapted for use in mental health settings, and the other is for use in all other health and social care settings.

Actions we are taking nationally

NHS England will promote the use, benefits, and importance of using ASSIST-Lite across mental health services and undertake work to improve the quality of this data on MHSDS.

DHSC and NHS England will explore how to support the development of data sharing agreements at a local level, including scoping the potential for data sharing guidance.

Recommended actions for service providers and commissioners

Service providers and commissioners should update service specifications, policies and clinical pathways to include ASSIST-Lite screening assessments as part of routine consultations with patients. They should also record assessments using MHSDS.

Service providers and commissioners need to develop a comprehensive understanding of unmet need regionally and locally and the treatment required by people with co-occurring needs. MHSDS already collects data from the health records of people in contact with mental health services. It is used across mental health services including community mental health teams and secondary care therapies.

ASSIST-Lite screening can be recorded within the MHSDS. This allows mental health services to monitor the number of people they are in contact with who also have co-occurring substance use and mental health needs. It is vital that ASSIST-Lite is consistently and regularly used in patient consultations to ensure that this essential data is captured.

Recommended actions for NHS talking therapies teams

NHS talking therapies teams should actively use a validated screening tool, such as ASSIST-Lite, to assess a patient’s substance use and provide appropriate advice or intervention.

NHS talking therapies for anxiety and depression is an NHS service that offers NICE recommended psychological therapies and interventions. ‘Substance misuse treatment for adults: statistics 2024 to 2025’ shows that only 3% of people in drug and alcohol treatment were engaged with NHS talking therapies for anxiety and depression.

Better screening of drug and alcohol use in NHS talking therapies services is required to support people with substance use conditions gaining access to these services. MHSDS data has shown that services are not routinely screening for drug or alcohol use when people start using the service. NHS talking therapies services and drug and alcohol treatment services will also need better joint working practices to ensure that patients can benefit from collaborative and integrated care by all the services that support them.

NHS England has already taken positive steps to improve how NHS talking therapies services identify people who have co-occurring substance use needs. This includes updating:

• the talking therapies data set to ensure drug and alcohol use is more widely identified by NHS services
• guidance in the NHS talking therapies for anxiety and depression manual on how best to work with people using drugs and alcohol

These changes aim to raise the profile of substance use in services, so they actively assess and respond to people who have problem drug and alcohol use. We encourage similar instances of improving data and screening in NHS talking therapies services.

Recommended actions on local data sharing agreements

All service providers need to work together with all relevant local services to agree data sharing arrangements that reflect the needs of people with a co-occurring mental health and substance use need.

It is important that local areas improve how they share and analyse data. This will help them to:

• better understand local needs across mental health and drug and alcohol services
• make evidence-based decisions
• efficiently distribute resources and funding

The Revolving Doors national expert citizens group is made up of people from across England with lived experience of multiple disadvantage. They have said that people who have had traumatic experiences often have to re-tell their stories every time they enter new services or engage with a different professional. This can result in people not wanting to engage with services or seek support due to feeling re-traumatised when they must re-tell difficult and traumatic experiences.

To address this, there should be easier and better ways for people to give consent on what personal information and data can be shared with relevant services involved in their care. This would enhance care in a trauma-informed way and improve the pathway and experience of care.

The working definition of trauma-informed practice provides guidance for professionals working in the health and care sector.

Priority area 3: workforce and training

Why the workforce and training are important

Dame Carol Black’s independent review of drugs highlighted the deterioration in the drug and alcohol workforce’s quantity, capability and morale. This has led to a loss of capacity and quality in the treatment and recovery system. The review also highlighted the need for staff working in the addictions and mental health sectors to be better trained in identifying and responding to co-occurring mental health and substance use conditions.

Mental health problems and trauma often contribute to many people’s drug and alcohol dependence. So, it is crucial that the workforce in mental health and drug and alcohol services is trained to effectively respond to co-occurring mental health and substance use conditions.

People working in mental health and drug and alcohol services require different levels of skills and knowledge depending on their role and seniority. However, all staff working with people with co-occurring mental health and substance use needs should have the basic competencies needed to provide effective support.

The drug and alcohol treatment and recovery workforce programme

Under the Health and Social Care Act 2012, responsibility for commissioning substance use services was passed from the NHS to local authorities. While local authorities are well placed to commission substance use treatment, commissioning this outside of NHS structures has created workforce challenges, including:

• increased competition between the mental health and addiction sectors for scarce regulated professionals
• a detachment from wider NHS professional training and development structures

Rebuilding the workforce and increasing the skills mix in the sector is a critical issue.

We are supporting local areas with our drug and alcohol treatment and recovery workforce programme to expand and upskill staff to provide better care for people with co-occurring mental health conditions. This support includes:

• introducing mental health and wellbeing practitioner training to drug and alcohol treatment services to improve:
  • the treatment of common co-occurring mental health problems
  • pathways into mental health treatment
• making more training places available for addiction psychiatrists
• increasing the number of addiction placements as part of clinical psychology training

As part of this programme, DHSC has commissioned NHS England to publish:

• the 10-year strategic plan for the drug and alcohol treatment and recovery workforce (2024 to 2034)
• annual national drug and alcohol workforce censuses to identify the gaps in the existing workforce and inform the development of future training across the sector
• a capability framework for the drug and alcohol treatment and recovery workforce, outlining the core skills, knowledge and behaviours for 15 core roles across the treatment and recovery workforce

DHSC and NHS England are also developing a workforce calculator (to be published in 2026) to support improved skills mix. It will guide local authorities and providers about the combination of different skills required in a core multidisciplinary drug and alcohol treatment team to meet local need. This could include increasing the number of some dedicated posts to meet the needs of people with co-occurring mental health and substance use conditions, including:

• psychologists
• psychiatrists
• nurses
• social workers

Action we are taking nationally

Building on the workforce programme, DHSC will commission NHS England to assess current training gaps and requirements for the mental health workforce. This assessment will inform the development of training materials to enable the workforce to support people with co-occurring mental health and substance use needs, as well as considering the needs of diverse populations.

DHSC, drug and alcohol treatment provider psychology leads, training providers and NHS England will continue to collaborate to increase the number of addiction placements as part of clinical psychology training.

DHSC will work to secure additional training places for addiction psychiatrists.

Recommended actions for training the mental health workforce

All training providers (including universities and mental health trusts) and service providers (including ambulances and emergency departments) should improve training materials and provide integrated placements within drug and alcohol treatment services and mental health services.

Who we need to train

As this work to expand and upskill the drug and alcohol treatment workforce continues, it is important other organisations improve training for the mental health workforce. This training should include the relevant skills and capabilities needed to effectively treat people with co-occurring substance use and mental health use conditions.

It’s important that mental health training programmes cover substance use better. This includes university courses providing more content about drug and alcohol use for:

• mental health nurses
• psychologists
• psychiatrists
• allied health professionals
• talking therapies clinicians

We also need training for postgraduates to improve the skills of people that are already working in mental health services to better support people using drugs and alcohol.

What training should include

To better support people with co-occurring substance use and mental health conditions, training for mental health staff should include:

• an understanding of drug and alcohol use, how it affects different mental health conditions, the impact of the stigma experienced by people with drug and alcohol conditions and suicide prevention for people with co-occurring conditions
• drug and alcohol screening using validated tools, such as ASSIST-Lite
• skills to deliver brief interventions after screening and an understanding of thresholds for referral into drug and alcohol treatment services
• how to deliver trauma-informed care and motivational interviewing techniques in a drug and alcohol use context
• how to work with drug and alcohol services to meet a person’s needs in line with clinical guidance
• integrating the General Medical Council general psychiatry curriculum for trainees to demonstrate competence in substance use disorder assessment and management

It’s also important to include drug and alcohol service placements in professional training to:

• help reduce stigma
• provide a better understanding of the support required for people with co-occurring conditions
• encourage the next generation of specialists to engage with co-occurring mental health and substance use conditions

As both sectors work to upskill their workforces, drug and alcohol treatment services and mental health services should support localised training in their area. Drug and alcohol treatment services should support training in mental health teams in their local area and mental health services should do the same for drug and alcohol treatment services.

Priority area 4: commissioning and incentives

Why commissioning and incentives are important

What commissioners plan, performance manage, include in service specifications and incentivise has a significant impact on the quality and effectiveness of care. It also guides which populations and specific needs services focus on.

Commissioners of drug and alcohol treatment and mental health services should work together to create a system that provides person-centred and integrated care. This is vital for people with co-occurring mental health and substance use problems.

The role of ICBs

ICBs are at the forefront of developing and overseeing the implementation of joint strategies and plans to meet the needs of their local populations.

For people with co-occurring mental health and substance use needs, NHS England will support integrated care systems by:

• supporting mental health and drug and alcohol services to work together, align care and embed each other’s expertise into their services, through the duty to co-operate guidance and the quality standard checklist (for more information, see the chapter on strategic leadership and service model design)
• promoting models of integrated services and joint commissioning across drug and alcohol services and mental health services

How care is paid for

Commissioners currently pay for mental health services in block contracts. This means service providers receive the same money irrespective of how many patients they see. Block contracts are not evidence-based and do not react to changes in local population need. They are often based on historical funding that is carried forward each year.

NHS England aims to review current payment methodologies in line with the 10 Year Health Plan. The goal is to move away from block contracting to an fair and evidence-based funding system that pays providers for effective care.

The plan also commits to test the development of year of care payments. This new payment method will:

• be calculated using evidence of the health needs of the population being served
• allow service providers to invest in high-quality, proactive, planned care for patients

Mental health and neurodevelopmental resource groups

NHS England has developed a currency model for mental health, called mental health and neurodevelopmental resource groups (MHNRGs). Currencies are a way of grouping patients or activities into units that are clinically similar and have broadly similar resource needs and costs. They help service providers and staff in local health systems to understand their patient groups better and help them to plan, fund, benchmark and improve their services in a more evidence-based way.

MHNRGs are structured in several groups of mental health conditions (such as psychosis and bipolar disorders) as well as 16 settings that track where patients receive care (such as a community mental health team).

For more information on MHNRGs and currencies, see ‘Mental health and neurodevelopmental resource groups guidance’ and ‘Annex B - guidance on currencies’ on the NHS Payment Scheme 2025 to 2026 webpage.

Additional complexity factors

NHS England previously included addictions and substance use disorder as one of the currency populations in MHNRGs. However, they decided that, instead of having a distinct population in the currency model, it would be better to identify patients’ co-occurring addiction or substance use as an additional ‘complexity factor’.

Complexity factors provide a methodology for understanding wider factors that may increase the complexity of a patient’s needs or require a more tailored treatment approach. Since substance use can co-occur with any mental health condition, introducing addictions and substance use as a complexity factor helps identify patients that need additional support for substance use as part of their mental health treatment.

Depending on the outcome of the NHS payment scheme 2026 to 2027 consultation, we will introduce addictions and substance use as a complexity factor across all currency populations. The complexity factor uses and expands the underlying data of the previous approach to include it as a distinct adult population.

Guidance for the NHS payment scheme will set out how mental health services can identify this additional complexity factor through various existing data points in the MHSDS. By 2026 to 2027, we will require:

• providers to improve their data collection on people with co-occurring substance use and mental health conditions
• commissioners to consider the resulting currency data in their planning, funding and service evaluation decisions

Over the next few years, we will also explore options on how to reflect additional complexity factors in the National Cost Collection and payment methodologies, clarifying requirements for providers and commissioners.

This will:

• encourage data collection on all mental health populations, including ASSIST-Lite
• help commissioners and service providers see who needs support when planning and commissioning services
• show the cost and impact of disjointed working or lack of early intervention, building the evidence base for more preventative care in the community
• enable commissioners and service providers to benchmark themselves against other local areas and identify best practice

Actions we are taking nationally

NHS England will call commissioners’ and services’ attention to people with co-occurring mental health and substance use conditions and services, for future funding and planning. This work will be subject to consultation and include developing addiction and substance use as a complexity factor within the NHS currency model.

DHSC’s regional teams will provide support for local implementation of guidance (including NICE NG58 and the forthcoming duty to co-operate guidance) for services, with examples of good practice, through:

• leadership, performance management and targeted support by national and regional teams
• implementation support and focused sessions related to the alcohol and drug commissioning quality standard
• releasing the workforce calculator, which will support commissioners to increase the skills mix in drug and alcohol services

DHSC will support drug and alcohol treatment commissioners by:

• exploring ways to improve the NDTMS data set and the reports DHSC gives to local areas to help commissioners better understand unmet need and the effectiveness of interventions provided to people with co-occurring substance use and mental health conditions

• exploring the feasibility and effectiveness of incentive schemes and changing funding allocations for drug and alcohol services to encourage better joint working with mental health services, including:

  • structuring any incentive schemes around the implementation of joint working practices (Donmall and others, 2017)
  • using improved mental health service data to inform funding mechanisms to ensure a system wide response and shared accountability

Recommended actions for partnership working

Commissioners of drug and treatment and mental health services should collaborate on co-occurring conditions, to jointly assess need and develop a joint commissioning plan to deliver integrated care.

Commissioners of drug and alcohol treatment and mental health services should work together to:

• assess need, including estimates of unmet need, based on the best available qualitative and quantitative data, including engaging people with lived and living experience
• develop a joint commissioning plan to provide integrated care for people with co-occurring mental health and substance use needs
• develop local plans with service providers to improve treatment and care for people with co-occurring mental health and substance use conditions that can be embedded in the service specifications of both drug and alcohol treatment and mental health services

These local plans should include (as a minimum) information for both services on:

• principles of joint working
• screening and referral pathways
• brief interventions
• harm reduction and suicide prevention interventions
• shared risk management protocols
• workforce development plans
• data and clinical information sharing
• reciprocal training
• the involvement of people with lived experience in service review, planning and development

References

Donmall M, Sutton M, Jones A, Millar T, Turnbull P, McSweeney T, Disley E, Mason T, Moretti A, Pierce M and others. Evaluation of the drugs and alcohol recovery payment by results pilot programme: final report. University of Manchester, National Drug Evidence Center, 2017.

Harris J, Dalkin S, Jones L, Ainscough T, Maden M, Bate A and others. Achieving integrated treatment: a realist synthesis of service models and systems for co-existing serious mental health and substance use conditions. The Lancet Psychiatry 2023: volume 10, issue 8, pages 632 to 643 (registration and subscription required for full article).

National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Patient suicide: the impact of service changes - a UK wide study (PDF, 309KB). University of Manchester, 2013.

National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH). Annual report: UK patient and general population data, 2012 to 2022. University of Manchester, 2025.

Reinert DF and Allen JP. The alcohol use disorders identification test: an update of research findings. Alcohol Clinical and Experimental Research 2007: volume 31, issue 2, pages 185 to 199.