No wrong door: A cautiously optimistic step towards supporting co-occurring needs
The release of the Co-Occurring Mental Health and Substance Use Delivery Framework by the Expert Reference Group in December marks a significant and long-awaited step forward. For those of us who have campaigned for years to end the exclusion of people with both mental health and substance use needs, this moment brings real cause for optimism, albeit with a necessary degree of caution.
As Involvement Manager for the National Experts by Experience Citizens Group (NECG), and as a supporter of lived-experience members who sat on the Expert Reference Group panel, I have seen first-hand the commitment, persistence and emotional labour that has gone into this work. The publication of the framework is the culmination of more than two years of sustained effort, shaped by the insights of academics, clinicians, service providers, and crucially, people with lived experience. It builds on the foundations laid by Dame Carol Black’s Independent Review on Drugs, the NHS Long Term Plan and the growing recognition that our current systems have been failing those with co-occurring needs for far too long.
The framework acknowledges at its core the simple truth that separating mental health and substance use services has created a system that does not work with the whole person. For years, people have been bounced between services, told they are “too complex” or “not ready”, trapped in what many describe as a co-occurring “ping-pong” that leaves needs unmet and hope eroded.
“I do not know anybody who has not had mental health issues with addiction. They go hand in hand.” – NECG member
The myth of “non-engagement”
One of the most welcome aspects of the framework is its clear rejection of the myth of so-called “non-engagement”. The report makes it explicit that disengagement is often a symptom poorly designed, fragmented and risk-averse services, rather than a failure on the part of individuals.
“Treatment services, not people, are ‘hard to reach’.” – NECG member
The proposed No Wrong Door approach places responsibility where it belongs: on services to recognise and respond to co-occurring needs wherever someone presents, whether that’s mental health services or drug and alcohol provision. Under this model, it is everyone’s job to help as opposed to someone else’s problem to refer on.
This shift is particularly important for people with histories of trauma, where the relationship between mental health distress and substance use is complex, dynamic and inseparable.
“It is near impossible to draw clear distinctions between these issues: they constantly overlap, merge, and affect each other.” – NECG member
A dual system cannot meet needs that are fundamentally intertwined.
Integrated care, shared responsibility
The framework places an emphasis on joint responsibility between commissioners and providers, calling for closer collaboration between mental health and drug and alcohol services. Through Integrated Care Boards, there is now an opportunity to close the long-standing gap between these systems and move towards genuinely joined-up care.
This includes commissioning services in collaboration with people with lived experience, ensuring they are purposefully designed to support mental health and substance use needs at the same time. It also signals a welcome move away from rigid block contracts towards fairer funding models. This is an important incentive for providers to treat addiction as a legitimate health issue, rather than viewing it solely through a criminal justice lens.
For NECG members, this aligns closely with the long-held vision of an end to the artificial separation of “dual diagnosis”. We need recognition that addiction should be understood and treated as a mental health issue in its own right: only then can services offer truly holistic and trauma-informed support.
Hope for people leaving prison
Nowhere is this shift more urgently needed than for people leaving prison. Transitions from custody are periods of heightened vulnerability with serious risks of relapse, mental health crisis and overdose. Too often, people are released into the community only to face fragmented systems, long waiting lists and thresholds that exclude them precisely when they most need support.
A No Wrong Door approach, backed by coordinated leadership from NHS partners and drug and alcohol services, has the potential to change this trajectory, meaning services can help people avoid the revolving door between prison and crisis services, and to stabilise and rebuild trust.
As NECG members have highlighted, (paid) peer supporters are essential in this process. They play a vital role in building relationships, supporting people through waiting periods, and helping navigate complex systems during times of transition.
Cautious optimism grounded in reality
The framework sets out a clear, step-by-step approach to improving responses to co-occurring needs, from service design and workforce development to data, incentives and accountability. If implemented well, these changes could be genuinely transformative, shifting the focus from forcing people to fit services to adapting services around people.
That said, optimism must remain cautious. Policy alone will not deliver change. Implementation, culture shift, workforce capacity, and meaningful co-production with lived-experience communities will determine whether this framework succeeds or becomes another missed opportunity.
Nevertheless, the world of multiple disadvantage this moment matters. It brings renewed hope to those caught in cycles of self-medication and worsening mental health, and it signals a growing willingness to listen.
