Scoping the challenges and opportunities for a public health diversion pathway for substance use in a county district in England: a qualitative frame analysis

Substance use, diversion scheme, interagency collaboration, partnership working, frame analysis, qualitative research ALL Metrics - Views Downloads How to cite this article Mills T, Jarrett M, Mallion J et al. Scoping the challenges and opportunities for a public health diversion pathway for substance use in a county district in England: a qualitative frame analysis [version 1; peer review: 1 approved with reservations]. NIHR Open Res 2025, 5:100 (https://doi.org/10.3310/nihropenres.14123.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente Select a format first ▬ ✚ Research Article [version 1; peer review: 1 approved with reservations] Thomas Mills https://orcid.org/0000-0003-2599-8930 1, Manuela Jarrett2, Jamiee Mallion3, Susie Sykes1, Jane Wills1, Eddie Chaplin1Thomas Mills https://orcid.org/0000-0003-2599-8930 1, Manuela Jarrett2, [...] Jamiee Mallion3, Susie Sykes1, Jane Wills1, Eddie Chaplin1 PUBLISHED 15 Oct 2025 Author details Author details 1 PHIRST South Bank, London South Bank University, School of Allied and Community Health, 103 Borough Rd, London, England, SE1 0AA, UK 2 Mental Health Nursing, Nursing and Midwifery, University of Birmingham, Birmingham, B15 2TT, UK 3 National Children’s Bureau, London, E8 3PN, UK 2 Mental Health Nursing, Nursing and Midwifery, University of Birmingham, Birmingham, B15 2TT, UK 3 National Children’s Bureau, London, E8 3PN, UK Thomas Mills Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Manuela Jarrett Roles: Data Curation, Formal Analysis, Investigation, Writing – Review & Editing Roles: Data Curation, Formal Analysis, Investigation, Writing – Review & Editing Jamiee Mallion Roles: Investigation, Writing – Review & Editing Roles: Investigation, Writing – Review & Editing Susie Sykes Roles: Funding Acquisition, Writing – Review & Editing Roles: Funding Acquisition, Writing – Review & Editing Jane Wills Roles: Writing – Review & Editing Roles: Writing – Review & Editing Eddie Chaplin Roles: Conceptualization, Formal Analysis, Writing – Review & Editing Roles: Conceptualization, Formal Analysis, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS Substance and alcohol use are well-established drivers of crime, anti-social behaviour, and harm, necessitating a comprehensive public health approach. Diversion schemes play an important role in engaging people entering or within the criminal justice system, whose crimes are linked to substance use. However, the emergence of public health diversion schemes has been slow. This study scopes the challenges and opportunities for a multiagency public health pathway to prevent substance use harm in Nottinghamshire, UK. Senior and frontline staff from diverse agencies were purposefully sampled for interviews based on their involvement in pathway development and/or implementation. 25 semi-structured interviews were conducted during a 12-month delivery period, involving local government public health, police, and treatment providers. A frame analysis investigated differences in perspectives regarding public health, the meaning of prevention, and pathway design. Pathway development requires balancing two sets of oppositional frames: public health vs. public safety and custody vs. community. While agencies’ stated commitment to public health presented an opportunity, intervention points across the custody suite and community setting could not be optimised during the delivery period. Operational siloes, resource constraints, and role congruency issues linked to contrasting understandings of prevention and role expectations frustrated progress. As such, a ‘reactive’ approach based in the custody suite took precedence over a ‘proactive,’ community-centred approach. Multiagency public health solutions are challenging to develop amid contrasting understandings of public health, role expectations, and resource constraints. There is a need for national-level multi-agency discussions to develop a shared understanding of a public health approach to diversion, including understanding the role and contribution of frontline police staff. Future research should engage service-users in pathway design and aim to establish optimal agency roles and processes for coordinating interventions across custody suites and community settings. We explored how different local agencies tried to create a “public health” diversion pathway for people whose offending was linked to substance use in one county in England. Diversion schemes aim to connect people to support, instead of relying only on arrest or prosecution. We interviewed 25 staff members from the public health, police, and treatment services to understand their views and how the pathway could work in practice. We found four main viewpoints shaped by both professional priorities (public health vs. public safety) and work settings (custody suite vs. community). All agencies supported the idea of a public health approach. However, there was no agreement on who should do what, especially whether the police should carry out assessments and referrals. Police staff preferred a supporting role, and interviewees noted that people might not be able to speak openly to police about substance use. At the same time, specialist substance use workers were needed in both the custody suite and the community setting to support frontline police, creating a staffing “pull” in two directions. Because of these tensions, the custody-based reactive parts of the pathway continued, while proactive community elements were not implemented. We conclude that clearer national guidance on roles (including the police role), sufficient resources, and involving people with lived experiences in pathway design are needed to make public health diversion work locally. Substance use, diversion scheme, interagency collaboration, partnership working, frame analysis, qualitative research Corresponding Author(s) Thomas Mills ([email protected]) Grant information: This project is funded by the National Institute for Health Research (NIHR) Programme NIHR131568; Award ID; NIHR135411]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © Crown copyright, 2025 Mills T et al.. This open access work is licensed under the Open Government Licence v3.0 How to cite: Mills T, Jarrett M, Mallion J et al. Scoping the challenges and opportunities for a public health diversion pathway for substance use in a county district in England: a qualitative frame analysis [version 1; peer review: 1 approved with reservations]. NIHR Open Res 2025, 5:100 (https://doi.org/10.3310/nihropenres.14123.1) First published: 15 Oct 2025, 5:100 (https://doi.org/10.3310/nihropenres.14123.1) Latest published: 15 Oct 2025, 5:100 (https://doi.org/10.3310/nihropenres.14123.1) The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Diversion schemes for addressing substance use in the Criminal Justice (CJ) system have been established globally since at least the 1970s1–3. While differences exist in the theory and practice of diversion, the fundamental idea is that service-users are diverted to assessment and/or support instead of arrest, prosecution, or formal caution4. Such schemes may be pre- or post-arrest, voluntary or mandatory, and offer diverse intervention types such as treatment for substance use, education, or employment support5. Recent years have seen an increased interest in public health approaches to diversion that favour voluntary entry points and aim to address service-users’ unmet health, social, and economic needs1. In the UK, diversionary schemes have received renewed attention at the national level6. The nationally mandated Drug Intervention Programme (DIP) was introduced in the early 2000s to reduce crime linked to substance use. Underpinned by a multiagency approach that included the National Health Service (NHS), the DIP combined voluntary and mandatory approaches, with police officers having the option to manage service-users into treatment, depending on various trigger offences. Evidence for the effectiveness of DIP in the long-term is debated, but the programme is known to have reduced crime during service-users’ time in treatment7,8. However, the end to national funding for DIP in 2013, coupled with austerity measures, created major gaps in local service provision9,10. In response to various independent reviews9,10, the UK Government published the policy paper ‘From Harm to Hope: a 10-year drugs plan to cut crime and save lives’, presenting a ten-year drug strategy consisting of increased funding and targets for diverting service-users into treatment6. Such renewed policy attention coincides with societal and organisational shifts towards public health approaches to policing1. The role of frontline police staff has been reappraised as part of the wider public health workforce by both policing11–13 and the public health profession14. The Policing Vision 2025, a ten-year plan for policing, highlights the importance of preventative activities within policing15. These developments present opportunities for public health approaches to diversion. This paper presents a formative evaluation of the development of a public health diversion pathway for substance use that spanned custody suites and community settings. The pathway was conceptualized by local government public health and senior management of the local substance use treatment provider, with the support of the Office of the Police and Crime Commissioner (OPCC). The service context was the county district of Nottinghamshire. Rather than solely engaging service-users within the custody suite, the pathway features new community referral routes for treatment. The aspiration was for service-users to receive personalized interventions across the three levels of service-user needs (see Table 1). In this section, we discuss the challenges and opportunities of this pathway concept. | Level | Intervention | |---|---| | L1 | Universal provision of health-related advice in police custody for cases involving substance or alcohol use at any level, including via a tailored Welcome Pack. (The implementation of alcohol brief interventions in the custody suite is explored in a different paper17. | | L2 | A voluntary referral into treatment services open to any service-user who wants it, either via custody or a community referral, for the standard treatment provided by the treatment provider. | | L3 | A voluntary or mandatory route whereby police staff (either in custody or in community settings) identify people who they view as priority cases for extensive and proactive support in community settings. The resource intensive nature of L3 meant that numbers would be limited to 18 people over the 12-months delivery period. | Local government public health successfully applied for evaluation support from Public Health Intervention Responsive Studies Teams (PHIRST) South Bank, funded by the National Institute for Health and Care Research (NIHR). The PHIRST South Bank research team, two Public Patient Involvement and Engagement (PPIE) personnel, and representatives from local government public health, the OPCC, the police, and the local treatment provider co-produced the evaluation design16. Data collection Data collection featured two rounds. First, senior staff of the main commissioning agencies (local government public health and OPCC) and staff with implementation responsibilities were recruited via purposive sampling and interviewed at the midpoint of the 12-month delivery period. The interview schedule explored interviewees’ perceptions of the proposed pathway, their implementation efforts, the strengths and weaknesses of the custody suite, community settings as entry points for treatment, and national policy developments. Second, a combination of purposive sampling and snowballing was used to recruit frontline staff towards the end of the delivery period, including substance use workers, custody police staff, neighbourhood police, and NHS Liaison & Diversion (L&D), a nationally commissioned treatment provider operating in the custody suite. Three senior stakeholders were interviewed for a second time because they were deemed to have vital insights for the evaluation. 22 participants were interviewed, with a total of 25 interviews ranging from 23 minutes to 1 h and 10 minutes (see Table 2). | Staff group | Quotation label | Number of staff | Number of interviews | |---|---|---|---| | Local government public health | LGPH (local government public health) | 3 | 5 | | OPCC | PS (Police staff*) | 1 | 2 | | Police | PS (Police staff) | 7 | 7 | | Substance use workers | SW (substance user worker) | 7 | 7 | | NHS L&D | L&D (NHS L&D) | 4 | 4 | | Total | 22 | 25 | All interviews were conducted by experienced qualitative researchers and were professionally transcribed. Recruitment concluded once the research team considered that they had interviewed staff from all the roles that might support the pathway, and that saturation had been achieved in terms of understanding staff’s views of the pathway locally. Data analysis A frame analysis was conducted to understand the institutional basis of differences in participants’ views18. An established approach in public policy19, previous frame analyses in public health have drawn attention to contrasting frames of obesity (individualistic vs. systematic), which align with contrasting policy responses20,21. Here, we utilised frame analysis to unpick differences in a) participants’ views of substance use harm and their role in addressing this, and b) participants’ contrasting positions on pathway design. The first phase of data familiarisation was followed by the development of a coding framework that was applied to all interview data using NVivo version 12. The coding framework was initially informed by established matrixes designed to identify and compare frames20. This was modified iteratively as the analysis progressed. Categories from the literature were incorporated to identify dominant frames, notably the distinction between public health and public safety22, whereas other categories were proposed and incorporated on an inductive basis. Concurrent with the frame analysis, a situational analysis was undertaken to better understand the internal and external factors affecting the pathway’s design, which is commonly used by organisations to optimise performance through enhanced understanding of the Strengths, Opportunities, Weaknesses and Threats (SWOT) underpinning decisions23. A SWOT infographic was created and presented to senior stakeholders at a midpoint evaluation meeting, which was then revised following the second round of data collection. Each step of the analysis involved shared coding, member checking, and group analysis among the research team to ensure rigour and credibility, while the different perspectives within the team (which included public health and criminal justice research perspectives) enhanced reflexivity. The final presentation of the results is the end-product of this process. The research team recruited two PPIE representatives who had experience of the custody suite and the local substance use support service. They attended coproduction meetings facilitated by the research team to decide on the research focus and methodological approach. The PPIE representatives supported the research team to develop interview topic guides, making important contributions about the need for accessible language. The PPIE representatives also advised on how to recruit service-users. However, it was not possible to sustain their engagement into the data analysis phase despite the research team’s efforts to support their involvement. It was also not possible to recruit more PPIE representatives from the custody suite or local substance use support service. Addressing challenges conducting PPIE in criminal justice and substance use settings should be a priority in future research. The frame analysis is summarised in two sections. Section 1 identifies the main frames underpinning participants’ perspectives. We identify a dual axis of Public Health (PH) versus Public Safety (PS) on the one hand, and custody versus community on the other, resulting in four main frames: PH-Custody, PS-Custody, PH-Community, and PS-Community. Section 2 explores the content of these frames in relation to questions about pathway design. Section 3 concludes with the SWOT infographic, which exhibits a commissioning dilemma that ultimately undermined the efforts to develop a diversion pathway. Public Health vs Public Safety Clear differences in perspective were evident between the police and those agencies whose primary role was to support public health. Figure 1 shows some of the key similarities and differences between PH and PS. Many police staff supported a PH approach despite there being some “old-fashioned police officers who absolutely believe in enforcement, in detention” [PS1]. Police attitudes had purportedly shifted due to the recognition of the ineffectiveness of prison [PS2] and experiential learning: As a young police officer there’s nothing more satisfying than when a perceived baddie, someone who’s causing chaos and carnage in the city centre [is arrested]: you arrest them, you detain them, you take them into custody, you interview them for whatever relevant offence, they are processed, they’re charged, they’re either remanded, or they go to prison. And you’re thinking: “I’ve done a good job there: that’s what my job is about”. And that is part of a police officer’s role, but then when you see that same person bounce out of prison in very short order … and then it happens a third and a fourth time, clearly there is something going wrong [PS4] However, police staff saw their role as supporting other agencies to deliver a PH approach, whereas other agencies proposed that police staff deliver interventions directly, such as brief alcohol interventions, or service-user assessments and referrals. Furthermore, where local government public health and both treatment provider organisations were primarily concerned with health and well-being, police staff were concerned with addressing the needs of the victims of crime, who were notably absent in PH framings: We need to be doing something right for that person [person with substance misuse needs] and right for the victims as well … [and] the victims’ families [PS5] Senior managers recognised these differences and sought a compromise in pathway design. The following quotes capture differences in the question of how to engage service-users, with references to ‘good-natured’ disagreement and a desire to ‘merge’ with the contrasting frame: Some of the criminal justice sector say, “These people are committing crime. We need to arrest them” …. Looking at it from a public health perspective, there’s a reason why these people are misusing substances: we need to help them and engage with them and bring them into treatment … We are on two different train tracks and it’s how we can sort of merge a little bit around the fundamentals [LGPH1] The key point of disagreement … and it’s a very good-natured disagreement – we don’t agree on this and we know we don’t and we talk about it – it’s the bit about engagement … [Public health professionals] and most treatment providers will say, “People have to want to engage with the treatment in order for it to be successful”, and I do absolutely get that, but I also know for some offenders being mandated to do it, so they had to do it or they’d be back in prison, that mandatory aspect, also really works for some people [PS1] Community vs Custody Contrasting perspectives also existed within the two overarching PH and PS frames linked to staff positions across the community setting and the custody suite divide. A dual axis of PS vs. PH and Community vs. Custody can therefore be identified to situate various agencies (see Figure 2). While broadly aligning with the PH frame, local government public health and NHS L&D had contrasting perspectives. Local government public health staff exhibited a strong population-level outlook and emphasised the importance of upstream prevention in community settings, thus exhibiting a distinct PH-Community frame. In the following quote, a local government public health professional reflects on the difference between this perspective and the NHS’, based on their experiences of working on the NHS-commissioned Drug and Alcohol Action Team (DAAT), which predated L&D: It’s been a culture change for me [moving from the NHS to local government] because how the Drug and Alcohol Action Team versus how Public Health do business is very different. Public Health think a lot more strategically and a lot more across the life course. So, they’re a lot more interested in “How do we break the cycle of intergenerational substance misuse?” … [It’s] that Public Health, population-level, thinking … [whereas before] I was very used to being interested in the [operational] detail … We were far more hands-on when we were in the DAAT, compared to how Public Health like to do business [LGPH3] By contrast, NHS L&D staff operating within the custody suite prioritised support for offenders and considered the community setting to be “quite a way from our service’ [L&D3]. Their preventative approach highlighted the importance of preventing further harm and supporting recovery in line with a more secondary understanding of prevention. Substance use workers, highlighted in blue in Figure 2, worked across the Community and Custody divide and sought to balance efforts to address health needs in the custody suite with preventative efforts in the community. This secondary distinction between Custody and the Community also underpinned differences in police perspectives, with custody police staff adhering to a PS-Custody frame that reflected their positioning in the custody suite. Although oriented towards crime prevention and supportive of mandatory entry points into treatment (in line with the PS frame), neighbourhood police shared the local government’s public health interest in upstream, community-centred prevention: The four frames revealed in Section 1 had distinct and sometimes clashing perspectives on pathway design, notably regarding whether specialist substance use workers should be deployed in custody suites or community settings. First, we present the PH-Community frame, as the frame of the local government public health commissioners who led the pathway’s redesign. We then consider how this contrasts with the other frames (PS-Custody, PH-Custody, and PS-Community). PH-Community Local government public health commissioners proposed that custody police staff manage referrals for treatment within the custody suite. They argued that this would enable the adoption of a more preventative, PH-Community approach by freeing up the time of substance use workers (who previously worked only in the custody suite) to engage in community outreach. Local government public health argued that this was important because having substance use workers in the custody suite was inefficient due to low footfall in the county. They also believed that repositioning substance use workers in the community would facilitate a more personalised service, as service-users already in treatment could be met in community locations, while substance use workers could engage in upstream prevention by identifying and supporting substance users prior to entry into police custody. This implied a more proactive approach than the previous model based on police custody, although local government public health recognised that the effectiveness of their favoured approach needed testing: In order to take that proactive approach, people can’t be just sitting in custody: we don’t have the capacity to have two [substance use] teams, one solely based in custody and one solely being assertive outreach. So, it’s where the bang for the buck is and what’s the best approach to test out in terms of, how do we engage people better into treatment? Is it sat in custody or is it being more proactive? … We have to take a punt and think about where resources will be best to test out this process [LGPH1] PS-Custody Police adherents of the PS-Custody frame rejected local government public health’s call for an enhanced police role in the management of referrals in the custody suite. While police staff professed support for a PH approach, role congruency issues and skill gaps were highlighted as barriers to police staff performing an enhanced assessment of service-users on entry into police custody. In this regard, police staff reluctance was linked to how they are perceived by service-users. Having “taken away their liberty” [PS5], police believed that service-users may not be truthful due to the criminal status of substance use. For police staff, forming a trusting relationship is challenging. I’ve spoken to quite a few different sergeants and detention officers and they’ve said exactly the same: it’s difficult to switch from being the ‘jailor’ to being someone who wants to help them. And I think it’s a real skill. Some people are able to do that and some people just can’t, or the service-user is just not receptive [SW2] As such, custody police staff called for concentrating the substance use workforce in police custody because, they argued, independence from the police was important for gaining trust: An independent person, doing that interaction or intervention around substance misuse [would be better], someone who understands the individual to actually gain some trust to then say, “Right: you’d benefit from support” [PS5] PH-Custody The NHS L&D staff had a broader remit than the substance use treatment provider, aiming to support people in the CJ system with vulnerabilities, including but not limited to substance use needs. Operating in the custody suite 12-hours a day, 7-days a week, NHS L&D staff recognised opportunities to engage with service-users but highlighted skills gaps in relation to substance use support. Hence, their position on pathway design was to call for substance use workers to be positioned in police custody, so NHS L&D could undertake joint assessments with them. In the absence of a specialist presence, NHS L&D staff were concerned that some service-users would not obtain the support they needed: There are discussions and queries about people on methadone … I’m not a specialist in any of that kind of thing and the different systems and where to get it from and signpost. I think having someone with that knowledge based in custody would be an advantage [L&D3] Substance use workers had a nuanced perspective on the question of where they might utilise their specialist expertise, voicing frustrations with unused time in the custody suite, while also highlighting the unique person-centred support which, they argued, only substance use workers can provide in police custody. An important part of their role there was picking up people with substance use needs who were missed in police-led booking in assessments, via informal ‘cell sweeps’: We’ve had more success by doing our own, a bit more confidential and private, cell sweeps, when the person’s been in their cell [SW3] PS-Community Neighborhood police in the community recognised that their knowledge of neighbourhoods meant they could identify individuals with substance use needs who might commit crimes. They also recognised opportunities for them to signpost people towards treatment and highlighted the potential for referrals to be generated at local Vulnerable People Panels attended by the local substance use provider. However, neighbourhood police saw their role as supporting other agencies within a PH approach, rather than delivering health interventions directly. They argued that referrals into the new pathway would have to be generated by substance use workers working ‘face-to-face’ with neighbourhood police, rather than by neighbourhood police alone, via electronic systems: Neighbourhood policing teams … should be able to identify people who’ve got issues or require support. And, if they’ve got a means to directly refer them in … they [would] take that. The issue is … [neighbourhood police staff] get confused with what’s out there and don’t get the feedback. So, it’s almost like, “Oh … I’ve put a form in or an electronic referral in and I didn't get anything back. I didn't know if they received it or not.” So, outreach and being part of those operational meetings … would work, face-to-face [PS3] Figure 3 presents the fundamental commissioning dilemma faced by local government public health commissioners as they sought to balance the contrasting frames explored in Section 1 and Section 2. As we saw in Section 2, stakeholders disagreed over frontline police staff roles in the pathway and the linked issue of where and how to utilise the substance use workforce. Reallocating substance use staff to community settings promised prevention through more proactive community engagement (as identified by the PH-Community frame), but risked gaps in custody support (as identified by the PH-Custody and PS-Custody frames), as custody police staff resisted a lead role in pathway delivery. Retaining substance use staff in police custody to support custody police staff addressed health needs there but preserved reactive provision that precluded community outreach. Opportunities were identified to develop NHS L&D staff’s role in substance use assessments, referrals, and support that might enable substance use workers to spend more time in the community, but this was aspirational. As such, the substance use workforce was pulled back into reactive mode in police custody. Furthermore, because neighbourhood police (in the PS-Community frame) insisted that they, like custody police, needed the direct support of the substance use workforce in the community, opportunities to utilise neighbourhood police’s community intelligence in preventative efforts could not be utilised. Diversion pathways for substance use have long been discussed in many countries, and evidence on service utilisation and recidivism is equivocal7,8,24,25. Amidst the ongoing discussion about public health approaches to substance use1,26, our findings indicate that a comprehensive public health pathway for substance use diversion would entail diverse prevention, treatment, and recovery options, with entry points into treatment across the custody suite and community settings. With primary prevention resting with public health and neighbourhood police to be provided in collaboration with specialist substance use workers in the community, secondary prevention would be within police custody. In England, such secondary prevention requires collaboration between custody police staff, substance user workers, and NHS L&D (who have broader remits than substance use treatment providers). However, we find that precise staff roles in such a multiagency pathway, as well as the interrelationships between the agencies mentioned, are yet to be established. In this study, considerable differences in opinions regarding the roles and contributions of frontline police meant that progress was limited. We identified a commissioning dilemma (see Figure 3) linked to decisions about where to allocate the substance use workforce, which entailed unavoidable trade-offs. Commissioned primarily by local government public health, this workforce had specialist substance use support skills that were highlighted as vital by the adherents of each of the four frames we identified: PH-Custody, PS-Custody, PH-Community, and PS-Community. This created a push and pull dynamic across the custody suite and community settings, as substance use workers were needed in both settings to support police staff who did not accept the enhanced health roles required for the pathway to function. Thus, our findings have significant implications for recent calls for collaboration between the police and public health. Leading public health and police organisations promote active involvement of frontline police staff in the delivery of health interventions11–14. While we detected clear trends among police staff towards support for a public health approach, this did not correspond to their direct involvement in the delivery of health interventions. Custody and neighbourhood police staff rejected calls to implement substance use assessments, referrals, and brief advice, insisting on substance use workers leading on these tasks with police support. Crucially, police staff highlighted that service-users may not be truthful with the police when discussing substance use because of the potential criminal implications, suggesting that some barriers to police engagement link to broader debates about drug criminalisation. Because use and possession remain criminalised in England, disclosure to police may be perceived as risky by service-users, reducing the feasibility of police-led assessment, even when police support the overall public health approach. It is interesting to note that Portugal’s national strategy approach, arguably the leading international example of a public health approach to substance use, combined drug criminalisation (in terms of use, purchase, and possession27) with the introduction of diversion pathways. Even here, however, the responsibility for assessment lies not with the police, but with ‘Commissions for the Dissuasion of Drug Addiction’27. These commissions comprise a small group of individuals, usually social workers, psychologists, and lawyers, all of whom have expertise in substance use. The police’s role is primarily crime prevention rather than health intervention delivery27. The Portuguese example suggests that a more cautious approach to changing police roles may be needed, with non-police staff being more suited to delivering health interventions. This resonates with the more cautious approach in the ‘Right Care, Right Person’ strategy in England, which suggests a more indirect and supportive role for police when collaborating with health agencies, including in substance use support28. These findings, highlighting the well-established challenges to effective collaboration in the area29–31, have significant national-level implications. With diverse agencies professing support for a public health approach to diversion, a cross-agency consensus is needed regarding what this entails for frontline staff as a precursor to developing more precise service specifications. In addition to the question of the role of frontline police, national policy documents suggest that referrals into treatment will proceed via NHS L&D6. However, NHS L&D staff highlighted skills gaps to fulfil such a role, which saw them request direct collaboration with specialist substance use workers. Clarity is therefore required, and any resourcing and skill development needs met if NHS L&D staff manage substance use referrals in police custody. Qualitative research involving a single case has limited transferability although we sought to ensure ‘thick description’ through the results section to partially offset this. A further limitation is the reliance on staff perspectives: recruitment of service-users from the custody suite was challenging and our two-person PPIE panel, formed at the start of the evaluation and helpfully involved in study design, could not be sustained through data collection and analysis. Public health approaches to diversion are challenging to develop in a context of contrasting agency understandings of what ‘public health’ entails, resource constraints and unclear national policy. There is a need for national-level multi-agency discussions to develop a shared understanding of a public health approach to diversion. We found contrasting opinions regarding the role of frontline police in assessments, referrals, and brief intervention delivery. A more realistic and sustainable approach may be to reposition the police as facilitators of referral while health professionals take the lead in assessment and intervention delivery. Addressing these questions openly at the national level will be critical if public health diversion pathways are successfully developed locally. Future research should engage service-users in questions of pathway design and aim to establish optimal agency roles and processes for coordinating interventions across custody suites and community settings. This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Institute of Health and Social Care Ethics Panel at London South Bank University (ETH2122-0131 and ETH2122-0176). All the participants provided written informed consent for participation. All interview participants provided written informed consent for publication. Qualitative data will not be made available because of the potential to reidentify the participants. The research team did not apply for ethical approval to share data because the study used interviews from a single context, increasing the risk of reidentification. This was an ethical concern, particularly because interviewees were staff in a work setting. We therefore do not have ethical approval to share data. However, data summaries are available upon request. An SRQR checklist for this manuscript can be found at: Open Science Framework, Frame Analysis Paper – SQPR_checklist, DOI 10.17605/OSF.IO/MY92A, CC0 1.0 Universal33 We would like to thank local Public Health Commissioning, particularly Sarah Quilty, who supported the research, two PPIE personnel who contributed to the evaluation design, and all staff who participated in the interviews. We also thank Emma Doohan and Anita Hoque of PHIRST South Bank, who made the research possible. Faculty Opinions recommendedReferences - 1. Bacon M: From criminalisation to harm reduction? 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Publisher Full Text Author details Author details 1 PHIRST South Bank, London South Bank University, School of Allied and Community Health, 103 Borough Rd, London, England, SE1 0AA, UK 2 Mental Health Nursing, Nursing and Midwifery, University of Birmingham, Birmingham, B15 2TT, UK 3 National Children’s Bureau, London, E8 3PN, UK 2 Mental Health Nursing, Nursing and Midwifery, University of Birmingham, Birmingham, B15 2TT, UK 3 National Children’s Bureau, London, E8 3PN, UK Thomas Mills Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Manuela Jarrett Roles: Data Curation, Formal Analysis, Investigation, Writing – Review & Editing Roles: Data Curation, Formal Analysis, Investigation, Writing – Review & Editing Jamiee Mallion Roles: Investigation, Writing – Review & Editing Roles: Investigation, Writing – Review & Editing Susie Sykes Roles: Funding Acquisition, Writing – Review & Editing Roles: Funding Acquisition, Writing – Review & Editing Jane Wills Roles: Writing – Review & Editing Roles: Writing – Review & Editing Eddie Chaplin Roles: Conceptualization, Formal Analysis, Writing – Review & Editing Roles: Conceptualization, Formal Analysis, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This project is funded by the National Institute for Health Research (NIHR) Programme NIHR131568; Award ID; NIHR135411]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright © Crown copyright, 2025 Mills T et al.. This open access work is licensed under the Open Government Licence v3.0 metrics VIEWS $counts.viewCount downloads Citations CITE how to cite this article Mills T, Jarrett M, Mallion J et al. Scoping the challenges and opportunities for a public health diversion pathway for substance use in a county district in England: a qualitative frame analysis [version 1; peer review: 1 approved with reservations]. NIHR Open Res 2025, 5:100 (https://doi.org/10.3310/nihropenres.14123.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. track receive updates on this article Track an article to receive email alerts on any updates to this article. Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 15 Oct 2025 Views 0 How to cite this report: Brown H. Reviewer Report For: Scoping the challenges and opportunities for a public health diversion pathway for substance use in a county district in England: a qualitative frame analysis [version 1; peer review: 1 approved with reservations]. NIHR Open Res 2025, 5:100 (https://doi.org/10.3310/nihropenres.15362.r39479) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-100/v1#referee-response-39479 https://openresearch.nihr.ac.uk/articles/5-100/v1#referee-response-39479 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 23 Feb 2026 Approved with Reservations VIEWS 0 Summary: This article uses qualitative interview with service providers to scopes the challenges and opportunities for a multiagency public health pathway to prevent substance use harm in Nottinghamshire, UK for those at risk or engaged with the criminal justice ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close Summary: This article uses qualitative interview with service providers to scopes the challenges and opportunities for a multiagency public health pathway to prevent substance use harm in Nottinghamshire, UK for those at risk or engaged with the criminal justice system. Operational silos, lack of training and perceived capability and roles are challenges to overcome.

It would be helpful in the abstract to define what a diversion scheme is.

I would like to know more about the recruitment process. How many people were approached? Was there any incentive for participation? How was it determined that some senior stakeholders would be interviewed twice?

In the discussion can you expand on how Right Care Right Person fits with your findings? (E.g. public health professionals believe that police should take the lead on interventions in custody). In the discussion I also found the section describing the role of NHS L&D confusing. This could be clarified by stating which policy and if and how it relates to Right Care Right Person. Limitations-please define ‘thick description’ as I am not familiar with this term.

Based upon your findings would another area of future research be related to identifying training gaps of professionals working across the care pathways?

It would be helpful in the abstract to define what a diversion scheme is.

I would like to know more about the recruitment process. How many people were approached? Was there any incentive for participation? How was it determined that some senior stakeholders would be interviewed twice?

In the discussion can you expand on how Right Care Right Person fits with your findings? (E.g. public health professionals believe that police should take the lead on interventions in custody). In the discussion I also found the section describing the role of NHS L&D confusing. This could be clarified by stating which policy and if and how it relates to Right Care Right Person. Limitations-please define ‘thick description’ as I am not familiar with this term.

Based upon your findings would another area of future research be related to identifying training gaps of professionals working across the care pathways? - Is the work clearly and accurately presented and does it cite the current literature? Yes - Is the study design appropriate and is the work technically sound? Yes - Are sufficient details of methods and analysis provided to allow replication by others? Partly - If applicable, is the statistical analysis and its interpretation appropriate? Not applicable - Are all the source data underlying the results available to ensure full reproducibility? Partly - Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Health inequalities, evaluation. Please note I am not a qualitative researcher. CITE HOW TO CITE THIS REPORT Brown H. Reviewer Report For: Scoping the challenges and opportunities for a public health diversion pathway for substance use in a county district in England: a qualitative frame analysis [version 1; peer review: 1 approved with reservations]. NIHR Open Res 2025, 5:100 (https://doi.org/10.3310/nihropenres.15362.r39479) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-100/v1#referee-response-39479 https://openresearch.nihr.ac.uk/articles/5-100/v1#referee-response-39479 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Alongside their report, reviewers assign a status to the article: - Approved - Approved with reservations - Not approved | Invited Reviewers | | |---|---| | 1 | | | Version 1 15 Oct 25 | read | Sign up for content alerts You are now signed up to receive this alert Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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