NHS Pilot — Cambridge ICB

One joined-up pathway.
Saving Money,
Saving Lives.

OTOS Continuity helps the NHS and partner organisations connect care, support and recovery services into one joined-up pathway — starting with the most underserved cohort in the system.

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877
Individuals identified
50
Pre-pilot target
25%
Addiction patients with hidden ADHD
OTOS Partner Pathway Diagram
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The Problem

Hidden in plain sight.
ADHD is driving addiction.

Thousands of people are cycling through addiction services, mental health crisis, homelessness and revolving-door hospitalisation — while the underlying cause remains undiagnosed and untreated.

23–45%

Of people in addiction treatment have undiagnosed ADHD

Royal College of Psychiatrists research shows ADHD is massively underdiagnosed in addiction cohorts — yet it is often the root driver.

Source: RCPsych, 2022
£1.3bn

Annual NHS spend on addiction services in England

Much of this spend is reactive. Treating the symptom without identifying the underlying neurodevelopmental cause keeps people trapped in cycles.

Source: NHS England
877

Individuals identified in Cambridge alone

OTOS has already identified 877 people within Cambridge who match the target cohort profile — adults cycling through services with likely undiagnosed ADHD.

Source: OTOS Continuity mapping
"
Treating ADHD in patients with co-occurring substance use disorder produces benefit — not only for ADHD symptoms, but for substance use outcomes too. There is more benefit than risk from treating ADHD in this cohort.
— Royal College of Psychiatrists, ADHD with Substance Use: A Clinical Dilemma (2022)
Our Solution

The Continuity Layer.
One thread through every service.

OTOS Continuity creates a connecting layer that links care, support and recovery services around one person's real journey — so nothing falls through the gaps.

01

Identify

Screen and identify individuals in addiction, recovery and crisis services who show signs of undiagnosed ADHD using a validated pathway.

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02

Connect

Warm-transfer individuals to appropriate NHS and partner services — ADHD assessment, Right to Choose, CPFT, GP, mental health support.

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03

Coordinate

Maintain a continuity thread across services so each partner knows where the person is in their journey — reducing gaps, duplication and crisis.

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04

Sustain

Support appropriate medication, ongoing recovery and re-engagement — building evidence for a permanent joined-up service model.

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ADHD-first approach

Treating the underlying neurodevelopmental condition reduces substance use, crisis behaviour, and revolving-door presentations — backed by NICE guidance and RCPsych evidence.

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Partner-connected delivery

OTOS does not replace existing services — it connects them. The model works with NHS, VCSE, and private partners already delivering in the community.

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Data-led and measurable

Every individual in the pilot is tracked through their thread. Outcomes are measured, evidenced, and ready for ICB commissioning review.

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Redirecting existing spend

The model is designed to redirect money already being spent on reactive crisis care into proactive, joined-up early intervention — reducing total cost.

The Pilot

50 people.
A proof point that changes everything.

The pre-pilot demonstrator targets 50 high-priority individuals from an already-identified cohort of 877 — with partners warmed up and ready to move.

Pre-Pilot Demonstrator

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Target cohort: Adults in Cambridge cycling through addiction, recovery, mental health and crisis services — with likely undiagnosed ADHD
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Scale: 50 individuals in the pre-pilot demonstrator, from an identified pool of 877 in the Cambridge area
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Partners: NHS GP, CPFT ADHD Clinic, Cambridge Recovery Service, Change Grow Live, WorkWell, Addenbrooke's, The Sun Network, QbTech, and others
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Governance: ICB commissioning pathway, Public Health alignment, NHS Right to Choose integration
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Evidence base: Builds the case for expanded NHS commissioning — with measurable outcomes from Day 1
877
Individuals already identified in the Cambridge area matching the target cohort profile
50
Pre-pilot target to demonstrate the model, gather evidence, and prove outcomes
Partners warmed up.
This is not a cold start. Key organisations are engaged and ready to move.

Proposed Timeline

Now
ICB & Public Health Engagement
Securing commissioning support and governance alignment
Month 1–2
Pre-Pilot Setup
Partner agreements, referral pathways, data framework
Month 3–8
50-Person Demonstrator
Live pilot, continuity tracking, outcome measurement
Month 9–12
Evidence & Evaluation
Full evaluation report for ICB commissioning decision
The Network

Built on real relationships.
Not just referral lists.

OTOS Continuity sits at the centre of an existing partner ecosystem — organisations already delivering services in Cambridge, already working with this cohort.

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NHS Clinical

  • CPFT ADHD Clinic
  • NHS GP (Right to Choose)
  • Addenbrooke's NHS Trust
  • NHS Right to Choose pathway
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Recovery & Addiction

  • Cambridge Recovery Service
  • Change Grow Live
  • The Sun Network
  • Mind Cambridge
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Diagnostic & Assessment

  • QbTech (objective ADHD testing)
  • Cambridge University research links
  • Jo Fenton Consultancy
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Employment & Support

  • WorkWell
  • Community employment partners
  • Housing and social support links
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The User Thread

The OTOS Continuity Layer connects these partners around one person's journey — ensuring that as they move between services, they are never lost, never starting over, and never falling through the gap between organisations.

Why OTOS

Born from lived experience.
Built for the system to use.

OTOS Continuity was built by someone who went through the system — addiction services, mental health crisis, revolving-door care — before finally being diagnosed with combined ADHD and privately medicated with Elvanse.

The transformation was immediate. The addiction fell away. The research confirmed what lived experience had always suggested: it was the ADHD driving it.

But thousands of people in Cambridge — and hundreds of thousands nationally — are still in the same cycle. Still undiagnosed. Still untreated for the root cause.

OTOS Continuity exists to change that. Not as a charity project — as a properly commissioned, evidence-led, partner-connected NHS pathway that saves money while transforming lives.

"

The research says what I always knew through my own journey. It's the ADHD driving it. Treat the cause, not just the symptom.

— OTOS Continuity founder
The Evidence Base

This is not a new idea.
It's an underused one.

RCPsych, 2022

"There is more benefit than risk from treating ADHD in patients with substance use disorder — both in terms of ADHD and substance use symptom reduction."

NICE NG87

NICE guidance covers ADHD with coexisting substance misuse — and supports assessment and treatment of ADHD even in active substance use contexts.

Progress in Mind, 2022

"Lisdexamfetamine appeared to reduce craving for cocaine in cocaine misuse. No evidence was found of misuse of lisdexamfetamine in patients being properly treated."

CGL Nottingham, 2024–25

Change Grow Live trialled an ADHD identification and referral pathway in Nottingham. Frontline workers, with light-touch training, successfully screened caseloads — with warm referral producing significantly better engagement.

Get Involved

Ready to build
the pathway together?

We are currently in active conversation with NHS commissioners, ICB leads, and Public Health teams. If you want to understand more or explore partnership, we want to hear from you.

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NHS & ICB Teams

Request a briefing on the pilot model, evidence base and commissioning pathway.

Request Briefing
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Partner Organisations

Understand how OTOS Continuity connects with your service and what the partnership looks like.

Explore Partnership
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Public Health Teams

Discuss the cost-redirection model and how this fits with wider prevention and population health goals.

Start Conversation
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