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Chapter 6: The Scottish Picture

This chapter gives a summary of the quality and scope of the services delivered in Scotland to people living with severe mental health and substance misuse problems. The interviews conducted with commissioners, providers and service users identified a number of problems and 'gaps' in the provision of these services. Although the focus differed, the problem areas identified and the beneficial aspects of service provision were similar across all groups. The chapter examines the research outcomes where appropriate in the context of current policy arrangements and good practice guidelines.

This section is divided into several broad themes based on the issues raised in interviews with the three participant groups:

• Accessibility
• Service Quality
• Holistic Care
• Hearing and Listening
• Opportunity
• Involvement
• Support for informal carers
• Stigma
• Training needs.

Accessibility

Encouraging people to seek early help for mental health problems is a key target for the mental health community (Department of Health 1999 - NHS Plan), but service users still faced problems in accessing the screening and assessment process. People with co-morbid mental health and substance misuse issues ran the risk of being turned away from mental health services if seen to have a drug or alcohol habit, and turned away from drug and alcohol services if seen to be involved with mental health services.

People with co-morbid problems faced particular difficulties accessing treatment services and obtaining the help they need in a timely fashion. They experienced long waiting times for services that were sometimes poorly funded and/or co-ordinated and managed. The complexity of co-morbid issues made such problems inherently challenging to manage and treat, yet there were a number of examples of good practice and many instances of good will.

• Raising awareness

Several discussions indicated that efforts to raise awareness of people at risk of poor mental health and/or substance misuse needed to go hand in hand with better signposting of services and sources of support.

Current services tended to focus on a telephone contact point for information and signposting to a range of other providers. The Internet was thought to offer a better source of up-to-date information than directories which needed continual monitoring and updating.

Although advice lines were useful and addressed a need, the expressed view was that there was still a gap between picking up the phone as an anonymous caller and making the effort to visit a service and accept intervention or support. As people with co-morbid issues were often chaotic and extremely vulnerable, there was a need to fill this gap.

• Basic information

Service users spoke of the need for the distribution of more information regarding mental health and drug misuse problems. It was felt that this would be helpful in accepting certain aspects of care that may be less desirable, such as medication, and enable easier access to services for those in need.

There was a distinct lack of systematic and proactive approaches to the provision of information about alcohol, substance misuse and mental health for users and carers.

Service users reported little consistency in the delivery of information about the availability and appropriateness of treatment and support, commenting on the lack of available information about where to go for help, what services existed, the nature of those services and associated threshold of access.

Some did mention that posters and pamphlets were available, but the general consensus was that this was insufficient and not targeted at the user's actual needs. Information was mainly communicated between peers and between those who have similar mental health and substance misuse problems. One service user suggested that pamphlets or booklets might cover not just the services available but also the focus and nature of those services.

• Waiting times

According to interviewees, many areas struggled to respond in a timely fashion to new referrals, with reported waiting times as long as 18 months. There were also wide differences in the time it took to complete an assessment for referral to detoxification and rehabilitation units. This was in part explained by the dearth of such facilities with the consequent decision to delay assessment until placements were available. Alternative input was not always followed up.

There were also delays involved in obtaining a prescription. For example, in one service, multiple assessments by different staff meant that service users needed to attend several separate appointments before a prescription was issued months later.

While providers and commissioners were largely aware of the difficulties service users faced when trying to gain support from specific workers and professionals, they also expressed frustration about the attitudes that were often displayed by service users. Providers pointed to the diminution of users' self-worth and sense of self-determination as a barrier in getting them to engage at all, compounded by the inevitable waiting times several services faced. A further factor hampering the planning of care was not knowing how long a service would take to accept a referral.

• Bureaucracy and policy

The sequence of events after an initial assessment varied widely across Scotland. In general, when a referral to a residential rehabilitation service was sought, the client's care plan needed to be ratified or approved by a senior social worker or team leader. In some areas, this individual might be able to authorise release of funding for the placement but in other areas, authorisation would have to be sought from a third individual, such as a service manager or locality manager. A referral for detoxification usually needed to be ratified or approved by a senior medical practitioner or consultant psychiatrist and authorised by the Health Board. Many residential agencies also had their own pre-admission assessment, although the rigour of this process was variable. This level of bureaucracy was felt by many to be a barrier to effective, efficient and equitable treatment and support.

The study suggested that service providers were concerned about an ever-evolving policy scene. While guidance was generally viewed as helpful, the rate of change and the volume of publications were felt to oversimplify the nature of work carried out and have the potential to skew the delivery of services toward politically driven goals and readily measurable outcomes. Statutory services and many non-statutory initiatives attempted to adhere to national policy and agency-specific national guidelines but there was a strong call for local interpretation to meet the specific needs of the locality where initiatives were based.

Research results also highlighted a further concern. An example referred to was the evolution from a focus on Standards for Schizophrenia to the current attention on Integrated Care Pathways. The fact that initiatives took a long time to develop and required a large amount of invested effort has led to disillusionment.

The message was that policy and educational curricula relating to multi-professional and multi-agency working appeared to be formulated by those remote from work contexts. Participants advocated a greater involvement of providers and users and better communication pathways between commissioners and practitioners.

• Consistency in care

Service users considered the lack of consistency in service provider staff to be potentially damaging especially when they had developed a particularly good relationship with the provider concerned. People spoke of the crucial importance of developing a rapport with a service provider, be it a psychiatrist, key-worker, CPN, and of their sense of disappointment when that individual was replaced by someone different. Sometimes a rapport was not struck with the new worker, which on occasions had led to a deterioration in the service user's physical and psychological health.

The changing political landscape and policy directives were also viewed as having an effect on the consistency of care delivered.

• Continuity of care

Service users, providers and commissioners all spoke of a general lack of long term support in the aftermath of a crisis situation or relapse. There was a general feeling that more after-care programmes and facilities were needed. Several service users spoke of the despair felt when having to face the 'real world' following a period of rehab or detox.

The role of housing support services had evolved in many areas to include support engagers whose job it was to work on a long term basis alongside people with their problems. The view was that simply re-housing evicted service users without dealing with the root cause of their problems would not provide a lasting solution.

Providers spoke of the frustration in trying to engage services during Bank Holidays and the festive period when staffing levels were at their lowest and family responsibilities particularly high. People were often left unattended at a time of year when they were most in need of social support. Both service users and providers gave examples of a lack of continuing care provision following discharge from an inpatient setting. Both the lack of follow-up services and the lack of expertise where these services exist were felt to be a serious problem.

• Crisis access

Faster intervention to help in crisis situations was raised as a key issue by service users and providers. This would require that people knew where to go and have enough confidence in the service to allow them to speak about issues that might be painful and highly personal.

Department of Health guidance on the care programme approach and the National Service Framework for Mental Health ( DOH, 1999)) stipulate that a crisis management plan where appropriate should be an integral part of the package of care provided for all under the care of secondary mental health services. Despite this guidance, several service users expressed a desire for 24-hour support services and were concerned at the lack of proper crisis plans. Overall, the need for improvements in this area was a priority among service users and providers interviewed. The Delivering for Health initiative has committed to a national standard for crisis services and out of hours working by December 2006.

The lack of crisis team support or the availability of a named individual to contact in an emergency was cited by several service users as a major problem. They also felt they had not been given sufficient instructions about what to do in a crisis.

According to the Department of Health (1996) review of service of the effectiveness of substance misuse services, any service that aims to provide 'low threshold' access to treatment must be available when its target population needs it. Yet few service providers appeared to operate outside normal office hours. Some offered limited evening and weekend opening.

• Financial complications

NHS Boards and local authorities tended to rate commissioning substance misuse treatment services as a low priority. Attempts were being made to introduce joint commissioning to increase service effectiveness and maximise economies of scale. Balancing different priorities, however, could prove difficult and have a knock-on effect on service delivery. Many providers were critical of the failure to secure finance to enhance current 'successful' activities, such as increasing opening hours for drop-in centres.

Statutory agencies referring an individual to a detoxification or rehabilitation unit usually had to make an application for funding. Only a few areas in Scotland had joint budgets for detoxification and rehabilitation. In most areas of Scotland, funding for detoxification (including detoxification in residential rehabilitation units) was managed by NHS Boards. Local authorities (Social Work) managed the funding for rehabilitation. This could mean that an individual, referred to a single residential unit for both detoxification and rehabilitation, might have to wait to take up the place if either the local authority or NHS Board had exhausted their respective budgets for the current financial year.

Many participants highlighted the lack of funding and service provision for children of co-morbid service users, which needed to cover protective and preventative measures as well as support to enhance resilience and increase coping skills in older children. Reflecting this, many providers were also highly critical of funding regimes that promoted new initiatives but failed to address ongoing difficulties in securing monies for core activities or opening times to help attract new service users and provide vital support during problem periods.

Service quality

• Appropriateness of service

Access to different types of treatment and care was an important requirement for people with mental health problems. Service users reported a number of good examples of this throughout Scotland, though they also complained of not always being able to get appropriate help when they did receive treatment. Existing systems did not always have safeguards to prevent mismatches between service user needs and service availability. Validated assessment tools were lacking and eligibility criteria setting out the type of service user most likely to benefit from the service were unclear.

• Flexibility

Service users placed a high priority on knowing there were places they could go during the day that were supportive, friendly and warm. They also felt that there should be more user groups and drop-ins available and that going out socially was hugely beneficial as it counteracted the feelings of isolation that so often experienced by those with co-morbidity issues.

Although there were many encouraging reports relating to contacts with community-based mental health services, especially regular contacts with key workers, for some service users the level of contact was insufficient. Outreach work with more regular contact was also mentioned as a crucial contribution to an enabled existence, especially following discharge from hospital.

• Respite, detoxification and rehabilitation

The Department of Health effectiveness review suggests that choice of setting should depend on the degree of motivation and preferences of the patient, the severity of the dependence, the degree of poly-substance use, associated physical and psychological complications and availability and accessibility of local services. Those with more severe problems associated with substance misuse, according to the same document, should ideally be catered for as an inpatient or in another residential unit.

Service users interviewed for this study reported beneficial experiences of inpatient substance misuse services. They had been helped by the respite offered by the treatment, the substance-free, safe and healthy environment and the specialist support, counselling and education.

The study has shown that specialist inpatient services were frequently lacking. Where they did exist, eligibility criteria and bed shortages prevented both timely access and the number of service users that could be helped.

Initial engagement by co-morbid service users was more likely to take place in low threshold facilities, despite the intermittent need for hospitalisation and detoxification. Besides lengthy waiting times for residential and detoxification facilities, there was a clear shortage of supported accommodation, much valued by service users.

• Over-reliance on medication

In general, pharmacological interventions played a more significant role in mental health treatment than in substance misuse treatment and were most often used to control symptoms. Though many mental health service users believed medication could be beneficial, they reported concerns over side-effects and the dominance of medication over other forms of treatment. More recently, the benefits and significance of psycho-social intervention has gained prominence with the advent of holistic care (Rethink, 2004).

• Alternative and complementary therapies

Evidence to support the effectiveness of alternative and complementary therapies was scarce, yet service users generally reported that such therapies helped alleviate stress, pain and the effects of withdrawal and promoted a feeling of well-being and calmness.

Several service users participating in the study also indicated receiving spiritual and personal support from faith-based services and complementary therapies. Some service users found that meditation helped them to relax and reduced anxiety levels. Others spoke highly of acupuncture and how this alternative therapy soothed the mind and helped them to unwind, remain calm and concentrate better.

• Group versus one-to-one work

While many service users perceived one-to-one therapeutic relationships extremely important, for some the sharing of experiences and social contact group work entailed proved a beneficial addition to their treatment.

Some service users felt hearing other people's stories and volunteering their own was helpful but others found the anxiety the group environment provoked prevented them from becoming involved in discussions and benefiting from the group experience. Others reported that the environment was limiting because group members continued to misuse. One female service user spoke of relocating to find another more appropriate group.

Service providers also expressed concern regarding the disparity between the availability of treatment and support and the suitability for co-morbid individuals presenting with complex problems and a wide range of needs. A beneficial aspect, however, was the consistent emphasis on peer-relations that was integrated into a wider care package or treatment program.

• Choice and range

The complex nature of co-morbid mental heath and substance misuse problems meant that service users often required different combinations of treatment interventions over time and needed to be supported along a 'treatment pathway'. Many also had multiple needs and some had difficulties with their social networks and accommodation. This meant that treatment options and support had to be carefully matched to different needs but a mismatch between available resources and individual service user preferences was a frequent occurrence. Providers also noted the need for structured day programmes and activities to prevent slippage and engage the user socially.

• Remit

The range of interventions offered by the same type of service varied and some services were only provided in a single location. Even when the right service existed, the style of the service might not be appropriate for specific and minority groups. On paper there appeared to be a plethora of appropriate services but the reality was somewhat different, with many services seemingly not being able to cater for the needs of complex clients.

Many people with complex co-morbid problems were involved with the criminal justice system. While the Government's 'Updated Drug Strategy' focused on interventions via the criminal justice system, the cohort of interviewed providers talked of services in prisons being particularly limited with blanket application of inflexible standard treatment regimes that lacked specialist provision. The view was that providers on the whole were reluctant to invest time and effort in obtaining appropriate interventions even when they did exist.

• Joint working

Most providers should have been aware of the DoH's Care Programme Approach in mental health or the Models of Care system in substance misuse. Both systems advocate a range of agencies working together effectively to promote service user wellbeing. In practice, however, collaborative working could be problematic and CPAs were often not implemented.

Service users undergoing a period of inpatient care were often not linked into community services for continued care following discharge. This could have the effect of increasing rates of relapse, especially if the residential unit was not in the service user's locality. Service users with children had particular problems, and delays in treatment intervention often followed.

The independent sector was less constrained by professional boundaries and traditional remits. One response to ineffective joint working was to have a system based around a key worker, whose responsibility it was to co-ordinate services.

What was accepted across the board was that a single agency acting alone was unlikely to be able to meet the needs of co-morbid service users. Several providers spoke of the difficulty in achieving a seamless pathway of care for their clients. Joint working remained patchy with little routine contact and communication between services to co-ordinate assessments and care. It was felt that good practice and good will was frequently met with disappointingly little co-operation.

Efforts were being made to improve shared care arrangements and there were signs of overall better alignment between generic and specialist services and primary and community care.

Holistic care

Although there were some very positive experiences relating to joint working and integrated care, many of the research participants reported that care planning often concentrated overwhelmingly on substance misuse or mental health issues with little reference to wider social needs including relationships, housing, personal development and employment.

The main focus tended to be on medication, including medical aspects of substance use. Service users frequently complained that psychiatrists tended to put problems down to the substances being misused and exclude mental health problems. The assumption seemed to be that abstention from drug-taking would make the problems go away.

Service users indicated that talking therapies and a wider approach to recovery were beneficial. Several would have preferred to have access to psychiatrists via community addiction services rather than attend an office-based appointment. They added that the one-to-one counselling enabled by such access would be more worthwhile than reaching for the prescription pad. This relates closely to the need for being viewed holistically rather than as a 'drug user'.

While the need for holistic approaches was widely recognised amongst providers and commissioners alike, some concern was expressed that small services with a specific remit would not be able to cater for all the needs of presenting co-morbid individuals.

Co-morbid persons often required help with basic amenities like assistance with form filling, accommodation and employment. There were clear examples of services striving to meet such basic needs, though these were not widespread.

Hearing and listening

Professional values and individual provider attitudes could seriously impede engagement with a service user. Approximately half the service users interviewed complained of not being listened to or taken seriously by some of the providers they encountered. There were notable exceptions, most typically psychiatrists and other doctors.

Having the opportunity to talk to staff, be heard and build meaningful relationships was extremely important for the current cohort of service users and helped to support them through their mental health and substance misuse journeys.

One service user with a highly-critical family indicated that he would have valued a community mental health nurse with a non-critical and non-judgemental understanding of his issues. Another spoke of services not picking up sooner on what might be contributing to his substance use. He described with regret how despite making the effort to report earlier sexual abuse to social services, they appeared to take no notice of this information.

The importance of being listened to was echoed by the majority of participating service providers. Referring to commissioners, they highlighted the need to listen to what service users and people working at the coalface were saying. Insufficient and ineffective vertical communication could lead to mismatches between service planning and addressing local need.

The narrow remit of many services, especially in the statutory sector, meant that there was no flexibility to provide holistic care. It seems that despite any effort to listen to the service user's needs the application of standard interventions left the user with unmet needs. There was a considerable degree of consensus that the non-statutory sector was in a better position to cater for the gaps in statutory service provisions.

A participant acting both as carer and provider told of the struggle to gain the attention of hospital staff to listen to what she and her son needed. Her son was admitted to a psychiatric unit as a voluntary patient because of his alcohol problem. Eight days later he discharged himself because the ward was overcrowded and chaotic. Despite the effort this service user made to redress his problems, staff were unable to attend sufficiently to his needs. This was compounded by no liaison service for his carer being put in place.

Opportunity

Employment and the importance of getting work was a key theme and an important priority for over half of the service users interviewed but few were receiving any support to help them achieve their work goals. The goals were also viewed as an access route for returning to a 'normal life'. Co-morbid individuals faced particular problems in gaining appropriate skills and in obtaining work, especially work that was enjoyed and valued. There is good evidence available about the effective service models required to support people back into paid employment.

Involvement

The involvement of service users in care planning (individual and service-wide) is a core part of the National Service Framework for Mental Health, (Department of Health, 1999). Users across the mental health services should be involved in decisions regarding their personal care and be invited to contribute to decisions regarding the planning and running of services. Implementation of these principles, however, was known to be patchy (Wallcraft et al 2003).

The results of the study suggested a general desire on the part of service users to be more involved in decision making about their own care and support. Where this occurred, people felt empowered and important. Service users who described examples of poor user involvement spoke of feeling disempowered and ultimately de-motivated to engage and change.

Feedback indicated that there was limited consultation and involvement in service development and treatment pathways. When service user groups did exist ( DAT-based), service users as well as providers felt that these structures were often token gestures and merely paid lip service to the issue of user consultation and involvement.

Service users suggested involving ex-service users in service provision. They were thought to have a better understanding of the specific predicaments of service users and would be able to 'guide' others through the system, help to identify appropriate services and aid access.

The issue of user involvement was largely discussed with commissioners and less emphasised during the focus group discussions. Nevertheless, interviews indicated that the opportunity to listen to voices least heard (including carers and those working at the coalface) was often not taken.

Support for informal carers

There was much agreement that support for family members was an important aspect of effective service provision. This is supported by evidence (Clark, 2001) that co-morbid people whose family members continue to support them have better outcomes than those with little or no support.

Families and carers also needed advice and signposting as to where they can receive help and support in the local community. Providers indicated that support for family members and other informal carers, in particular children affected by either or both parental substance misuse and mental health problems, was lacking in many respects.

Many service providers cited the dearth of services for children and adolescents. Only three services in Scotland provided facilities for the children of drug users. This was a major concern, given the level of 'hidden harm' caused by parental substance misuse and the higher likelihood that children of parents of drug misuse may go on to misuse substances and have more mental health problems over the long term than children of non-abusing parents.

Stigma

The recent Social Exclusion Unit report (June, 2004, Office of the Deputy Prime Minister) highlighted how stigma is a major barrier to social inclusion for people with mental health problems. Having substance misuse problems in addition to mental health issues provides for 'double' stigma.

The stigma attached to being under the care of both mental health and substance misuse services meant that some interviewees were reluctant or unwilling to access these services. Feelings of guilt and shame were prevalent, as was a fear of being criticised and looked down on.

Providers and commissioners were clearly acutely aware of the prejudices people with mental health and/or substance misuse issues often face. National initiatives such as 'See Me' were viewed favourably. Providers and commissioners hoped these campaigns would help to 'destigmatise' current public attitudes.

• Attitudes

Many service users had both negative and positive experiences of service provider staff. The attitudes of psychiatrists and non-specialist staff such as GPs attracted more negative comments. Variations in staff attitudes and perceptions of helpfulness also differed between the treatment tiers. It was generally felt that low threshold flexible services such as drop-in centres and voluntary services were more appropriate for everyday support. Tier three and four specialist services were viewed as being necessary during crisis situations.

Criticism regarding professionals' attitudes was largely levied at ward staff. An example was given of one A&E department, staffed by nurses who did not seem to have adequate levels of knowledge and training regarding mental health and substance misuse problems.

What service users perceived as prejudice and intolerance was described somewhat differently by service providers. The frustration of working with a cohort of people who frequently are difficult to engage with and notoriously difficult to manage long-term, manifested itself in terms of a substantial need for support rather than the need to modify 'wrong' attitudes.

Further frustration was expressed regarding the use of drugs that were socially 'acceptable' but were known to cause significant problems for certain people. Providers reported that motivating people to change their attitude to substance misuse was not helped by the decriminalisation of cannabis.

• Normalisation

A recurring underlying theme was the need for service users to normalise their situations. They wanted to feel empowered through leading a normal life, and this was reflected by their expressed desire to live in their own home or in their own council house, to be involved with social activities, have meaningful relationships and to be involved in treatment decisions.

One homeless man waiting for accommodation to be allocated spoke of the value of having his own tenancy and how this might contribute to a more responsible existence. He felt having a tenancy would force him to save money and so give him reason to concentrate on aspects of life other than his substance misuse.

Providers recognised the difficulties people with complex problems not only faced but may have experienced in the past and how these potentially damaging events had contributed to the inability to lead 'normal', fulfilling lives.

Training needs

The Department of Health's Dual Diagnosis Good Practice Guide recommends that services assess their training needs. Along with this assessment, providers should attain core competencies including knowledge of co-morbidity, substance misuse awareness, assessment skills for both mental health and substance misuse issues and knowledge of how to manage these problems, ability to conduct motivational interviewing to engage service users, relapse prevention work, preventative work and knowledge of the Mental Health Act. Training should also be evidence-based supported by ongoing professional development for the creation of an informed and non-judgemental workforce.

The study showed that there were gaps in service provider knowledge and a lack of confidence and competence to deal with such complex issues. The majority of research participants were unable to identify training opportunities on the issue of co-morbidity, other than those provided by STRADA. This resulted in wide variations in practice and standards of services.

The need for increased knowledge of other professions and disciplines, the services available and the nature of these services were repeatedly mentioned. Suggestions ranged from basic training days to shadowing and secondments to different agencies. Training opportunities for service providers were limited and what was available was poorly attended and too basic to address knowledge gaps adequately. Further issues deemed important for training included basic drug and alcohol awareness, basic mental health awareness and the interactions of substances with prescribed medication.

As reported by the Audit Commission (2004), staff shortages across social and health care professions further limited the ability to meet service demands. This was compounded by the rapid development of service delivery.

In 2004, Rethink and Turning Point produced a dual diagnosis toolkit for staff guidance. The toolkit is based on practical information, supported by good practice examples and underpinned by national policy. This introductory guide is intended for those with little time to wade through research evidence and as such is a valuable contribution to raising the profile and knowledge base of co-morbidity-related issues.

Summary: a Scottish picture

Service users with co-morbid mental health and substance misuse issues were dealt with in an inconsistent and ad-hoc manner. This varied between services and between individual practitioners. Individual levels of confidence and competence in working with particular issues played a vital role, as did individual threshold levels. While the needs of some service users were met, this was clearly not the case for the majority.

At the time this report was written, there was only one reported dedicated team who worked specifically with co-morbid service users. Existing service provision tended to be based on a single issue such as addiction, rather than a plethora of complex issues, such as accommodation, education and legal difficulties. There was, however, evidence of mental health workers working with service users with drug and alcohol problems and of substance misuse workers working with service users with mental health issues.

Many difficulties associated with successfully treating co-morbid problems stemmed from uncertainty regarding what worked and what was good practice. While evidence was growing internationally, there was still no strong research base in Scotland for the treatment of co-presenting mental health and substance misuse problems. This knowledge gap made purchasing, configuring and providing services all the more challenging.

Problems regarding access were particularly acute in times of 'crisis' when someone was in need of immediate help and support. Difficulties listed by service users included not knowing where to seek help, time delays in getting help, services not being open and difficulties accessing specific individuals. Providers pointed out that many services did not have the structures in place to provide a timely service, resulting in frustrations when people did seek help.

Many service users interviewed reported positive experiences of individual providers. Providers, however, were aware of a continuing lack of appropriate provisions, in particular, supported accommodation and rehabilitation and detoxification facilities and the absence of appropriate skills. The 'one size fits all' model of services was particularly inappropriate for complex problems. A more suitable approach needed to consist of flexible packages of care tailored to meet individual requirements.

While some service users clearly benefited from group work, the form of treatment favoured more than any other was based on one-to-one contact. Service users' reasons for assessing one-to-one contact as the most helpful form of service were based on their wish to build a trusting, empathetic one-to-one relationship with one person over time. The issue of trust and aspects of behaviour that engender trust, such as retaining confidentiality, pervaded the interviews directly and indirectly.

Key concerns for service providers as well as for service users were difficulties in building therapeutic relationships. Problems relating to staff retention disrupted continuity in care pathways. Developing trust and confidence in professionals was clearly of key importance to service users.

Service users needed the opportunity to be heard and to feel their views mattered. This reflected both their need for recognition as individuals and their wider needs that stretched beyond specific co-morbid mental health and substance misuse problems. These service users had more comprehensive psycho-social needs than others with fewer complex problems.

Prescriptions, especially Methadone and depot injections, were viewed as extremely important aspects of service provision. The reasons mentioned for this mainly rested with the stability medication brought to chaotic and itinerant lives. Sole concentration on the medical aspect of care, however, was viewed as insufficient for successful recovery and social and psychological aspects of care were deemed extremely important. People spoke of the need to be assessed holistically and for staff to look beyond the 'diagnosed' problems.

Similar overtones were notable during the focus group discussions, with providers acknowledging the need to address wider issues over and above the primary problem(s). However, when asked how cases might currently be tackled it became apparent that for many transparently holistic care, partly afforded by sound interagency working, remained in its developmental stages. Providers regularly described a way of working commensurate with consecutive care as opposed to the recommended concurrent approach.

Commissioners expressed concern over the resource implications, in terms of staff time and finance, of new national initiatives. They were also concerned about the impact new arrangements might have to service delivery in a climate of rapid health and social care change. Providers believed a better understanding of local needs together with an improved understanding of the remits and limitations of different services would go some way to redressing the balance between availability and appropriateness. The expressed view was that more effective liaisons between services and increased information sharing and collaboration could be brought about by joint or multidisciplinary training.

Further issues considered ideal by users and providers included better education about substances and alcohol, more structured activities on wards, the opportunity to go away on trips and outings, a more positive attitude and outlook toward people with substance misuse issues coupled with increased support and a more caring response and better communication between different members of staff and between different services.

Well co-ordinated tailored packages of care bringing together appropriate support from a range of services only existed on a limited basis across research sites. Service users' needs remained unmet, heightening the possibility that users might fall by the wayside and end up re-entering the system on numerous occasions. Pathways through care and aftercare following treatment needed to be managed more effectively.

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