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Parallel Lines A Report on Dual Diagnosis Service Provision in Croydon

2 A Report on Dual Diagnosis Service Provision in Croydon

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This report was produced through partnership working between substance misuse services in Croydon (the Lantern Hall Service User Involvement Co-ordinator, Service User Representatives, and the WDP Dual Diagnosis Practitioner) and Hear Us (Croydon’s mental health service user group).

On behalf of all the project partners, we would like to express our sincere gratitude to everyone who has contributed to this report. Many thanks to the Hear Us Linkworkers and Service User Representatives who were instrumental in developing the research model and who have supported clients to complete surveys and focus groups, in order to allow them to be open in expressing their views about service provision.

We would also like to express our gratitude to mental health and substance use services who opened their doors and took part in the project, supporting us to hear the voices of their clients so that recommendations for improvement could be made.

Our specific thanks to: Lantern Hall, WDP, PLUG/Plugettes and Tamworth Road Resource Centre.

This report provides an insight into the experience of dual diagnosis clients when accessing mental health and substance use services. Without the openness and honesty of the clients surveyed, this report would not have been possible. We hope we have done justice to their words and are humbled by their innovativeness, honesty and ability to articulate the breadth of their experience.

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Report By:Liz Barnes (WDP Croydon)Karen Handy (Croydon DAAT)Allie Cairnie (Hear Us)Tim Oldham (Hear Us)

A Report on Dual Diagnosis Service Provision in Croydon 3

Parallel LinesContents Page Parallel Lines

Acknowledgements 2

Introduction 4

Executive Summary 6

Methodology 9

Findings 11

Conclusions 24

Recommendations 25

Closing Remarks 28

Glossary of Terms 29


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This report aims to provide an insight into the experiences of service users accessing both mental health and drug and alcohol services, in Croydon with a specific focus on the experiences of service users who identify as having a dual diagnosis (this includes both those service users who have formal mental health diagnoses and those who self-identify as having mental health needs).

Project Aims

Through questionnaires and focus groups, the project sought to explore the following questions:

1. What is the proportion of service users who identify as having a dual diagnosis in both mental health and drug and alcohol services?

2. What was the service user experience of gaining access to mental health and drug and alcohol services, and what was their experience of treatment within those services?

3. What are the barriers to accessing services and the gaps in service provision for both mental health and drug and alcohol services?

4. What recommendations could be made to mental health and drug and alcohol services to better serve the needs of their service users, in particular those service users who have a dual diagnosis?

This report presents and summarizes the voice and experience of the participants in their own words.

Project Background

Croydon has made a commitment to working with dual diagnosis clients in the recent past. An Integrated Care Pathway for Dual Diagnosis was developed by a team of professionals from both adult mental health services and adult substance misuse services in 2010. This clearly set out who would take the lead in working with dual diagnosis clients, and what to do in case of disagreements about which service a client would fall under. It aimed to develop clear care pathways in order to ensure that clients did not find themselves bouncing between services or falling through gaps in service provision. It also called for the use of a dual diagnosis forum for case discussions and to provide clinical support around working with dual diagnosis clients.

Since this document was produced, several changes have occurred in the borough; mental health and substance misuse services have been restructured. There was previously a specific dual diagnosis post based within substance use services, but the funding for this position was lost. Additionally, the dual diagnosis forum is under-attended and under-used; this forum could be a very important resource, but staff need to be released from duties in order to attend. The lack of attendance suggests that service managers do not view the forum as a priority task for staff members.

The above factors are likely to have contributed to a loss of focus on dual diagnosis in Croydon, and a resulting reduction in clarity about care pathways, as well as a lack of communication and interagency working between mental health and substance use services.

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There has not been any recent research into the experiences of dual diagnosis clients in Croydon. This report aims to explore the situation in greater detail and to make recommendations about how services could be improved in light of the evidence. It also aims to give a voice to individuals with a dual diagnosis who often feel isolated and stigmatized, and to allow them to speak out about what they would like from their treatment services.

Partnership working

This report was a developed in partnership between the Lantern Hall Service User Involvement Co-ordinator, Service User Representatives, the Hear Us Linkworker Manager, Hear Us Linkworkers, and the WDP Dual Diagnosis Practitioner.

The Linkworking Project recruits current or ex local service users (Linkworkers) to visit mental health services and conduct consultation sessions with service users. Through these sessions, Hear Us provides an opportunity for service users to raise their concerns, issues and needs as they arise, which can then be fed back to the service providers (via the Linkworkers).

In substance misuse services, Service User Representatives are recruited from current or ex local service users, and these individuals inform service providers on their perspective of using treatment services. They are also involved in consulting with other service users about their experiences.

In conducting research into the experiences of dual diagnosis service users, we were able to draw on the expertise and support of Service User Representatives and Linkworkers, who were instrumental in conducting the questionnaires with clients.

We were also able to utilize the service user peer support groups in substance use services, PLUG and Plugettes, and the Hear Us Forum in mental health services. This meant that we were able to use the existing mechanisms that were in place to access dual diagnosis service users and to consult with them about their experiences.

Through the support of Linkworkers and Service User Representatives, we were able to use the model of peer-to-peer support and user focused monitoring to encourage service users to share their experiences. We also used the co-production model, as Linkworkers, Service User Representatives and individuals who identified as having a dual diagnosis were involved with developing the research perameters, designing the questionnaire and deciding in which services the research should be carried out.


Parallel LinesExecutive Summary Parallel Lines

This report aims to explore the experiences of dual diagnosis clients when accessing mental health or substance misuse services in Croydon. The intention is to discover whether services are meeting the needs of this client group, and if there are areas where provision is lacking, to develop recommendations for improvements.

The strategy

This report was developed in partnership between between the Lantern Hall Service User Involvement Co-ordinator, Service User Representatives, the Hear Us Linkworker Manager, Hear Us Linkworkers, and the WDP Dual Diagnosis Practitioner.

The project partners main aim was to engage service users in a dialogue around the following questions:

1. What is the proportion of clients who identify as having a dual diagnosis in both mental health and drug and alcohol services?

2. What is the client experience of gaining access to mental health and drug and alcohol services, and what is their experience of treatment within those services?

3. What are the barriers to accessing services for dual diagnosis clients and what are the gaps in service provision for both mental health and drug and alcohol services?

4. What recommendations could be made to mental health and drug and alcohol services to better serve the needs of their clients, in particular those clients who have a dual diagnosis?

Using the Hear Us Linkworking Project and the Service User Representatives the project partners were able to reach current clients of both mental health and substance use services. A mixture of quantitative and qualitative data was gathered using questionnaires and focus groups. This report summarises the voices of the survey and focus group participants in their own words. The data was then analysed through the identification of categories and common themes emerged.

The Findings

1. Overlap between mental health problems and drug and alcohol use – just under 50% of people identified as having both a mental health and drug or alcohol problem. A significant number of these clients were not receiving support for both problems, and questions were raised about whether services were equipped to meet the needs of the dual diagnosis clients they were working with. However, it was also found that information on the dual problem was being provided by both services to a large number of clients

2. Barriers to accessing drug and alcohol services – concerns were raised about long waiting times, lack of information about available services, and suitable services not being commissioned eg. For binge drinkers. Clients also raised the issue that their mental health was a problem when accessing drug and alcohol services, as they had to do too many separate things. They also felt that it impeded their treatment journey as access to suitable rehab options was limited.

3. Improvements to drug and alcohol services – Clients would like to see


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improved access to detox and rehab, support with mental health, more group treatment options and increased access to their keyworkers.

4. Positive experiences of drug and alcohol services – 32 clients said that they did not need any additional support from services, and several individuals praised the treatment providers and the quality of care they received.

5. Barriers to accessing mental health services – a large number of individuals had been refused mental health treatment, and some of these stated that they had been told it was due to their drug or alcohol use. It was identified that thresholds for receiving a service are extremely high, and that in some cases high risk situations have to develop before individuals are offered treatment. Concerns were raised that mental health professionals were not understanding of their clients’ needs and that they did not listen to them. Some clients found that even when they were offered a service, it was inadequate and did not meet their needs.

6. Improvements to mental health services – Clients identified that improvements were needed in the following areas: greater access to talking therapies, increased support from CPN’s, more practical support, a more streamlined and quicker assessment process, and clearer communication about diagnosis and reasons for refusal of treatment. Clients wanted professionals not to make judgments about their substance misuse and the interaction between this and their mental health, prior to meeting them. They felt that there was a lack of support for people with a

personality disorder, and that this led to these individuals turning to substances in order to cope.

7. Positive experiences of mental health services – 22 clients felt that their mental health treatment was adequate and did not want any additional support. Clients valued their relationship with their CPN more than any other treatment offered.

8. General recommendations for services – Clients said that they mainly wanted to feel listened to and taken seriously. They wanted increased contact with professionals, including doctors where relevant. Other recommendations were faster access to services, increased group and social support and better information on how to access services/available service provision.

9. Focus groups – Themes identified from the focus groups were: The difficulty of getting a referral into mental health services; clients felt that GPs were not taking their problems seriously enough. The clients stated that they were frequently told that their mental health was due to their drug or alcohol use, when they believed the opposite to be true. Some clients identified that they were discharged from drug and alcohol services before being drug or alcohol free, and that this was due to their needs not fitting in with service timelines, as they did not recover from their drug/alcohol problem quickly enough. Clients felt that they were stigmatized and judged for either their mental health or drug/alcohol use, and that this made it hard to be honest with professionals. They stated that they needed time to build a relationship and learn to trust a professional.


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They found the assessment process too brief at times, and stated that they needed space to open up about their difficulties. They echoed the questionnaire responses as they found that waiting times were too long.

Additional support the focus group participants would like to see is increased access to talking therapies, social/peer support groups, regular medication reviews and more information about the support available.

Recommendations

This report presents nine recommendations to Croydon’s mental health and substance misuse communities, including commissioners, service providers and local community organisations. The recommendations to improve dual diagnosis service provision are as follows:

Recommendations for both mental health and drug and alcohol services

1. Each team to have a named point of contact for dual diagnosis who would attend the dual diagnosis forum. This could improve communication between teams and resolve disputes about care pathways.

2. More group treatment options – clients wanted greater access to peer and social support, as well as longer term treatment and practical support. All this could be achieved with a greater range of group treatment.

3. Assessments should include reference to both drugs/alcohol and mental health and clients should be encouraged to be open about both problems.

Recommendations for drug and alcohol services

4. A specialist Dual Diagnosis Worker to be appointed at Lantern Hall. This would facilitate the process of referral into mental health services for drug and alcohol clients.

5. Increased understanding of mental health needs and the experience of dual diagnosis clients by drug and alcohol staff. This would allow them to offer clients more appropriate advice and information, and it would enable them to refer clients on appropriately as well as facilitate their treatment journey into detox/rehab where appropriate.

6. Increased access to psychological therapies/counselling within drug and alcohol services – this would improve the treatment experience for clients and reduce the gaps in service provision. It would enable clients to address the underlying causes of their substance misuse prior to becoming substance free.

Recommendations for mental health services

7. An improved understanding of the needs of dual diagnosis clients and their experience, for example, staff not making the assumption that the clients’ drug/alcohol use has caused their mental health problem. This would enable professionals to be more empathetic to clients’ experience, which would in turn encourage clients to be more honest about their drug/alcohol use.

8. Increased access to psychological therapies – this was one of the main ways clients thought mental health


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services could be improved. Waiting times are currently very long for these services, at around 18 months.

9. Increased staff contact and improved communication – clients valued time with staff very highly. They also felt that communication was poor, and were confused about the reasons for treatment decisions, and what their diagnosis was.

Methodology

Research design

The purpose of the study was to find out about the experiences of clients accessing mental health and drug and alcohol services, and any barriers that they encountered when trying to get support for these issues. Clients were also asked about areas where services were performing well, and times when support could be improved. The respondents were asked to provide information about their drug/alcohol use and any mental health problems they were experiencing, in order that data could be collected about the experiences of clients with a dual need, or dual diagnosis. This includes both clients who have a formal mental health diagnosis, and those who self-identify as having both mental health and drug/alcohol problems.

Questionnaires were developed by a team of two service user involvement workers, one dual diagnosis worker and four peer support volunteers, some of whom themselves identified as having a dual diagnosis.

Data Collection

42 questionnaires were collected at service user groups for drug and alcohol users. 16 questionnaires were collected at a statutory mental health service. 21 questionnaires were collected at a statutory drug and alcohol service. 23 questionnaires were collected at a voluntary drug and alcohol service. 3 questionnaires were collected at a housing service. 10 questionnaires were collected at a mental health service user forum. This information details where the questionnaires were carried out, but in fact many of the clients questioned are accessing more than one of the above organizations in order to fulfill different needs.

Clients were supported to complete the questionnaires in order to improve accuracy of responses, and to ensure that they were able to read and understand the questions. The individuals carrying this out were either peer support workers where possible or staff who did not work in the service where the questionnaires were being carried out, in order to allow respondents to feel comfortable to answer


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the questions honestly. The questionnaires were kept anonymous for the same reason.

Two focus groups were carried out, with 6 participants in each group. All of the clients that participated in the focus groups identified as having a dual diagnosis. The clients were asked ten questions (see appendix) about their experiences of having mental health and drug/alcohol problems, and accessing services for support with these issues. These responses were recorded by writing up statements on a flip chart, in order that clients could see what was being written and make corrections if necessary. They were also recorded on a digital recorder for increased accuracy.

Limitations of the report

Respondents did not always answer every question fully, for example, they might be accessing several different services, but put down one or two on the form. Some of the missing data could be gathered from their responses to other questions, but because of this the numbers do not always tally correctly. In addition, some of the questions asked about potentially sensitive material, and respondents may have been reluctant to answer fully, despite the questionnaires being anonymous. For example, the question about why people were accessing mental health services was not answered in full by many of the respondents. This was also a problem in the focus groups, as some of the participants may have been reluctant to share personal details in a group setting. Conducting one-to-one structured interviews rather than focus groups could have resolved this difficulty.


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Findings

Through an analysis of the data gathered using focus groups and survey questionnaires, a range of complex themes and issues were identified. The research yielded both qualitative and quantitative results, and the below findings are a presentation of the themes that emerged.

1. Overlap between mental health and drug and alcohol services

2. Barriers to accessing drug and alcohol services

3. Improvements to drug and alcohol services

4. Positive experiences of drug and alcohol services

5. Barriers to accessing mental health services

6. Improvements to mental health services

7. Positive experiences of mental health services

8. Focus groups

The findings offer an insight into the experiences of clients who self identify as having both mental health and drug and alcohol problems, when accessing treatment services in Croydon. These findings inform the recommendations in this report.

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Overlap between mental health and drug and alcohol services

There is a large degree of overlap between drug and alcohol use and mental health problems – 19 people (or 44%) receiving a mental health service were using drugs or alcohol problematically, and 42 people (or 45%) receiving drug and alcohol services identified as having a mental health problem. Clients with drug or alcohol problems who tried to access support for their mental health had done so for a variety of reasons, including depression, feeling suicidal, PTSD, psychosis, bipolar d/o and personality d/o. This suggests that there is no pattern around a particular mental health condition being linked to a drug or alcohol problem.

The degree of overlap between drug and alcohol use and experience of mental health difficulties suggests that staff in each service should be working closely together to support these clients, and communicating frequently.

2 mental health service clients who had a drug or alcohol problem were unsupported by substance use services. 16 people who were accessing drug/alcohol services had tried to access mental health services but were receiving no support, either statutory or voluntary. There were an additional 13 people receiving drug/alcohol services that identified as having a mental health problem, but had not tried to access any support with their mental health.

These findings highlight that assessments should include reference to both mental health and drugs and alcohol, and that clients should be encouraged to be open about both problems.

Clients were asked how honest they felt they could be about both their substance use and mental health. Some did not feel able to be open because they felt judged

There is access to counselling at Lantern Hall, but there is no provision for psychological therapies. This may result in clients missing out on an intervention that could be key to their recovery.

Others worried about the consequences of honesty:

The dual diagnosis quadrant model states that people with mild/moderate mental health problems should be supported through substance use services, however this is only effective if substance use services are equipped to meet these needs.

However, on the positive side 26 clients felt that mental health services had supported them around their substance use, and 30 clients were receiving support for their mental health through drug and alcohol services. This demonstrates that

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“If I’m honest about my drug and alcohol use they treat me differently.” Service User

“They (service providers) judge by what they see on computer screens.” Service User.

“I tried to access counselling at Mind, I put alcohol use on the form and they wouldn’t see me.” Service User

“If you tell them everything they just want to section you.” Srevice User

“I went to Lantern Hall (drug/alcohol service) - there was no support for my mental health, they mentioned counselling but I never had any.” Service User


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staff in each service are engaging with clients around both these issues in an effective way.

42 people had received advice from their mental health worker about their drug or alcohol use. The average score service users gave the usefulness of this support was 7.9. 42 people had received advice from their substance use worker about their mental health and the average score service users gave the effectiveness of this advice was 5.2. This demonstrates that mental health workers are knowledgeable about drugs and alcohol, but drug and alcohol workers could improve their knowledge about mental health treatment. This may be because mental health is a broader area, and often requires greater specialist knowledge in order to address it effectively. In addition, drug/alcohol workers may not see mental health as part of their remit or responsibility.

Barriers to accessing drug and alcohol services

37% of people who identified as having a drug/alcohol problem stated that they had faced barriers to receiving support with their drug/alcohol use.

Of those who had faced barriers to receiving support, the largest group were those who felt that there was a lack of available support in the community that met their needs.

Specific problems faced included long waiting lists:

Feeling that services were unhelpful:

Not knowing what services were available:

And lack of support for those using alcohol problematically, but not dependently:

People also felt that their mental health needs had been a barrier to their drug or

alcohol treatment, and having to access multiple services was challenging:

Clients said that they used substances in order to cope with their mental health difficulties. This then complicated their treatment.

Lack of access to rehab or detox was a barrier for several people, and aftercare following detox was also seen as an important gap in service provision. This

“They took a long time to see me.” Service User

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“Some organisations did not want to help or know.” Service User

Not knowing or seeking the help that was out there.” Service User

“There is no help for binge drinkers.” Service User

“I’m having to do all these separate things.” Service User

“Mental health problems a barrier as harder to access services.”

“Diagnosed with BDP [borderline personality disorder] and know many others in the same situation. Most with PD’s [personality disorders] turn to drugs as they receive inadequate MH [mental health] care, and use substances to simply maintain normality and deal with crises.” Service User

“You can’t drink while you’re doing therapy, but I was drinking to cope with therapy.” Service User


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is particularly pertinent as mental health services often ask people to stop using drugs or alcohol before they can access support for their mental health. They may also find it difficult to stop using drugs or alcohol, as they cannot get access to detox/rehab or alternative aftercare. Clients with mental health problems are sometimes required to attend specialist rehab facilities, which are more expensive. They may also find it challenging to attend the required appointments that are necessary to get funded for detox, such as a pre-detox group, because of their mental health symptoms.

Barriers to accessing drug and alcohol services

37% of people who identified as having a drug/alcohol problem stated that they had faced barriers to receiving support with their drug/alcohol use.

Of those who had faced barriers to receiving support, the largest group were those who felt that there was a lack of available support in the community that met their needs.

Specific problems faced included long waiting lists:

Feeling that services were unhelpful:

Not knowing what services were available:

And lack of support for those using alcohol

problematically, but not dependently:

People also felt that their mental health needs had been a barrier to their drug or alcohol treatment, and having to access multiple services was challenging:

Clients said that they used substances in order to cope with their mental health difficulties. This then complicated their treatment.

Lack of access to rehab or detox was a barrier for several people, and aftercare following detox was also seen as an important gap in service provision. This is particularly pertinent as mental health services often ask people to stop using drugs or alcohol before they can access

support for their mental health. They may also find it difficult to stop using drugs or alcohol, as they cannot get access to detox/rehab or alternative aftercare.

“They took a long time to see me.” Service User

“Not knowing or seeking the help that was out there.” Service User

“Some organisations did not want to help or know.” Service User

“There is no help for binge drinkers.” Service User

“Diagnosed with BDP [borderline personality disorder] and know many others in the same situation. Most with PD’s [personality disorders] turn to drugs as they receive inadequate MH [mental health] care, and use substances to simply maintain normality and deal with crises.” Service User

“You can’t drink while you’re doing therapy, but I was drinking to cope with therapy.”Service User

“I’m having to do all these separate things.” Service User

“Mental health problems a barrier as harder to access services.”Service User


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Clients with mental health problems are sometimes required to attend specialist rehab facilities, which are more expensive. They may also find it challenging to attend the required appointments that are necessary to get funded for detox, such as a pre-detox group, because of their mental health symptoms.

Ways drug and alcohol services could improve support offered

Additional support that clients wanted included: improved access to detox/rehab - with aftercare following detox, support with mental health (such as counselling), and practical support (such as housing and benefits issues).

More group work:

Increased contact with keyworker:

Some ideas for other support were “drop in care - disappointed at the lack of on the spot care when I’ve needed it,” and referrals and information about other services.

Positive findings about drug and alcohol services

Many clients felt well supported by drug and alcohol services, when asked what additional support they would like to see 32 people said they did not need any additional support. Clients also made many

positive comments about the service they had received, such as:

Barriers to accessing mental health services

35 people, or 44% of those who identified as having a mental health problem, felt that they had faced barriers when trying to access services for their mental health. 16 people, or 32% of those who had tried to access mental health services, were receiving no support with their mental health, either from statutory or voluntary services. There were an additional 13 people who identified as having a mental health problem, but had not tried to access any support with their mental health.

22 people, or 44% of those who had tried to access mental health services, said that they had been denied a mental health service in Croydon (some of these people may have gained access to a service at a later date). The main reasons people gave for having been denied a service were their drug and alcohol use and the lack of services or available resources.

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“More groups during the week for distraction.” Service User

“More regular and frequent support” Service User

“More one to one and group sessions” Service User

“This service (WDP) is precious to us as all who suffer, God bless you all x” Service User

“WDP have given me a lot of support within their service and referrals.” Service User

“I have felt excellently supported by Lantern Hall.” Service User

“Very good and fast access to service.” Service User

“Overall I’m really happy with the support I have received, I have had a very positive experience and high quality care.” Service User


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One individual wanted

Another said:

High thresholds for services were also thought to be an important factor in denial of services, as people were told they did not need or qualify for a service. One individual commented:

Another reported,

This was also a problem for those whose mental health conditions were deemed too severe. There were people with specific mental health conditions who were not able to access therapy because of this.

Two people said that they had been given no explanation for why they had not been offered a service, and stated:

This suggests that one client found it so hard to get a service, that his/her needs were only addressed after someone “got hurt.” This is problematic, as service thresholds may have reached a level where high-risk clients are being denied services.

The other most significant barrier to getting support from mental health services was drug and alcohol use:

Two people pointed out that this problem was exacerbated as they could not get funding for detox/rehab either, and so were struggling to manage their addiction as well as their mental health problem.

Six people found that there was a lack of understanding from mental health professionals, and felt that this had prevented them from accessing mental health services:

“Psychologists/psychiatrists pass the buck to keep to their budgets.”

“To have the resources put in place and not have to keep going to GP.” Service User

“Further counselling denied due to cost and limitation of NHS.” Service User

“Been d/c due to lack of doctors. Not good enough.” Service User

“Do not fall into threshold for various services.” Service User

“I was having a breakdown, suicidal. Got assessed then left. No help.” Service User

“I was denied talking therapy with a psychologist a few years ago as I have psychosis, so I had to fight for it.” Service User

“Denied therapy as my condition was considered too severe when I was assessed.” Service User

“No reason, only got help after people got hurt” Service User

“They never gave me counselling and they ignored me.”Service User

“I need to stop drinking before I can get help.” Service User

“I got refused treatment by Purley Resource Centre three times because I was on drugs.” Service User

“They might say my mental health is down to the drink, but I know something’s not right.” Service User

“I was on crack so I couldn’t get mental health support.” Service User


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One stated

Another said

This suggests that even when someone was offered a service they felt that this was inadequate, and that no further support was forthcoming.

Two people said that long waiting lists were a barrier, one would be waiting for 2 years for therapy, but they were already 63, and the other said:

Ways mental health services could improve support offered

The area which the most clients identified as needing improvement was talking therapies. They said that they would like access to therapy, counselling or at least someone to talk to on a one-to-one basis.

Clients also wanted to have more support with practical matters such as housing, benefits and managing finances. One client said:

Clients wanted a clear idea of their diagnosis or formulation following assessment, and for assessments to take place in a timely manner. They also wanted their problems to be taken seriously and

did not want to be denied an assessment. They felt that professionals should not make judgments about them before meeting them.

Clients would also like increased support from their CPN, including long term support:

There were also comments about dual diagnosis and the additional problems this brought up for service users, one person commented:

He/she would like services to help with this:

Another client identified that he/she would like to see:

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“doctors don’t listen.” Service User

“Very little help from psychiatrist - who to turn to?” Service User

“No one specifically deals with it, the long wait with no contact when I gave my number, still no contact.” Service User

“Support around physical wellbeing and homelessness.” Service User

“Actually checking the facts rather than accusing me of drug use/addiction.” Service User

“Yes an assessment before things got too bad.” Service User

“Not being refused help.” Service User

“More visits from care coordinator.” Service User

“Long term catch ups to see if you are ok.” Service User

“More time for patients.” Service User

“[I] keep getting help with drug abuse when wanting help with mental health.” Service User

“By seeing if my substance misuse is to do with my mental health.” Service User

“Faster access to detox/rehab for motivated people. Mental health diagnosis - even while drinking alcohol.”


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This highlights the common problem faced by people with a dual diagnosis; that they cannot get support from mental health services while using substances, but in turn it is harder to get treatment and to stop using substances while their mental health is untreated.

Another client pointed out:

There are a number of possible reasons for this client’s experience; it could be that personality disorders require a long term intervention, and are not always effectively treated within mental health services, as was highlighted in Personality Disorder: No Longer a Diagnosis of Exclusion. Alternatively, this could be because the recommended treatment for personality disorder is talking therapy, and this is not often offered to individuals using substances.

Positive findings about mental health services

22 clients were happy with the support they had received from mental health services, and did not want any additional support. Some statements clients made about the services they were receiving suggest that they valued contact with workers more than any other form of support:

General recommendations for services

The number one priority for clients of both drug and alcohol and mental health services was to feel listened to. They wanted staff to spend time with them and to feel that their needs were a priority. They felt that workers should care about their clients, and be knowledgeable and understanding.

Some changes clients would like to see were:

This was also important for doctors:

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“They come around to see how I am getting on and they talk to me.” Service User

“There is a massive problem of PDS [personality disorder] and substance misuse which is not addressed as it’s deemed too time-consuming/challenging etc.” Service User

“Listening to patients more, recommending a wider range of help.” Service User

“Have people that understand about MH problems and they need to support MH patient more.” Service User

“More time and understanding / care.” Service User

“I would like my key worker to listen to me more and not constantly put me on hold.” Service User

“After being sectioned I was given advice and support.” Service User

“Cc contact/ telephone contact, both once a week, Star worker.” Service User

“Overall I’m really happy with the support I have received, I have had a very positive experience and high quality care.” Service User

“GPs need more training. Psychiatrists need a regular MOT.” Service User


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On a similar note, clients also wanted increased contact with workers, including doctors. This is positive, in that it demonstrates that clients value the time that workers spend with them, and shows that this support is an important part of their recovery. However, it also speaks to a lack of resources and large caseloads meaning that workers have less time to spend with their clients. Some comments were:

A need for long term support was identified. This did not have to be the same level of support, but they wanted to know that there was help available if they needed it. This suggests that clients have found that for recovery to be successful long term, either for mental health or drug/alcohol problems, they need to have long term support systems in place.

For both drug and alcohol and mental health services, length of waiting times was a problem. Clients would like faster access to services, speedier assessments and quicker prescribing.

One client said that his/her experience of accessing support was:

Clients wanted to have access to groups and places where they could meet and socialise with others. This suggests that social contact and peer support is a valued part of service provision. Clients would like to see:

“See Dr. more often at Tamworth Rd.” Service User

“More one-to-ones.” Service User

‘More time for patients.” Service User

“Nothing available for those who have been clean for some time. Ongoing support is essential.” Service User

“Keeping in touch and support in recovery.” Service User

“I could have done with different support towards the end of my treatment.” Service User

“I think people need to receive their prescriptions much quicker. Assessment is too slow.” Service User

“IAPT has not responded to referral form from 2011 [this was reported in 2013]. Croydon Health Service say that referral was sent and will resubmit but haven’t heard anything for a couple of months.” Service User

“Long and drawn out.” Service User

“More groups - places to go for friendship - to learn life skills.” Service User

“Groups more than once a week.” Service User

“Not enough places to go to get advice & friendship. Not able to cook & sew but need to learn. Embarassing not being able to do these things. Don’t like to ask but would like to know where to go.” Service User

“To be reassessed throughout my recovery. To be listened to by doctors.” Service User


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Clients also wanted to be given better information on how to access services. They said that the process of finding out about services was not always easy, and that it should be made more straightforward:

Focus groups

During the focus groups, the participants made the largest number of statements about the topic “denial of services.” Some of these responses related to the attitude of GPs, and the difficulty of getting an initial referral into mental health services through your GP.

They said:

They also felt that the threshold for access to services was too high. This led to increased risk as services were not

received in a timely manner. They felt that some problems could have been avoided if they had received help sooner.

There were also a large number of statements made about mental health services being denied due to drug/alcohol use. Clients felt that they were told their mental health problems were due to their drug/alcohol use, but they experienced this differently.

They felt that when you have a dual diagnosis

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“Was difficult to find out at the beginning - doctor wasn’t very helpful.” Service User

“Should be a lot easier than it is and there should be more info and support.” Service User

“If something drastic happens they will help you.” Service User

“You have to nearly kill yourself before you get help.” Service User

“They’d rather wait until something bad happens than give you a service - it’s frustrating.” Service User

“I’m worried about having another psychotic episode, and the help won’t be there.” Service User

“I struggled at the GP, they wouldn’t refer me to mental health services. They brushed me off and said ‘you’re not that bad.’ Another GP then referred me.” Service User

“I was begging my doctor for help.” Service User

“It depends on the GP you’ve got and what borough you live in.” Service User

“The GP said if I self harm I should present to A&E and show them my wounds. I felt very pissed off.” Service User

“The people that turn you away don’t understand that drink/drugs might not be the reason you are depressed in the first place.” Service User

“At first they thought my mental health problems were all down to drugs. I got help when I started cutting myself.” Service User

“You are thrown from pillar to post.” Service User

And additionally: “They don’t want to help you if they think you’re on drugs.” Service User


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Being refused mental health treatment was particularly problematic when clients were also prevented from continuing with drug/alcohol treatment. When clients do not address their drug/alcohol use within a particular timeframe they can be told to return to services when they are ready to address this. At times this may be an appropriate response, however services do not always recognize that clients with mental health problems may find it more challenging to address their drug/alcohol problem and may need additional support for unmet mental health needs. One client said:

Clients felt that it was very important for staff to be understanding and non-judgmental. They made numerous statements which suggest that they frequently feel judged, and have a sense of being stigmatized due to their mental health or drug/alcohol problems.

They said:

Family want you to get a job

Clients were reluctant to be honest about either their mental health or drug/alcohol problems:

And they found that the relationship with the staff person was a big factor in enabling them to be more open:

Being able to trust the particular worker was identified as important, and this may be related to anxiety about how professionals would react if they were honest and open. A point raised by several people was their fear of being sectioned if they were open about their mental health.

They wanted staff to be “passionate” and “genuinely caring” and to understand their difficulties. They wanted to be listened to.

“In drug and alcohol services, when you’ve been there for a long time, they won’t let you come back.” Service User

“People assume you walk in the middle of the road and are “a bit nutty.” Service User

“You feel like people are going to judge you and think you’re a nutcase.” Service User

“They laugh at you.” Service User

“They [service providers] judge by what they see on computer screens.” Service User

“You are labeled.” Service User

“Alienated.” Service User

“Vulnerable.” Service User

“Told to pull your socks up and sort yourself out - they don’t understand.” Service User

“I’m honest and I get put down and judged like a useless waste of time.” Service User

“I’ve never properly talked to anyone about being depressed.” Service User

“I opened up about my feelings. You build relationships and then workers leave.” Service User

“I tried to tell the psychiatrist how it really was, but I was only there for 10 minutes and they said I was normal.” Service User


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Another area that the focus group participants felt was important was assessment. They felt that assessments were too brief; that workers did not want to spend time with them, and therefore that they were not able to get the correct support. This may be due to the sensitivity of the information being asked, and clients finding it difficult to answer the questions. This also relates to the earlier point about trust and the need to build a relationship with the worker before being open and honest. Clients said:

This shows that assessment is a daunting process for clients, and that they may feel confused by some of the questions asked.

They do not always have the confidence to speak up about this during the assessment, and so leave without having spoken about the true nature of their difficulties. In addition, staff carrying out mental health assessments sometimes focus more on the drug/alcohol problem. This does not give the client the opportunity to explain what mental health difficulties they are experiencing, and does not allow the professional to get a clear picture of the clients’ needs.

Clients felt that having to go to different services to meet all their needs was unhelpful, and that their difficulties were exacerbated by this complex process.

This added to the increased distress they felt due to having both mental health and drug and alcohol problems. They acknowledged that often their substance use was a way to cope with an untreated mental health problem, which made it more challenging for them to become drug/alcohol free.

“People don’t understand how you feel.” Service User

“[I’m] not being heard.” Service User

“Some professionals don’t understand - it’s the luck of the draw who you get.” Service User

“It’s not the outside that counts - it’s what’s going on inside.” Service User

“They don’t ask the right things, it’s like they can’t wait to get you out of there.” Service User

“They don’t assess you - they ask you what you think your diagnosis is.” Service User

“I had an assessment with a psychiatrist that lasted 5 minutes.” Service User

“Waiting for an assessment was a worry in itself.” Service User

“Explaining to the GP - they ask questions I don’t know the answers to.” Service User

“You come out feeling worse.” Service User

“In drug and alcohol services you should get your mental health assessed at the same time.” Service User

“People don’t know how to get help.” Service User

“Now I’ve got sober I have to go back to the GP to get support with my mental health.” Service User

“You have to use alcohol or drugs to cope with your mental health problems”. Service User

Drink/drugs are like a medication.” Service User


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An additional area for improvement was waiting times, clients felt they had to wait too long for an assessment, and that this could lead to increased risk at times. They stated that they were told to access emergency services if things got worse, but they did not feel that this was adequate.

Further support clients would like to be offered included talking therapy, social support, including peer support and regular medication reviews. This echoes many of the responses from the questionnaires.

They also wanted to be given more information about available support:

“It’s a 2 month wait to see a psychiatrist. You are told if anything happens to you they can fast track it.” Service User

“I’m still waiting on a psychiatrist assessment - it’s a long winded process.” Service User

“It’s a long wait for a diagnosis.” Service User

“Quicker and easier access - you have to be suicidal before they do anything.” Service User

“There is no support with social networks - before I was going to the day centre or drop in centre.” Service User

“Social networks and meeting people with similar problems keeps your mind away from your mental health problem.” Service User

“You need to be told the options available - they hold things back.” Service User

“No information was offered about bipolar self help groups.” Service User

“I wanted to be advised on treatment I needed.” Service User


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The findings indicate that the clients we surveyed are seeking a clear improvement in the quality of service provision for those with a dual diagnosis, both in mental health and substance misuse services in Croydon. The report identified that there are numerous clients in Croydon who see themselves as having a dual diagnosis, and that not all of these clients are receiving adequate care for both their difficulties. Services that are receptive to the needs of dual diagnosis clients, and empathetic, non-judgmental staff would be likely to result in better outcomes for dual diagnosis clients.

Dual diagnosis clients spoke about their frustration at the difficulty in getting access to treatment services, and the fact that they had to attend two different services to address both their needs. They found that lengthy waiting times and challenging assessment processes made the process of getting help for their problems seem even more daunting.

Clients stated that they find it frustrating when they are told that their mental health problems are caused by their substance use, when their experience is that the mental health difficulty preceeded the substance use problem.

The clients were able to come up with a comprehensive list of changes that they would like to see implemented, in order to improve service provision and eliminate some of the gaps in services. It can be concluded that, in order to improve treatment outcomes for dual diagnosis

clients, a series of actions should be taken by commissioners and senior management within drug and alcohol and mental health treatment services. Those steps are summarised in the list of recommendations below, and are based on suggestions and solutions to problems identified by clients.

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Both services

1. Each team to have a named point of contact for dual diagnosis who would attend the dual diagnosis forum

This would improve communication between services and could address problems, particularly at the assessment stage, where there is a disagreement over who the treatment provider should be. Improved communication could reduce instances of both inappropriate referrals and clients who do require support being denied access to mental health services. Where mental health services could not offer support to a particular client at that time, they could offer advice on management of the client to drug and alcohol services. They could then offer to see the client when they are drug/alcohol free to re-assess their support needs. This more integrated approach to support could stop clients feeling that they are being passed back and forth between services, and could also result in improved treatment outcomes.

2. More group treatment options

Clients stated that they would like to have more access to group treatment and social support. They identified a desire to learn life skills and to get support with practical issues. They also wanted more long term treatment to improve their chances of recovery. The above support could be offered in a group setting, where practical needs could be addressed, as well as improving social support and offering more opportunities for long term treatment. This could be achieved with a greater range of group treatment options, from highly structured support through to mutual aid or peer support.

3. Assessments in both services should include reference to both drugs/alcohol and mental health and clients should be encouraged to be open about both problems

This includes completing the basic questions asked on the assessment form, but also involves greater exploration of the issue by the staff member carrying out the assessment. It is only through further exploration of the issues that staff will be able to determine the extent of the problems. There may be complex and interlocking factors at play, which would need to be brought out through a thorough assessment. It would be important for staff not to assume that mental health problems are drug/alcohol related, but rather to explore this fully with the client.

It may be necessary to return to the assessment at a later date when a more trusting relationship with the client has been built. This is also linked to point 7, as it is important for staff to demonstrate an empathetic and non-judgmental attitude, and give the client time to open up in the assessment.

Drug and alcohol services

4. A specialist Dual Diagnosis Worker to be appointed at Lantern Hall

This would address some of the difficulties service users had when attempting to get support from secondary mental health services, as this worker could make referrals and recommendations for treatment directly to mental health services and work closely with them. This would streamline service provision, allow clients to feel more supported and facilitate the process of appropriate clients being referred into mental health services.

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This individual could also support drug and alcohol services to manage mental health clients more effectively. This could improve the treatment experience for dual diagnosis clients, and improve their pathways into detox and rehab. This worker could also facilitate the completion of point 2 below.

5. Increased understanding of mental health needs and the experience of dual diagnosis clients by drug and alcohol staff.

Drug and alcohol staff would benefit from a greater understanding of the mental health needs of clients. This would allow them to offer clients more suitable support and facilitate their pathways into detox and rehab. They would be better placed to make assessments of mental health needs and refer on appropriately. They would be able to advocate for their clients to get fast tracked into detox/rehab when necessary, and would be able to explain the urgency for this on mental health grounds. They would be more likely to empathise with clients’ experiences, and so build trusting partnerships that would improve treatment outcomes. This could also reduce the problem of clients being discharged from services before having addressed their drug/alcohol use - it would require staff to recognise that dual diagnosis clients have additional problems and will often take longer to recover from an addiction, and have more support needs, than other clients.

6. Increased access to psychological therapies/counselling within drug and alcohol services

This could be achieved cheaply through the use of student counsellors/psychologists. It would address barriers to treatment as

clients could begin to address underlying causes of addiction before becoming drug/alcohol free. This would also make service provision for drug/alcohol use and mental health more integrated. It would address current gaps in service provision as those with mild/moderate mental health needs could have these addressed within drug/alcohol services. It would reduce the sense of being passed between services that many clients identified.

Mental health services

7. An improved understanding of the needs of dual diagnosis clients and their experience

The study found that mental health staff were providing helpful advice to clients about drugs and alcohol, however, it also found that clients did not feel listened to by staff and frequently felt judged if they were honest about their drug/alcohol use. This suggests that mental health staff may need more education around the experiences of dual diagnosis clients, which would enable them to be more empathetic and spend more time listening to clients in a non-judgmental manner. This would improve the experience of clients in both assessment and treatment stages, and would enable clients to be more open and honest, through building trusting relationships with staff members, which was also felt to be an important factor in recovery. This would also involve an understanding of the part drug and alcohol use plays in mental health, and that it may at times be a strategy for coping with an underlying mental health problem rather than its cause.

8. Increased access to psychological therapies


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This was one of the main areas service users felt was lacking, both in terms of being denied an appropriate service, and having to wait a long time to receive a service. It would support a client to remain drug/alcohol free if they were able to access a therapeutic service to address the underlying causes for their substance use, especially if this was trauma-related, following detox/rehab.

9. Increased staff contact and improved communication

Clients placed a high value on staff contact. They identified that they were not always sure of the reasons why they had been denied a service or taken off a waiting list. Having a larger staff team could help with both improving communication and increasing contact time with clients. This could be achieved through the use of volunteers, social work and nursing students and lower paid support staff.


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Providers have long been aware of the difficulties that are faced by clients with a dual diagnosis, and there have been numerous initiatives which have attempted to improve service provision and prevent these individuals from being passed back and forth between services, or from falling through the gaps in service provision. The Dual Diagnosis Good Practice Guide was developed in 2002, there was also the Dual Diagnosis Toolkit, and more recently the Nice guidance on Psychosis and Substance Misuse. All of these documents make strong recommendations for integrated care, and making dual diagnosis clients the responsibility of both mental health and substance misuse services.

Unfortunately, when services are stretched, caseloads are high and funding cuts due to economic hardship have resulted in changes to service provision and reduced resources, it seems that the most vulnerable clients may be the ones who suffer most.

The recommendations outlined in this report can be implemented with very little additional cost or resources, and in some cases with no monetary outlay. Therefore, the authors of this report want to encourage the wider community working in substance use or mental health services to take responsibility for the care of dual diagnosis clients - not allowing them to be passed between services or to fall into the gaps in service provision.

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A&E LIAISON Accident and emergency liaison is a service within A&E departments for mental health assessments and referral to special mental health services.

ACUTE MENTAL HEALTH WARD/SERVICEOffers inpatient care to someone who has an acute mental illness and require 24 hour hospital care. Acute illnesses start quickly and have distressing symptoms.

ADMISSIONWhere a person may begin a period of care.

ADVANCE STATEMENTS/DIRECTIVESCan include individual’s wishes in certain circumstances, to refuse or request for certain treatments.

ADVOCATEIs someone, who supports a service user or carer during his or her contact with mental health services.

AFTERCAREThe support a person receives once discharged from inpatient care.

ALTERNATIVE THERAPIESThese are therapies that are not part of standard medical practice (example aromatherapy).

ANTIDEPRESSANTSAntidepressants aim to treat the symptoms of depression by helping those who suffer feel more motivated and energetic.

APPROVED SOCIAL WORKER (ASW)Employed by social services, usually working in hospitals and the community as part of community mental health teams.

ASSERTIVE OUTREACHAims to offer outreach support services to people in the community who have

difficulty in maintaining contact with mental health services.

ASSESSMENTThis is the process to identify a person’s needs and treatment at first contact.

BLACK AND MINORITY ETHNIC (BME)A term used to describe people from minority groups because of their skin colour and/or ethnicity.

CARE PLANA care plan is an agreement between a patient and the health professional to help the patient manage their day-to-day health.

CLINICAL ACADEMIC GROUPS (CAGS)Set up to help SLaM to organise and manage their services, research and education and training, for the benefit of patients.

COMMUNITY MENTAL HEALTH SERVICECommunity mental health services are aimed at patients who are mentally unwell, with significant mental health needs, and need support in the community to continue on the road to recovery. Service users will be treated in a community based setting and/or in their homes, depending on individual needs.

COMMUNITY DEVELOPMENT WORKER (CDW)A community development worker works collectively with a particular community or communities to bring about social change and improve quality of life. They work with individuals, families or whole communities to empower them to take appropriate action.

CHILD AND ADOLESCENT MENTAL HEALTH SERVICES (CAMHS)They are a multidisciplinary team that


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provides mental health services for children and adolescents.

COGNITIVE-BEHAVIOURAL THERAPY (CBT)Is a method of treating psychiatric disorders based on the idea that the way we think about the world and ourselves (our cognitions) affects our emotions and behaviour.

COGNITIVE THERAPY A method of treating psychiatric disorders that focuses on revising a person’s thinking, perceptions, attitudes and beliefs.

COMMISSIONERRefers to the person within the PCT (see pct) who is responsible for allocating money to chosen service providers.

COMMUNITY MENTAL HEALTH TEAM (CMHT)A multidisciplinary team that offer specialist community care services.

COMMUNITY SUPPORT SERVICESEnable individuals to live independently and access opportunities for social involvement locally.

COMMUNITY PSYCHIATRIC NURSE (CPN)These are registered nurses who work with people in the community.

COMPLEMENTARY THERAPIESThese are therapeutic practices or techniques that are not currently considered part of conventional medical practice.

COMMUNITY OPPORTUNITIES SERVICE (COS)Provide a range of day and employment related opportunities to help people who have severe and ongoing mental health problems lead a more active life in their communities. They work closely

with patients, their carers and care co-ordinators to set goals that reflect personal needs and aspirations.

COUNSELLINGRefers to a talking therapy that attempts to deal with an upsetting event(s).

DIAGNOSIS The determination by a health care professional of the cause of a person’s problems, usually by identifying both the disease process and the agent responsible.

DUAL DIAGNOSISRefers to two or more disorders affecting one person.

EARLY INTERVENTION SERVICEProvide support and treatment for young people with psychosis and their families.

HOME TREATMENT TEAMThe home treatment is a multidisciplinary team made up of consultant psychiatrist, associate specialist, qualified nurses, social workers and support time and recovery workers. Home treatment teams help avoid admission to a mental health inpatient ward by supporting people in acute mental crisis in their homes. The teams also help people who have been discharged from hospital as they make the transition back into the community.

INPATIENTInpatient care is the care of patients whose condition requires admission to a hospital.

LINKWORKER Linkworkers are ex or current service users that visit mental health sites across the borough of Croydon to meet with service users to listen to issues, problems, worries or needs. . Through these meeting, the Linkworkers provide an opportunity for service users to raise their concerns, issues


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and needs as they arise, which can then be fed back to the service providers.

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE (NICE)Is a specialist health authority of National Health Service (NHS) that publishes guidelines in the following three areas: (1) The use of health technologies within the NHS (such as the use of new and existing medicines, treatments and procedures) (2) Clinical practice (guidance on the appropriate treatment and care of people with specific diseases and conditions) (3) Guidance for public sector workers on Health promotion and ill-health avoidance.

OCCUPATIONAL THERAPIST (OT)Occupational therapists work in hospital and various community settings, providing both assessments and treatments in order to develop, recover, or maintain the daily living and work skills of patients with a physical, mental or developmental condition.

PATIENT-CENTERED CARE Is the active involvement of patients and their families, in the design of decision-making regarding the patient’s options for treatment.

POST-TRAUMATIC STRESS DISORDER (PTSD) A debilitating condition that is related to a past terrifying physical or emotional experience causing the person who survived the event to have persistent, frightening thoughts and memories or flashbacks, of the ordeal. People with PTSD often feel chronically emotionally numb.

PRIMARY CAREThe care you receive when you first come into contact with health services.

PRIMARY CARE TRUST (PCT)This is the organisation that looks after primary care.

PROGNOSIS The patient’s chances for recovery; a medical assessment of the probable course and outcome of a disease, based on the recorded history of the disease, the physician’s own experience of treating the disease, and the patient’s general condition and age.

PSYCHIATRIC NURSE Is a nurse with special training in the treatment in patients with psychiatric disorders.

PSYCHIATRISTIs the medical doctor who specializes in the treatment of mental, emotional or behavioural problems.

PSYCHOLOGIST Is the specialist in the diagnosis and treatment of mental and emotional problems. Because psychologists are not physicians, they cannot prescribe drugs. Their role with patients usually involves testing, counselling and psychotherapy.

PSYCHOTHERAPY Is the treatment of mental and emotional disorders using psychological methods, such as talk therapy.

SECTIONEDThis is used to describe someone detained under the mental health act.

SEDATIVESA group of drugs used to produce sedation (calmness). Sedatives include sleeping pills and anti-anxiety drugs.

SELF DIRECTED SUPPORT (SDS)


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Previously known as Direct Payments, Self-directed support is designed to help people to manage their own social care support and choose the services that suit them best.

SERVICE USERThis is some who uses health services.

SOUTH LONDON AND MAUDSLEY (SLaM)Provide the widest range of NHS mental health services in the UK.

TALKING THERAPIESTalking therapies can help a patient work out how to deal with negative thoughts and feelings and make positive changes. This usually involves talking to someone who is trained to help you deal with these feelings.

USER FOCUSSED MONITORING (UFM)Interaction with service users, conducted within mental health settings, providing them with an opportunity to raise any issues and express their concerns regarding their service experience.

USER INVOLVEMENTRefers to a variety of ways in which people who use health services can be involved in its development and improvement.


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Hear UsOrchard House 15a Purley RoadSouth CroydonCR2 6EZ

020 8681 6888@ [email protected] www.hear-us.org

Company No. 6891337 Charity No.1135535

Liz BarnesWDP CroydonAction House,28 Sydenham Road, Croydon, CR0 2EF

020 8662 4790, @ [email protected] www.wdp-drugs.org.uk

Company No. 2807934Charity No. 1031602

Karen HandyService User Involvement Co-ordinatorCroydon DAAT020 8726 6000 x14764

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Documents

service user experience

experiences of service

service user representatives

proportion of service

alcohol services

mental health needs

formal mental health

usa report