Recently, Rutter, Manley, Weaver, Crawford and Fulop (2004) have conducted case studies of user involvement in the planning and delivery of mental health services in two London Primary Care Trusts. The purpose of the study was to identify models of user participation that were practised in the two areas, to identify from both areas the main outcomes and objectives, and to consider the positive and negative aspects of user involvement. Trust employees with responsibilities for user involvement in the two areas were interviewed as part of the research study. In the first Trust, 32 interviews were undertaken; 10 with user groups, 4 with voluntary sector representatives and 18 with Trust staff. In the second Trust, 17 interviews were undertaken; 3 with user groups, 5 with voluntary group representatives and 9 with Trust staff. Chief executives, managers, consultant psychiatrists and ward managers were interviewed as part of the staff sample. Trust staff reported a variety of opinions about the limitations and goals of user participation in health care services. While managers were quite positive about including users, nursing staff were more ambivalent and expressed some reservation about the purposes of user participation. Most staff were concerned about the context of user participation (venues and appropriate discourses), rather than the overall positive impact of users involvement on decision making. Several staff reported concerns about emotional outbursts by users during professional planning meetings and a perception of their potential to disrupt policy and procedure. Furthermore, “A fundamental difference between users and staff was that users felt that their (largely negative) experiences were not marginal, but central to their motivation for involvement, and to their agenda for change. Involvement for users was fundamentally about change in the social status of people with mental health problems, rather than making (sometimes superficial) changes to services” (p 1975). For users, participation in management and planning was about promoting anti-discriminatory practice and elevating the social status of individuals with mental health difficulties. In both Trust’s, the managers reported that they retained rights over the users in terms of using the discretion to consult with them or not on different matters, and there was considerable regional difference in the degree of user participation. User groups led by patients, or former patients, represented the most common form of user participation in both Trust areas. Some of these groups worked closely with Trust management to change service provision, while others aimed to be independent from the Trust. User groups expressed frustration at their lack of power to force changes on the Trust, and some user groups had opted out of dealing with Trust business altogether due to lack of progress and a wish to channel energies towards national campaigning. Trust staff were invited to comment on ways that user participation was beneficial for the health care system. However, only a few examples were cited but there was consensus between staff members in the areas of benefit. These were in the areas of user involvement in campaigns against Trust plans, achieving refurbishment of inpatient units, monitoring of catering and domestic services, women’s safety policies and the integration of the NHS and Social Services ‘joint working’ arrangements. Trust staff reported a level of disappointment associated with the difficulties getting users to participate in service delivery as they would have hoped for. Furthermore, there was a sense that only the most vocal users with strong opinions, and negative experiences of the health care system that motivated their participation, were ‘heard’ at meetings. There was also concern about the lack of payment arrangements for users who were required to contribute to the working of the Trust without financial remuneration. Payment was discouraged because it could lead to suspension of welfare benefits for the patient. Furthermore, there were some concerns about the ethics of apply ‘work like pressure’ to active users, who maybe currently undergoing treatment for stress related emotional difficulties.