Utrecht June 6th 2014
Research Partners Meeting
Service User and Workforce
Involvement: The UK
Stephen Bach
King’s College, London
Stephen.bach@kcl.ac.uk
With financial support
from the European Union
Service user Involvement
• Role of user involvement:
- many agendas – reaction against targets & markets
- Coalition government: choice and voice
• Peripheral actors (parents/pupils/patients) mainstreamed
- altered roles and expectations of actors
- growth and influence of regulatory actors
• Components:
- legitimation from above – government policy
empowering and punitive e.g. parental responsibility
- altered forms: individual v collective
- responses of actors – employers and trade unions
Education v. Health
Strong impetus in Health
• Potential impact on all citizens (compared to schools):
- scale, service diversity, priorities
• Rich legacy of campaigning/advocacy organisations
- Community Health Councils (1974 – 2003)
• NHS:
- democratic deficit
- professional dominance/hierarchy
- NHS pivotal to future structure/role of welfare state
• Scandals…
Equity and Excellence: Liberating the
NHS (2010)
• We will put patients at the heart of the NHS, through an
information revolution and greater choice and control:
a. Shared decision-making will become the norm: no
decision about me without me.
• Choice of provider and reformed patient voice
• The health and social care system is not so good at listening. That is
the lesson of Mid Staffs, Winterbourne View and Morecambe Bay. It
is why the consumer or user is now being put centre stage and why
Healthwatch has been created. It is time to do things differently.
(Healthwatch annual report 2013: 6).
Forms of Involvement
Industry level
• Pay determination (pay review bodies):
- reserved for social partners
- indirect link implementing Francis and 1% pay increase
our first priority must be to ensure that the NHS can afford to employ
the right number of frontline staff needed to ensure the safe,
effective and compassionate care that patients have a right to
expect [recommendations] are unaffordable and would risk the
quality of patient care. (Health Minister, March 2014)
• NHS social partnership forum:
- workforce consequences: whistle blowing
• Need to consider impact user involvement on the
employment relationship not just social dialogue
Forms of involvement:
Moving beyond direct v. indirect
Campaigns/
Governance:
Alliances
Organisational
stakeholders
single issue
campaigners
Pupils, patients,
Trade unions
parents, staff
Local groups
Regulation/
Inspection
e.g. Ofsted;
Care Quality
Commission
NMC
Governance in flux
Hospitals and Schools
• Variable levels of formal autonomy:
- academies: admissions, staffing, board composition
• Structure:
- Foundation Trusts two-tier boards: governors not NEDs
- Academy schools: usually single-tier - governing board
• Membership – different types of governor:
- schools: parents, staff, community (LA/experts)
- hospitals: patients, staff, community governors
• Appointment process –mixture election/appointment
Remit
• Context: executive managers; centralised accountability
• Foundation trust hospitals:
- can remove trust chair and NEDs
- ability to challenge executive – don’t attend main board
- specific difficulties of staff governors
• Schools:
- appoint head teacher; performance manage head
- staff governors - less central role?
- parent governors
- shortages and capability
Governance:
Pupil voice
• School councils: >90% schools (voluntary)
e.g. anti-bullying policy; fund raising; school meals
• Lesson Observation (NASUWT, 2013)
‘meaningful lesson observation can only be undertaken by adults
who are suitably qualified’
‘Legitimises criticism of teachers’
• Staff recruitment: inappropriate to seek ‘the view of
pupils on the relative merits of an applicant’s teaching’
• Consequences.....
n
1030
930
830
730
630
530
430
330
230
130
Nurses: Number of new referrals made by
public 2007-13
Member of public, service
user or patient
2007-08*
2008-09*
2009-10*
2010-11*
2011-12
2012-13
* 2007-11 data refers to ‘public’ only; 2011-13 data to ‘member of
public, service user or patient’
26
%
Percentage of referrals made by public of total
2007-13
24
22
20
18
16
Member of public, service user
or patient
14
12
10
8
2007-08*
2008-09*
2009-10*
2010-11*
2011-12
2012-13
* 2007-11 data refers to ‘public’ only; 2011-13 data to ‘member of
public, service user or patient’
CCC and HC final adjudication outcomes
2011-12
0%
Striking-off orders
Suspension orders
Caution orders
Conditions of practice orders
Fitness to practise impaired – no sanction
Fitness to practise not impaired
2012-13
14%
16%
0%
7%
48%
43%
11%
13%
12%
18%
18%
Responses of Actors
• Employers: emphasis on patient experience
- workforce: values based recruitment/selection
- service users as adjunct to performance management
• Service user involvement/alliances higher profile:
- TUC work on co-production
- lower priority than pay, jobs, austerity....
• Issues:
- personalisation/personal budgets – casualisation
- localism/communities: inequalities and accountabilities
- must complement not erode collective voice
Consequences
Responses of trade unions
• Governance: engage with new structures and institutions
e.g. Foundation Trust (staff) governors
• Community campaigns v. community organising
• Community campaigns:
- hospitals; station (rail) closures
• Issues:
- effectiveness dependent on local factors e.g. Lewisham
- NGOs: reluctance to be political ‘campaign fodder’
- service user criticism of workforce
Community Organising
(See Wills 2013)
• Drivers:
- limited results of organising activity
- austerity – membership losses
- overcome producer interests label
• Focus: Beyond the workplace
• Influence of Citizens UK:
- Living wage campaigns
May 2010
(3 days before the election)
Community organising
• Investment in community organisers:
Unite – 9 community branches
‘This is the real Big Society – ordinary people organising
for themselves – in action’ Unite general secretary
• Unison, PCS (Living Wage) ad-hoc campaigns
• Challenges:
- different aims (membership v. influence)
- distinctive governance structures
- beneficiaries? visibility/resources
Discussion
• Tensions exist between user and SP involvement:
- differing aims, constituencies, funding
• Trade unions:
- union decline may foster openness to new strategies
- if public service users view services as producer
dominated/self interested alliances are fragile/limited
• User involvement is increasing in importance in public
services but more breadth than depth
- shifting channels of ‘voice’ individualised via complaints
• Institutions are sticky: respond more slowly than actors
Coalitions - conditions:
1. Shared concern & goals
2. Organisational capacity
Employers (a)
3. Opportunity structures to
change policy/practice
Performance
coalitions (a + c)
Grand
Coalitions
Service users (c)
Community coalitions (b + c)
Partnership
[insider]
coalitions (a +b)
Trade
unions (b)