With financial support from the EU
New Challenges for Public Services Social Dialogue: Integrating
Service User and Workforce Involvement in Italy
Stefano Neri and Lorenzo Bordogna, Università di Milano
European Commission project, coordinated by Professor Stephen Bach, King’s College,
London: ‘Industrial Relations and Social Dialogue’ VP/2013/0362, January 2015
Executive Summary
Background
This report examines service user involvement in the health and secondary education
sectors, focusing especially on hospitals and schools. It is based on data collected from a one
year comparative European Commission project that considers the connections and
consequences of user involvement for industrial relations and social dialogue. It involved
data collection in Denmark, Italy, the Netherlands, Slovakia and the UK (England) with
differing traditions of social dialogue and service user involvement, facilitating comparative
analysis.
The analysis in each report builds on four underlying research questions:
a) How is the pressure of service user involvement altering which actors are represented
directly & indirectly within systems of social dialogue?
b) To what extent has an emphasis on service user engagement encouraged new forms of
direct user involvement & what are the implications for traditional representative voice?
c) How is the scope of social dialogue changing? In what ways has the agenda of social
dialogue changed & are the concerns of service users compatible with the interests of the
social partners?
d) What are the consequences for the social partners & workplace practice of these new
challenges?
Introduction
The national report is organized as follows. Section 2 briefly introduces social dialogue
institutions and actors in the health and education sector. Sections 3 to 7, the bulk of the
report, analyse the Italian experience of user involvement institutions and practices in the
health and education sector, and present in detail the two case studies, a (territorial) local
health enterprise with its hospitals, and a first-level secondary school (or scuola media, 1114 year old pupils), both located in an Italian region (Emilia Romagna) traditionally
characterized not only by a high trade union density but also by a rich participation of
citizens and civil society organisations in social and political life. Brief concluding remarks
complete the report.
The report is based on interviews with key representatives at national, sectoral and
organisational level, documentation from organisations that participated in the study,
government and policy reports and academic literature. Semi-structured interviews were
conducted with employees, managers, trade union representatives and other key
stakeholders in one hospital and one school.
Drivers of user involvement
Over the last decades in all Italian public services, and especially in education and health
sectors, there has been an increased attention to service user involvement, although framed
within quite different cultural and political discourses. In the 1970s, in connection with the
mass social movements of that period, the key-word was ‘democratization’, and the
emphasis was mostly on users as citizens and on user involvement as a form of democratic
participation, instrumental to a deeper ‘democratization’ of society and public institutions.
In the partly NPM-inspired regulatory framework of the 1990s and 2000s, the role of service
user involvement was mostly framed within the key-words of ‘consumer choice’,
‘transparency’ and ‘performance evaluation’ as means to achieve a greater efficiency and
effectiveness of public services.
Forms of user involvement
The Italian case illustrates the importance of sectoral differences. In general, traditions of
user involvement are less well developed, but this is not the case in schools in Italy. The
legitimacy of users is less well established in hospitals in Italy where service user
involvement is closer to placation in Arnstein’s terms.
Hospital
At the local (and operational) level, references made to the creation of consultative bodies
as well as to joint programmes to promote health service adaptation to citizen needs seem
to open up space for institutional forms of collective participation, able to have a larger
impact on the organisational decision-making, although the influence played by users still
looks limited in general terms. User involvement is mainly intended as consultation and
placation, in Arnstein’s language, but partnerships can be developed between user
organisations and public healthcare organisations. However, unlike Arnstein’s ladder,
participation may not be simply classified as “tokenism” even in the consultation bodies, as
we will see in analysing the case study.
School
Using Arnstein’s framework, user participation can be interpreted as “partnership” and
maybe also as “delegated power” by public school authorities. Power in school organisation
and management is shared with traditional public institutions (Ministerial peripheral offices,
2
school headmaster and school teacher bodies); citizens seem to be able to condition school
decision making and have their say in teaching and educational issues. Moreover, unlike the
user representatives in the healthcare sector, users within the school collegial bodies are
highly representative because they are selected by means of direct elections by their
constituencies, so they are granted a high level of legitimacy. Three-year council renewal by
elections should also provide these bodies with a certain degree of accountability.
Social dialogue and user involvement
Despite this increased emphasis, the dense network of service user involvement bodies has
remained, and still remains, formally separate from the institutions and procedures of social
dialogue, without any formal, systematic, direct link between the two systems. The only
partial, but substantially unsuccessful, exception is probably the legally-based involvement
of service user/citizen associations in the regulation of the exercise of the right to strike in
essential public services. While confirming these broad features, the two case studies (a
local health enterprise with its hospitals, and a first-level secondary school), suggest
however that the two guiding principles of service user involvement – ‘democratization’ and
‘consumerism’ – are not mutually exclusive but can coexist, and that if a direct impact of
service user involvement on social dialogue institutions is limited or absent, this is not so
with regard to the impact on the organization of services and on working conditions and
practices.
Consequences for the social partners and workplace practice
Both in the hospital and the school that have been surveyed, service user representatives
help raise issues in the interests of patients, students and their families, the solution of
which implies consequences for the organisation of work and employment conditions. These
consequences regard in particular a re-organisation of working time and working shifts of
employees – doctors, nurses, teachers, janitors –, and in some cases an intensification of
their workload. The impact of service user involvement, to improve the quality of services
provided, on the working conditions of employees is clearly detectable, despite the absence
of formal channels of communication with social dialogue institutions and practices.
Finally, the case studies show that for trade unions the development of service user
involvement can be a challenge to their traditional culture and strategy. Satisfying users’
demands might threaten and compromise the ‘vested interests’ of employees and union
members. However, precisely the potential impact on work practices and employment
conditions suggests that to see only a challenge and a threat, and not also an opportunity for
renewal, could be in the short run a myopic attitude on the part of trade unions, and in the
longer run a self-defeating strategy.
Integrating service user and workforce involvement can be a problematic process, but also a
promising way to revitalize social dialogue institutions and practices.
3