With financial support from the EU
New Challenges for Public Services Social Dialogue: Integrating
Service User and Workforce Involvement in the UK (England)
Stephen Bach and Alexandra Stroleny, King’s College London
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
This report is concerned with the experience of England, because increased devolution of
health and education policy has resulted in a different policy context in Scotland and Wales.
The report: considers the emergence and evolution of service user involvement; puts this in
the context of existing systems of employment relations in each sector; identifies the forms
and character of service user involvement in each sector; details case study evidence of
service user involvement in schools and hospitals, before identifying conclusions.
The report is based on:
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Interviews with 26 representatives and key stakeholders at national, sectoral and
organisational level amongst employers, trade unions, government and civil society
organisations in England;
interviews with employees, managers, trade union representatives and governors in
one hospital and one school;
documentation from organisations that participated in the study, government and
policy reports and academic literature.
Drivers of user involvement
There are many terms to describe the service user - citizens, customers, consumers and
clients – signalling different ways that service users may interact with public services. Within
health and school education, the term service user refers primarily to patients and pupils
that interact directly with service providers. Parents and school/hospital governors
constitute indirect service users.
Public policy has become increasingly supportive of user involvement in public services. In
the 1960s and 1970s the main drivers were the emergence of new social movements that
were critical of paternalistic services that neglected user concerns and public policy attempts
to enhance democratic participation. From the 1980s major structural changes of public
services and the emergence of new public management encouraged managers to give more
attention to the perspectives of service users, especially in hospitals. Government became
more prominent in promoting this agenda centred on user feedback and customer care. In
schools there was increased interest in ensuring pupils became active citizens and more
involved in their own learning. Government also had an increasing interest in effective
governance in hospitals and schools. These trends were reinforced by enhanced autonomy
for schools and hospitals that increased the importance of effective local stakeholder
involvement and accountability.
In the current context, government sponsored involvement measures are being used to try
and square the circle of reconciling fiscal consolidation and rising citizen expectations of
public services. In the health sector, service user involvement is intended to enhance cost
effectiveness and improve the patient experience by listening actively to the views of
patients. This agenda has been strengthened by recent scandals. Another component of this
agenda, which includes schools, is heightened interest in effective governance. Finally
government has taken this agenda further by enabling parents, teachers and community
groups to set up their own schools.
Forms
Successive governments have encouraged user involvement by establishing new structures
that incorporate users into governance structures (foundation trusts, academies, free
schools); delegated resources to users through personalisation and individual budgets,
enabling service users to have a direct role in funding and employing staff and required
providers to be more open and accountable to service users.
Service user participation takes a number of forms. The health sector has many high profile
condition specific organisations as well as broader patient organisations involved in agenda
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setting as well as the delivery of services. Many of these organisations have a prominent
national profile but don’t always speak with one voice. In school level education there are
few organisations that specifically represent user interests in national debates. In both
sectors a variety of well organised trade unions have a high public profile that engage in
agenda setting that connect with service user interests. In the health sector there has been a
proliferation of institutions and mechanisms of user involvement that encourage broader
citizen involvement in planning/commissioning and the monitoring of service standards (e.g.
Health Watch). Regulators in health and education (CQC, OFSTED) have increased user voice
in inspection systems. NHS trusts gather a variety of feedback from patients. The Friends and
Family Test question is mandatory and there has been an increase in the use of qualitative
data (e.g. patient stories). More attention is being paid to the role of service user
involvement through governance structures. In health, the establishment of foundation
trusts stimulated these developments and in schools increased responsibilities are being
delegated to governors, including in relation to HR issues.
Social dialogue and user involvement
There is little direct connection between social dialogue and user involvement. The former is
centred on collective bargaining/pay review bodies and other forms of employee
participation whilst service user involvement occurs in other forums. Consequently user
involvement and social dialogue remain institutionally separate and often operate at
different levels within national government. Much of the emphasis of user involvement
occurs at local level within individual employers or a specific locality, but pay determination
remains shaped by national frameworks, especially in terms of the pay review bodies. This
picture is not static, however, as the case of performance related pay for teachers illustrates
in which governing bodies have an enhanced role.
Service users regard issues of pay and working conditions as the responsibility of employers
and trade unions as well as government. Service users focus on issues that affect directly
their constituents - service standards, quality of service, availability of information, ensuring
redress when things go wrong etc and also engage with broader policy issues that affect
their members, such as changes in health and education provision at local and national level.
There is a recognition that staffing issues and the structure of the workforce impact on
service standards but these are not primary concerns. The social partners recognise the
importance of the issues raised by service users, but concentrate on their members’ main
concerns – pay, employment and working conditions.
Consequences for the social partners and workforce practice
There is acknowledgement amongst the social partners that service user involvement is a far
more prominent component of the public services agenda than a decade ago and this
recognition is especially marked in the NHS. These trends are viewed by the social partners
as creating opportunities but also generating actual or potential risks for their constituents.
There are overlapping themes in the experience of health and education, but also some
important differences.
Employers in the acute hospital sector are focused on the patient experience, concerned
with patient safety, quality and governance. Employers are receptive to enhanced patient
voice as a means to: improve the patient experience; consider the implications for working
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practices; and assist in efforts to be more cost effective. The increased attention to the role
of governors in hospitals and schools can be time intensive, but if used effectively can
strengthen governance structures and, especially in hospitals, provide additional insights
into the experience of users.
Trade unions have become more alert to the ways in which user involvement opens up a
series of institutions that can provide additional channels to exercise influence. In the main,
however, constraints on capacity and the rather diffuse nature of the user involvement
agenda makes it a lower priority than responding to the more immediate challenges
confronted by their membership. Trade unions have only intermittently viewed user
involvement as complementary in a direct way to social dialogue but have opportunistically
formed alliances with service users to advance common objectives such as in relation to
nurse staffing levels and hospital closure campaigns, but these alliances do not tend to be
sustained. There is some ambivalence amongst trade unions and user groups about
developing closer and more sustained alliances, reflecting different overarching interests
and different ways of working. Trade unions also identify some indirect threats to social
dialogue from increased user involvement because of concerns that user involvement will be
used by government or employers as an additional mechanism to performance manage and
discipline members.
Finally, service user involvement has implications for workforce practices. These effects are
most likely to arise at local level with service users involved in recruitment and selection
processes in education and health and also contributing to the training and development of
staff, for example, by sharing their experiences in hospitals in patient stories. Service users
also have an indirect effect on performance management by registering complaints and also
through the feedback provided by pupils and parents in schools that can trigger an OFSTED
inspection. Service users also can express their views on matters that impact on working
arrangements and work organisation.
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