With financial support from the EU
European Commission project
Coordinated by Professor Stephen Bach, King’s College, London
‘Industrial Relations and Social Dialogue’
VP/2013/0362
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Introduction
The public services are in a period of great upheaval. Since 2010, the Conservative-led coalition government has stated its ambition to use fiscal consolidation as a basis for restructuring public services to make them more responsive to service users. Its 2011 White
Paper Open Government outlined five principles of public sector reform, including ‘increase choice’ and ‘accountability to users and to taxpayers’ (Cabinet Office, 2011). Commitment to encourage user involvement has been a secular trend that originated many decades ago, but has increased in prominence as an integral component of public sector reform. New motives for user involvement have emerged as policy makers seek to draw on user perspectives to develop more cost effective and high quality public services. These policy concerns sit alongside longstanding demands for recognition and equal treatment amongst women, people with mental health and learning disabilities (amongst others). This led to a surge of citizen activism from the late 1960s, but these movements were not the first attempt to involve service users in health and education services.
A ground-breaking attempt to involve patients and the local community concerned the efforts of Sir Archie McIndoe, a pioneering plastic surgeon, who during the Second World
War worked with badly burned airforce veterans to produce effective treatment as defined by these veterans. A key criterion used was acceptance by the local community and reintegration into civil society (Mayhew, 2004). This example is interesting not only because it illustrates that user involvement can be effective in assisting patient recovery, but also in contrast to the current preoccupation with government-sponsored and mandated structures of involvement, it indicates that little can be achieved unless there is a commitment at local level to understand and integrate the perspectives of service users, staff and local communities.
This report examines service user involvement in the health and secondary education sectors, focusing especially on hospitals and schools and examines the connections with worker voice and social dialogue. In particular it examines the implications for the workforce of the increased prominence of the service user. It is based on data collected from a one year comparative European Commission project that considers the consequences of user involvement for employment relations and social dialogue. 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.
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The evolution of service user involvement
Terminology
The topic of user involvement has attracted much attention from the policy and academic community (Cotterell and Barnes, 2012; Simmons et al. 2009) but often in ill-defined ways.
As a health parliamentary report noted:
Patient and Public involvement often appears to be a nebulous and ill-defined concept, used as an umbrella term to cover a multiplicity of interactions that patients and the public have
with the NHS (Health Committee, 2007: 10).
Many different terms have emerged - citizens, customers, consumers and clients – with different connotations in terms of how service users engage with and experience public services and how those working in these services perceive them. A recurring theme of public policy debate is to differentiate between consumer and citizen engagement with public services. The label consumer is associated with an individual identity in which the relationship with public services is private and bounded rather than public and connected/relational in terms of other users. The emphasis on individual consumption is associated with the expression of individual needs and governments have focused on strengthening choice for service users, usually framed in terms of type of provider.
By contrast the idea of citizens is associated with collective identities in which citizens are undifferentiated in the sense that they belong to a community that confers certain entitlements or rights, such as social rights that stem from the development of the welfare state and the expansion of public services (Marshall, 1950). The implication is that these rights are delivered in a universal and standardised form to all citizens, an assumption challenged by some critics that highlight the gendered and class bias of citizens’ access to public services (see Fudge, 2005). Nonetheless the notion of citizen is positioned in relation to rights conferred by a nation state and it is at the community level that citizens become involved in expressing preferences via collective voice.
These contrasting perspectives have generated tensions about the respective balance between the roles of consumers and citizens in public services. A stylised account of these overall trends suggests that the growth of the public services in the 1950s and 1960s was associated with a citizenship and rights orientation in which access to universal public services was extended beyond the ‘deserving poor’ to incorporate all sections of society, even if access to services remained unequal in terms of gender and social class (Black et al.
1982). Nonetheless during the 1960s and 1970s attempts were made to equalise and standardise provision via policies such as the national hospital plan, the establishment of comprehensive schools and the resource allocation mechanism in hospitals (Timmins, 1995).
Towards the end of this period, moves towards more universal and standardised services started to be reinterpreted and re-evaluated. Criticisms of the bureaucracy, monopoly
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character and unresponsiveness of public services led to the advocacy of choice and marketisation from the 1980s onwards and a more consumerist approach to user involvement was advocated. These reforms unleashed a different set of concerns about new forms of inequity, the limits to consumer sovereignty and the decline of ‘the public’ in public services (Marquand, 2004).
The Labour government in its period of office between 1997 and 2010 directed considerable attention at trying to balance and reconcile the needs of consumers and citizens, suggesting that public service users even when acting as individual consumers retained a clear understanding that individual interests had to take into account the wider collective interests of citizens (Blair, 2002). The term citizen–consumer became a prominent label to describe this synthesis (Newman and Clarke, 2009). It informed reforms, such as the emergence of foundation hospitals which aimed to reconcile the impulse of users to act as consumers but also as citizens with a wider interest in how public services are governed for local communities. At the same time other perspectives on user involvement emerged as increasingly person-centred approaches to health and education became more prominent and an emphasis on collaboration and network governance sought to break down professional ‘silos’ and ensure more integrated and joined-up public services with the patient and pupil at the centre of service delivery. Since the financial crisis and the emergence of an era of austerity, the contribution that user involvement can make to ensuring value for money and the sustainability of the NHS in particular has been a prominent public policy concern (Foot et al. 2014).
The emergence of service user involvement: social movements and citizen rights
The rapid growth of public services from the 1950s gave very limited attention to the role of service users. As Le Grand (1997) has argued service users were cast in the role of pawns i.e. they were passive and subservient. The 1960s and 1970s were marked by substantial economic and political upheaval. It was in health, amongst groups largely neglected by the focus on hospital services, that pressure solidified for change. New social movements exemplified by charities such as Help the Aged, Mencap, Mind and the National Association of the Welfare of Children in Hospital were highly critical of the paternalistic assumptions of welfare professionals and the manner in which they ignored the concerns of service users.
These movements were especially vocal in the areas of disability rights and mental health, strengthened by scandals highlighting poor standards and neglect in long-stay hospitals
(Robb, 1967).
In 1974 for the first time patient voice was formalised and patients ceased to be ‘the ghosts in the machine’ (Klein, 1989: 77). Community Health Councils (CHCs) were established as separate organisations with a duty to represent the interests of patients and a right to be consulted on local service changes. CHCs could delay and challenge proposals such as ward and hospital closures by referring them to the secretary of state for health for a decision.
CHCs had a statutory role that meant NHS administrators had to take their views seriously
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even if they were generally regarded as an irritant rather than a lubricant (Hogg, 2009). As one nursing manager commented to the NHS Royal Commission:
They watch aggressively and seem permanently to be seeking to find fault with loyal and hard pressed National Health Service staff on whose patients they are constantly requesting
surveys and for whom they offer little, if any, practical help (cited in Merrison, 1979: 148).
Overall, the NHS Royal Commission was supportive of CHCs and argued that their role should be developed as the patient’s friend.
In schools, concerns emerged about school standards and teacher quality that precipitated lengthy debate about the organisation of schools. The Plowden Report, which appeared in
1967, emphasised the importance of parental support for a child’s education. The Labour government was committed to a more participatory style of local democracy and the Taylor
Report (1977) argued for more parental and community involvement in schools, in a period when Local Education Authorities (LEAs) were starting to appoint parent school governors
(Dimmock et al. 1996). Plans to appoint parent governors, community governors and to give parents rights to more information about schools did not become law as the Labour government lost the 1979 election (Timmins, 1995: 328), but these policies subsequently reemerged. In contrast to the NHS the issue of a democratic deficit was less prominent because elected politicians had oversight of schools within local authorities.
In summary, this phase of user involvement until the end of the 1970s was precipitated by twin concerns about the rights of service users and unease about poor standards in schools and hospitals. There was an emerging sense especially in the NHS that hospitals should not be left exclusively to professionals. The views of individuals – patients, pupils and parents – and communities should be heard and this voice would improve services and strengthen local democracy.
Enter new public management: the emergence of the consumer
The 1980s and 1990s represented a very different period of public service reform that was underpinned by managerialism, marketisation and measurement. Associated with the principles and techniques of the new public management (NPM) (Hood, 1991) the emphasis was on the public sector mimicking the structures and practices of the private sector in order to be more accountable to users. In the NHS, the highly influential Griffiths Report
(1983) commissioned by Mrs Thatcher and written by the managing director of the supermarket group Sainsbury’s argued for a stronger customer orientation in the NHS. The break-up of centrally managed public services into more autonomous separate employers, notably NHS trusts and grant-maintained schools, also encouraged more consideration of the needs of customers. Enhanced managerial responsibilities encouraged emergent hospital chief executives to go In Search of Excellence (Peters and Waterman, 1982). Public service managers and staff were encouraged to become more customer driven. It was
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during this period that hospitals started to more systematically survey patients and developed total quality management and customer care programmes to gather feedback from patients (IDS/IPD, 1989).
A significant boost to these efforts was provided by the development of the Citizen’s
Charter movement, championed by the incoming Conservative Prime Minister. John Major succeeded Mrs Thatcher in 1990 and was more committed to improving existing public services than his predecessor. Major championed responsive public services underpinned by the White Paper: Citizen’s Charter: Raising the Standard (HMSO, 1991). The Citizen’s Charter identified service users as customers with clearly identified standards. For example, a
Parent’s Charter promised parents would receive regular reports on their child’s and the school’s progress (DfE, 1995). More than forty national charters and more than 10,000 local charters were developed after 1991 (McGuire, 2001).
These charters were not always warmly received by professional staff. In the NHS it was argued that the Patient’s Charter recalibrated managerial priorities but in ways that distorted professional priorities and work patterns. As one clinician commented:
In order to fulfil the Patients’ Charter and see the required number of patients on time and minimize waiting times, I stick rigidly to the schedule…if a patient with more complicated symptoms than anticipated, presents themselves for first appointment, they will probably be asked to come back for a second appointment. In the past I would have dealt with them immediately and caused a delay to the outpatients clinic. I do not think this helps patients
(cited in Ferlie et al. 1996: 184).
These criticisms were reinforced during the Labour government’s period in office in which standards were developed further and criticisms arose that targets resulted in behaviour that hit the target but missed the point (Bach, 2004; Bevan and Hood, 2006). Despite these shortcomings the charter movement was important because it established explicit standards and identified ways in which redress could be sought.
In summary, the 1980s and 1990s witnessed major structural changes of public services and the emergence of more powerful cadres of managers in hospitals and schools working within more autonomous employer units. With governments starting to develop policies to promote provider choice, underpinned by competition or at least contestability, hospitals and schools were encouraged to pay more attention to the perspectives of service users.
This was often centred on individual customer feedback via survey instruments or analysis of complaints. Consequently there was more emphasis on patient involvement rather than public involvement and it was government that was promoting this agenda, encouraging managers to be more responsive to service users. Service user pressure for more recognition remained important but it was not the dominant driver of change as had been the case in previous decades.
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From New Labour to the Coalition government
The election of the Labour government in 1997 marked an important turning point in the reform of public services and service user involvement moved centre stage. The Labour government emphasised targets, choice and provider diversity but also encouraged collaboration between providers to ensure more integrated joined-up services to encourage more person-centred services (Bach and Kessler, 2012). New Labour started to engage and promote the voluntary sector as part of an entrepreneurial ‘third way’ (Giddens, 2000: 81-
2). Often termed the third sector it comprises ‘non-governmental organisations that are value driven and which principally invest their surpluses to further social, environmental and cultural objectives’ (Cabinet Office, cited in Public Administrative Select Committee (2008:
5).
The Labour government viewed the third sector as having a better understanding of the needs of service users and more effective in involving service users, assisting in transforming public services (Public Administration Select Committee, 2008). In addition personalised services were encouraged, exemplified by the growth of direct payments and personal budgets (Leadbeater, 2004; Yeandle and Stiell, 2007).
A raft of Labour government initiatives provided a collective voice for citizens to engage at the organisational level, particularly in the design and operation of services, albeit mainly on a consultative basis and with limited binding effect. The NHS Plan, the centrepiece of the
Labour government’s plans for the NHS enthused that ‘For the first time patients will have a real say in the NHS. They will have new powers and more influence over the way the NHS
works’ (Department of Health, 2000: 12).The Health and Social Care Act, 2001, placed a new obligation on NHS institutions to make active arrangements to involve and consult patients
(Department of Health, 2004). However, these changes were accompanied by the abolition of CHCs attributed to their oppositional stance towards policies such as the establishment of foundation trusts (Hogg, 2009).
At trust level, new mechanisms were established, strengthening the right to complain and establishing a patient advice and liaison service in every NHS trust, supported by the creation of an independent complaints advocacy service. These reforms, however, had a chequered history and the 2000s were marked by continuous restructuring of patient and public involvement as different mechanisms for user involvement within the NHS came and went in rapid succession (Health Committee, 2007). Enhancing patient and public involvement was also integral to the governance of foundation trusts that emerged after
2003, establishing new channels of public involvement as members and governors
(Department of Health, 2005).
The emphasis on citizen involvement was also reflected within the governance of schools.
Citizen classes were encouraged and so was more active pupil involvement, with the establishment of the youth parliament movement with elected members aged 11-18. In
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England, school governing bodies were able, to nominate pupils to act as associate governors. More widespread was the spread of student councils. Whilst schools were also encouraged to work in partnership with parents and give them more say in schools the
Labour government also emphasised that citizenship involved rights and responsibilities.
Parents were being offered more opportunities to exercise choice in relation to school provision but they were expected to act responsibly and control the behaviour of their children (Ball, 2007).
Schools were encouraged to be more responsive to their school community, whilst also paying attention to the wider needs of the locality. The emphasis on joined up government was apparent in the Every Child Matters (DfES, 2003) agenda with its notion of the extended school that reached out into the local community. This shift of emphasis was reflected in the retitling of the Education Department as the Department for Children, Schools and Families, a decision reversed by the incoming government in 2010.
Since 2008 and the onset of the global economic crisis government priorities in relation to the public sector have altered. In 2010 a Conservative-led coalition government took office committed to reducing the deficit and devoting a smaller proportion of national income to public services. Austerity policies have been the dominant component of public sector policy with substantial reductions in employment, wage freezes and ongoing restructuring (Bach and Stroleny, 2014; Grimshaw, 2013). The Coalition government has continued to endorse user involvement, continuing many of the same themes of choice and personalisation of the previous Labour government, but in a very different economic and political context.
Emphasis on choice and diversity of provider has been developed further and parents and local communities have scope to set up free schools. In health, market style reforms have encouraged new providers to deliver health services, mainly from the private sector, but also from amongst social enterprises and mutuals. In addition, personal budgets are being extended from social to health care.
The Coalition government also emphasised the role of citizens and communities in the transformation of public services under the rubric of the Big Society. The Coalition government’s ambition has been to develop more active citizens that voluntarily contribute to the provision of local services. The Big Society generated considerable critical commentary because of its vagueness and the suspicion that it represented little more than a smokescreen for cuts and privatisation (Bach, 2012; Jordan, 2011; Whitfield, 2012).
Policy towards user involvement has also been influenced by scandals at Mid Staffordshire
NHS Foundation Trust (and at Winterbourne View private hospital) that revealed appalling standards of care and neglect. Managerial cultures developed that ignored and ostracised local groups that tried to highlight failures in care standards and misaligned priorities
(Francis, 2013). These events have recalibrated NHS priorities with an emphasis on understanding the patient experience but as Foot et al. (2014: 7) contend:
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The instinctive policy and political response – for understandable reasons - has been to regulate and protect, rather than liberate and empower. Creating the conditions in which people have more say has not been the dominant narrative.
Discussion
There is a considerable legacy of user involvement and campaigning in relation to public services. From the 1960s a new period of service user activism emerged in health and welfare services in response to dissatisfaction with the neglect of specific client groups by the NHS or their portrayal by statutory services. Changes in society were also drawing attention to the democratic deficit in many public services, exacerbated by the increasingly centralised model of policy and service delivery. In schools the role of school governors increased and this was bolstered by the devolution of responsibilities to schools as part of the Local Management of Schools reforms (Ironside and Seifert, 1995).
An important characteristic of user involvement in England has stemmed from the contradictory role and structure of health services. Health care is distinctive because few if any other European countries (or elsewhere) associate health services with one nationally defined, state provided and state funded, organisation – the NHS. The upshot is that the
NHS is invariably a highly sensitive political issue that almost without exception has a prominent role in electoral politics. Paradoxically the NHS has been a public service that has been devoid of formal political and public influence in the sense that there no universal electoral mandate for appointments within the NHS. This democratic deficit has been noted and therefore attempts have been made to address it by the establishment of institutions that provide increased voice, such as CHCs and subsequently by the governance structures of foundation trusts.
In schools, the tradition of local authority control provided a form of direct political control over schools. Since the late 1980s, however, schools have become increasingly detached from LEAs and operate as more autonomous organisations, directly accountable to the
Department for Education. The school landscape has become more fragmented and diverse and therefore local accountability of schools to local citizens and service users has become more important, but also more difficult, as illustrated by the increased interest in school governance arrangements.
In health and education services different policy drivers of service user involvement have been present at different periods. This has resulted in great complexity and uncertainty about the priority, role and consequences of service user involvement. Rather than service user pressure and demand for rights falling away to be superseded by consumerism and then person-centred care, instead different concerns have been layered onto previous user involvement initiatives, shaped by different policy priorities and with different end goals in mind. These multiple goals and perspectives, reflected in differing terminology, has created uncertainty amongst the social partners about how they should address this agenda.
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2: Overview of social dialogue in health and education
Employment in health and education sectors
The public sector in the UK is divided between central government, local government and public corporations. This three-fold classification of different parts of the public sector is based on their legal and administrative responsibilities and the extent of financial independence. First, 2.8 million staff are employed by central government. It includes all government departments, executive agencies and non-departmental public bodies who are controlled and financed by central government. This sector includes HM Forces and the
National Health Service and academy schools because they are not controlled or financed by local government. Second, 2.3 million staff are employed by local government covering a specific geographical location. Local government includes social services, police, fire, schools
(i.e. the diminishing proportion of schools controlled by the local education authority) and staff that support schools and other staff employed in environmental and civic services.
Finally, 186,000 staff are employed in public corporations that are companies or quasicorporations controlled by government, but with substantial freedom to conduct their activities along commercial lines, such as London Underground Ltd (ONS, 2014).
Since 2008 and especially after 2010 public sector employment has declined markedly.
However there were considerable variations between sectors in terms of employment reductions with local government especially hard hit as well as the civil service. Focusing on
England, school level education funding has been relatively protected and the school workforce has been relatively stable since 2010 (Table 1).
Table 1: School workforce in England, 2010-2013
Total
Headcount
School
Workforce
Teachers in the
Leadership
Group Teachers
Teaching
Assistants
Non
Classroombased
School
Support
Staff
Auxiliary
Staff
Pupil:
Teacher
Ratio
ENGLAND
2010*
2011
2012
1,293,512 61,610
1,237,647 61,008
1,275,570 62,724
341,168
486,026 323,150
492,874 340,480
191,038
177,913
182,967
267,878
250,558 17.8
259,249 17.7
2013 1,296,216 64,861 502,727 351,457 184,197 257,835 17.2
Source: Department for Education, available at https://www.gov.uk/government/collections/statistics-schoolworkforce , School Level School Workforce Census files
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The NHS has been relatively protected in terms of public expenditure and this is reflected in continuing albeit slow employment growth after 2008 in England. As Table 2 indicates, the
NHS is made up of a highly professionalised workforce, with the majority of staff being
(professionally) qualified.
Table 2: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics - July 2014,
Provisional Statistics, England
Headcount FTE Role Count
Total 1,203,740 1,057,154 1,227,170
Professionally qualified clinical staff (1)
All HCHS doctors (incl locums)
All HCHS doctors (non locum)
Consultants (including Directors of public health)
Registrars
Other doctors in training
Hospital practitioners & clinical assistants
Other medical and dental staff
637,015
111,740
109,512
42,139
38,387
16,280
1,226
11,805
569,585
105,507
103,418
39,866
37,255
16,121
278
9,899
650,267
114,274
111,841
43,228
38,776
16,305
1,297
12,235
All HCHS doctors (locum)
Consultants (including Directors of public health) - locum
Registrars - locum
Other doctors in training - locum
Hospital practitioners & clinical assistants - locum
Other medical and dental staff - locum
Total HCHS non-medical staff
Qualified nursing, midwifery & health visiting staff
Qualified Midwives
Qualified Health Visitors
Qualified School Nurses
Total qualified scientific, therapeutic & technical staff
Qualified Allied Health Professions
Qualified Therapeutic Radiography Staff
Qualified Diagnostic Radiography Staff
Qualified Speech & Language Staff
Qualified Healthcare Scientists
Other qualified scientific, therapeutic & technical staff
Qualified ambulance staff
Support to clinical staff
Support to doctors & nursing staff
Support to scientific, therapeutic & technical staff
Support to ambulance staff
NHS infrastructure support
Central functions
2,415
1,814
314
70
28
189
1,092,118
352,743
26,465
11,784
1,492
154,186
76,984
2,683
15,079
7,792
27,258
50,032
18,570
357,843
279,394
64,368
14,636
211,294
105,650
2,089
1,568
304
68
8
142
951,646
312,873
21,807
9,878
1,195
133,594
65,159
2,411
13,192
6,223
25,132
43,302
17,610
303,884
236,476
54,078
13,331
183,685
95,014
2,433
1,829
314
70
28
192
1,112,896
358,295
27,053
11,917
1,520
159,091
79,984
2,709
15,465
8,519
27,460
51,647
18,607
363,212
283,421
65,097
14,694
213,691
106,454
Hotel, property & estates
Senior managers
69,182
11,262
53,893
10,554
70,341
11,333
Managers 25,445 24,225 25,563
Source: Health and Social Care Information Centre (2014) : http://www.hscic.gov.uk/searchcatalogue?productid=16025&topics=0%2fWorkforce&sort=Relevance&size=10&page=1#t op
Structure of health and education sectors
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In contrast to many other European countries health services remain centrally financed and managed by central government with most services provided by the National Health Service
(NHS). The NHS is therefore part of central government and financed from general taxation with the overwhelming majority of health services directly provided by it. The NHS comprises: secondary healthcare, mainly revolving around acute hospitals; primary healthcare delivering a range of community services including general practice, district nursing and health visiting; tertiary care, dispensing more specialist services, in a small number of hospitals.
The combination of state financing and provision has made the NHS susceptible to high levels of centralized control. Since the 1980s a more corporate-style management structure has evolved and an internal market was established from the early 1990s. The Labour government in office until 2010 went with the grain of earlier reforms. From 2003 onwards hospitals and groups of hospitals were encouraged to become foundation trusts. These trusts were granted additional flexibilities in relation to national pay and conditions, established new governance arrangements and were subject to direct control from the
Department of Health rather than managed by intermediate tiers of the NHS. The purchaser/provider division remained in place but with some attempts to encourage collaboration between providers and enable more integration of health services.
The Conservative-led coalition government pledged that there would be no more top-down
NHS reorganisations but immediately embarked on complex and contentious NHS reorganisation. The rationale was that commissioning and the budgets associated with them would be shifted to networks of family doctors (GPs) termed clinical commissioning groups
(CCGs). All trusts would gain foundation status and patient choice would be extended by allowing ‘any qualified provider’ to operate in the NHS, provoking concerns about increased privatisation (Tailby, 2012). In autumn 2014 the new NHS chief executive unveiled a five year plan for health services in England (NHS England, 2014a). It recognised the financial challenges the NHS confronted, called for much greater integration of health services and a focus on prevention and re-emphasised the role of patients and communities in shaping health services, but framed in part through a narrative of choice:
A third step is to increase the direct control patients have over the care that is provided to them. We will make good on the NHS’ longstanding promise to give patients choice over
where and how they receive care (NHS England, 2014a: 11-12).
The school sector has also been subject to similar reform principles. In particular successive governments have advocated more devolution of managerial responsibilities to schools, increased choice for parents in the selection of schools and more transparency and accountability of schools to raise standards. Traditionally schools comprise a key part of local government and were managed by local education authorities (LEAs). The trend over
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the last quarter of a century has been for a loosening of the relationship between local government and schools as more autonomy has been ceded to schools.
These trends stem from the landmark 1988 Education Reform Act that introduced the local management of schools (LMS) which delegated responsibility for financial and staff management to governing bodies. At the same time central government intervened to an unprecedented degree in shaping the working lives of teachers, a national curriculum was established and a more punitive system of inspection was introduced by the establishment of the Office for Standards in Education, Children’s Services and Skills (OFSTED). The Labour government sought to differentiate the school landscape by encouraging specialisms in schools and seeking industry sponsorship to establish new schools.
This broad policy trajectory was extended further by the Coalition government that provided financial incentives for all schools to become academies, answerable directly to the Department of Education rather than local education authorities and linked to an external sponsor. There are 22,000 schools in England of which 16,800 are primary schools and 3,300 are secondary schools (11+ age group) with other smaller categories (e.g. special schools). 55 per cent of secondary schools are academies (OFSTED, 2013), but the rate of conversions has slowed considerably. Since 2010, local communities i.e. parents, teachers and the voluntary sector have been able to gain government funding to set up free schools;
331 had been opened or approved by July 2014 (DfE, 2014). Local authorities are under a statutory obligation to establish new schools only on the basis of one of these two models.
Overall, these reforms combine centralisation of accountability directly to central government and devolution of managerial responsibilities to the level of the individual school, most evidently in the case of academies and free schools, undermining further LEA influence.
Institutions and main features of social dialogue in health and education sectors
The term social dialogue is not widely used in a UK context, reflecting more adversarial employment relations traditions and a less encompassing role for trade unions and employers in the administration of welfare services. Public sector employment relations has been characterised by industry-specific national negotiating machinery accompanied by local consultative arrangements, a pattern that existed in the education and health sectors.
In addition to industry collective bargaining structures, at employer level, joint consultative committees (JCC) were established on a voluntary basis, comprising employer and employee representatives. JCCs tended to focus on non-pay matters such as agreeing local disciplinary and other procedures and acted as a forum for employers to communicate their plans and consult with local trade union representatives. Over the last two decades employers have placed much greater emphasis on the direct involvement of their workforce, for example, via periodic employee staff surveys and team briefings (Van Wanrooy et al. 2013: 65).
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The tradition of national level bargaining was challenged by the Thatcher government
(1979-1997) who engaged in extensive privatisation and eroded public sector trade union influence. Following protracted disputes with trade unions in the health service in 1982, and in schools in the mid-1980s, partly for reasons of political expediency, the government established an independent pay review body for nurses, midwives and professions allied to medicine in 1983, and one for schoolteachers (in England and Wales) in 1991. The expansion of the system of independent pay review sat uneasily alongside an emphasis on single employer bargaining rather than industry bargaining, implemented most fully in the civil service. The attempt to develop local pay on an NHS trust by trust basis in the early 1990s was a policy failure (Bach and Winchester, 1994), but led to a recognition amongst all parties that the NHS pay system required modernisation (Perkins and White, 2010).
The Labour government (1997-2010) favoured more local flexibility within national systems of pay determination and encouraged social partnership between trade unions and employers to assist pay and workforce modernisation. In the mid-2000s, the NHS staff council negotiated a major reform of NHS pay determination termed Agenda for Change.
The main consequences of these changes were: pay systems were equality proofed reducing the risk of equal value claims; the scope for flexible working was increased by harmonising terms and conditions; pay was substantially improved for many groups, and the system of pay review was extended further to cover the whole NHS workforce.
More recently, the Coalition government has aspirations to decentralise pay determination reflecting long standing Conservative party antipathy to national pay determination. The pay review bodies, however, rebuffed moves towards regional pay. The scale of austerity measures had a marked impact on pay determination with a two year pay freeze followed by at least two years when pay awards have been limited to an average 1 per cent. The commitment of the government to remove ‘automatic’ increment based pay progression and encourage more individualisation of pay has also been a prominent feature of government plans. From September 2013 a system of performance related pay is in operation for all teachers and teaching staff are required to achieve their appraisal objectives to be eligible for a performance-based increment.
Main organisational and workforce challenges in health and education
The public sector confronts a number of challenges to service delivery that affect health and education services. The first challenge relates to sustained pressure on public expenditure.
Schools and hospitals are in relative terms more protected than other parts of the public sector such as local government and the civil service. In both sectors however, demand is increasing. The upshot is that the NHS in England confronts a mismatch between resources and patient needs of nearly £30 billion a year by 2020/21 unless action is taken to address
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demand, efficiency and funding (NHS England, 2014). In schools the funding pressures are less high profile and the coalition government has committed itself to protect schools spending in real terms until 2015/16 but related components of the education budget e.g. local authority funding to support school improvement has been reduced markedly, reflecting deep cuts to local government funding.
A second common challenge relates to recruitment and retention pressures that have been partly masked by the deep economic recession that followed the 2008 crisis, but have started to become more apparent as economic growth returns. In the NHS staff shortages are evident amongst some nurse specialties, midwives and specific medical specialties. NHS trusts have started to recruit actively overseas, often in European countries hit hard by the economic crisis. In schools, the government is missing its targets in attracting graduates into subjects such as Maths and Science (TES, 2014).
A third key challenge relates to service standards. In schools, all governments have been seeking to raise educational standards and ensure improved performance on the OECD PISA test results. This has translated into increased pressure on schools to demonstrate improved performance and ‘value added’, but this is against a backdrop of more demanding OFSTED inspection. In hospitals the challenge relates more directly to patient safety following the scandal and public outcry concerning avoidable patient deaths at Mid-Staffordshire Hospital that resulted in a series of reports and recommendations to address patient safety (Francis,
2013; National Advisory Group, 2013). Apart from budgetary restrictions and associated restructuring, the post-Francis agenda has been the dominant preoccupation of the NHS with much effort directed at culture change, achieving safe staffing levels and ensuring that staff have internalised the appropriate patient-centred values.
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3: Mapping service user involvement in health and education sectors
Introduction
Public policy has become increasingly supportive of user involvement in public services.
Government sponsored involvement measures are being used to try and square the circle of reconciling fiscal consolidation and rising citizen expectations of public services. Policy makers therefore view user involvement predominantly as a means to an end rather than an end in itself. In other words service user involvement, especially in health, may be a vehicle that enables policy makers to develop health services that are more cost effective and responsive because users take more responsibility for their own care and make more conservative choices than health professionals about their needs, reducing service demands. At the same time increased voice for users and more involvement in decision making is expected to increase user satisfaction with services. In schools this policy has been taken further by enabling service users – parents, teachers and community groups - to set up their own schools. There is an additional component in this evolving policy landscape that arises from the existence of a coalition government since 2010. Although the
Conservative party are dominant, the presence of the Liberal Democrats in government with a long-standing preference for localism and local government provision has influenced health policy, for example, in terms of an enhanced role for local government in areas such public health.
Health sector service user involvement
In health services there are many organisations that have responsibilities for involving service users and the voluntary sector also has a key role. In the NHS, these range from direct providers and commissioners of health services (NHS England, foundation trusts, clinical commissioning groups) to official public involvement organisations such as Health
Watch and also regulatory and inspectorate organisations such as the Care Quality
Commission that have also increased their engagement with service users in the inspection regime in recent years. Many voluntary organisations also play a key role in representing the interests of service users and have also been more attuned to service user involvement than the NHS, embedding service user involvement in their own management and governance structures in ways that have few equivalents in the NHS. The voluntary sector however is very diverse making generalisation difficult.
There are many large national charities often linked to specific conditions (e.g. diabetes, cancer, heart disease etc) that provide services often in partnership with the NHS (e.g.
Macmillan nurses) focused on the needs of the patient groups they serve. In addition there are a number of organisations with a wider remit to represent patient interests, including the Patients Association and National Voices. Ten of the largest health charities have
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established their own network, The Richmond Group, that advances policy positions on health and social care based on five over-arching themes (Richmond Group of Charities and the King’s Fund, 2010). As well as variations in size and degree of integration within the health sector, there is an important difference between organisations focused on patient or public involvement.
Patient involvement tends to revolve around long-term chronic conditions and the priorities of carers or individuals with those conditions because as one respondent explained:
There is no organisation for patients with a broken arm because it is mended in six months and you go off on your own way whereas long term conditions create – people with long term conditions regular use the health system, see what is wrong with it, face the challenges trying to access better care or to make complaints or whatever. That creates a reason for
coming together and getting involvement in trying to do stuff (I29).
By contrast public involvement has broader concerns, focused on accountability, enhancing local voice and shaping service provision. These organisations concentrate more on collective community and citizen concerns to ensure good local services. In addition, coalitions and alliances may come into existence when specific threats galvanise local communities, for example, the successful campaign in South London to maintain Lewisham hospital, rather than to downgrade and reconfigure its services.
There are a number of frameworks and institutions established by central government that are seeking to change the relationship between the NHS and service users with some ambiguity about the focus of these initiatives. Within NHS England one of its six directorates comprises ‘Patients and Information’ indicative of the higher profile attached to patient involvement in the NHS. An important starting point is the NHS Constitution for England launched in 2010 and refreshed in 2013 with more duties placed on the NHS to promote its use (NHS England, 2013a). The NHS Constitution: establishes the principles and values of the NHS in England. It sets out rights to which patients, public and staff are entitled, and pledges which the NHS is committed to achieve,
together with responsibilities, which the public, patients and staff owe to one another (NHS
England, 2013a: 2).
The NHS Constitution has not yet caught the imagination of patients or staff and an NHS expert group concluded:
‘the relevance, visibility and impact of the NHS Constitution in practice and in the day-to-day
delivery of NHS services all remain limited (Expert Advisory Group to the NHS Constitution,
2014: 3).
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The government is seeking to embed and promote the profile of the NHS Constitution and the establishment of an expert advisory group, chaired by the health minister, indicates intent. Nonetheless, respondents suggested that the NHS Constitution has limited meaning for patients, in part because the term ‘constitution’ is associated with US political traditions.
The NHS Constitution is accompanied by a 146 page handbook (NHS England, 2013b), suggesting that it not easily interpreted. There is also a degree of ambiguity as to whether the NHS Constitution is aimed primarily at staff or patients.
NHS England was established as part of the 2012 NHS reforms and concentrates on the commissioning side of the NHS, absorbing staff from abolished organisations (PCTs, SHAs).
Its business plan is entitled Putting Patients First and is concerned - especially post-Francis - to facilitate culture change and place patients at the heart of everything the NHS does (NHS
England, 2013c). One element of this culture change has been NHS England developing
‘NHS Citizen’ that aspires to involve ‘real’ citizens rather than use existing institutions of patient voice in the NHS. The challenge, for NHS Citizen, however, is that the secretary of state for health retains overall responsibility for the NHS and therefore NHS Citizen is not responsible for NHS policy making (NHS Citizen, 2014: 4). NHS Citizen has been created in a top-down manner in a new organisation (NHS England) that has little profile amongst citizens, generating uncertainty about its capacity to harvest bottom-up citizen voice. The establishment of NHS Citizen does indicate, however, that NHS policy makers are attuned to the NHS democratic deficit and are seeking mechanisms to increase user involvement. What is less clear is how receptive NHS providers and frontline staff are to these types of voice structures, in a context of austerity and other service pressures.
Within the local health economy that will include at least one main NHS trust there are additional opportunities for service user involvement. At the core of the 2012 Health Act is commissioning of health services by local, GP-led, clinical commissioning groups (CCGs) that have an explicit duty to involve patients in decision making and are required to have lay members on their governing board. In recent years, GP surgeries have also been active in developing practice based patient participation groups. In each locality wider public involvement in NHS services is fostered by Healthwatch organisations that collect feedback and provide information on health and social care services, but curiously are not required to have members (although some do) and there are also Health and Wellbeing Boards within local authorities. In addition health regulators, in particular the Care Quality Commission, actively seeks out user perspectives when inspecting NHS trusts. Many of these institutional arrangements are relatively new (2013-).
A very different national form of involvement relates to the requirement for each acute hospital to administer the Friends and Family Test (FFT) for patients visiting A&E (emergency services) or using inpatient services. It is more focused on consumer satisfaction and
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potentially provides a national benchmark in addition to more local systems of user feedback – complaints, comment cards etc. It is based on a single question ‘How likely are you to recommend our ward/A&E department to friends and family if they needed similar care or treatment?’ and uses a five point scale from ‘extremely unlikely’ to extremely likely’ to calculate a net promoter scale. The FFT was introduced in April 2013 to provide public feedback on how hospitals are performing to assist patients make decisions about where they receive treatment and in addition:
Through FFT, NHS staff are receiving regular, near real time feedback about the job they are doing. Often this feedback confirms what a great job they are doing, but where it is less positive it encourages staff to make changes in order to improve the quality of care
experience (NHS England, 2014b: 5).
FFT is at a relatively early stage of implementation, but has received a cautious reception within the NHS. There have been concerns raised about the extent to which the methodology is robust and that local implementation of the FFT may be highly variable and subject to ‘gaming’.
NHS trusts also use a variety of other mechanisms to involve patients, implementing national policies such as FFT identified above. All trusts also have a Patient Advice and
Liaison Service (PALS) that provides information and deals with complaints, a subject that has also witnessed many recommendations for improvement in recent years (e.g. Clwyd and
Hart, 2013). NHS trusts that provide maternity services are also involved in Maternity
Services Liaison Committees (MSLCs) that provide a channel for users to influence local maternity services. NHS trusts hold public meetings when they publish their annual report and additional meetings to address key issues and statutory consultation on issues such as trust mergers. There is considerable variation between trusts in the extent that they reach out beyond these established mechanisms to encourage user involvement. In some trusts additional public meetings are held and specific user groups operate, bringing together service users with long-term conditions. A more recent development has been the use of patient stories, often used at the start of trust board meetings, and other managerial forums to highlight scope for improvement. Patient stories are used to demonstrate how HR and nursing policy and practice can be amended to ensure more effective work organisation and higher quality of care (e.g. East Kent Hospitals University NHS Foundation Trust, 2013;
2014).
Foundation trust governance
Statutory requirements for user involvement at trust level relate primarily to corporate governance and the role of trust governors. Foundation trusts (147 in England) are intended to encourage greater accountability and responsiveness to their local communities. The
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statutory duties of governors was laid out in the 2006 Act and extended in the Health and
Social Care Act 2012 with agreement of 50 per cent of governors needed for a decision such as a merger or dissolution of the trust. Each NHS foundation trust has members, a unitary board of directors (comprising executive and non-executive directors) and an elected council of governors. The council represents member interests, holds non-executive board members to account for the performance of the board of directors and appoints the chair and non-executive directors of the board (see Monitor, 2014a). The council of governors has powers to remove the chairperson or any other non-executive director but should only do this only ‘after exhausting all means of engagement with the board of directors’ (Monitor,
2014a: 23). Governors are drawn from a variety of public, patient and staff constituencies
(see case study section for details).
The scope for connecting the concerns of service users and staff as brought together in the council of governors confronts a number of challenges. First, trusts have difficulties in attracting candidates to stand as governors and this is most pronounced amongst staff governors with 41 per cent of trusts experiencing difficulties in this membership category
(Monitor, 2011: 14). Depending on the constitution of the NHS trust, around a quarter identify the trade union staff side as a named organisation enabling the trade unions to nominate an individual or individuals as an appointed governor. Some of the NHS trade unions, such as Unison, however opposed foundation trust status and therefore members may be reluctant to participate. In addition, a trade union official pointed out that staff: are working very long hours and why would you want having done that for six days a week,
then go to a meeting to talk about it all over again? (I29).
Second, governors confront ambiguities about their precise role and limited awareness and other understanding about their roles from other staff. Staff governors represent their occupational or workplace constituency but at the same time they must act in the overall interest of the trust. Nonetheless, staff governors bring valuable insights from their everyday working lives to bear. As an employer representative explained:
So there is a big push towards really understanding what people think about your services.
Governors are, potentially a rich source of information. And staff governors as well. If you’ve got doctors and nurses who are saying about your organisation actually if I was ill I wouldn’t be treated here. Then that speaks volumes about you (I22).
A third challenge for all governors relates to the difficulties of influencing developments because of the limited time available to undertake their role, uneven training provision and the limited engagement between the council of governors and trust non-executive directors. This has not precluded governors removing chairs of trust boards on specific occasions but councils of governors have not yet capitalised fully on their role. Consequently
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trade unions whilst recognising the value of members becoming trust governors and publishing guidance to encourage it, they have not pro-actively encouraged involvement
(see Unison, 2012; RCN, 2014).
Despite these uncertainties about the practice of user involvement, there have never been as many opportunities for the public and patients to become involved in expressing individual and collective voice in the NHS as at present.
Secondary education - schools
In schools, there has been less reform of user involvement structures with the exception of statutory guidance on school governing bodies. In addition to the main head-teacher (ASCL,
NAHT) and classroom teacher unions (ATL, NASUWT and NUT) it has been the National
Governors Association that has been an important voice in influencing education policy. In contrast to the health sector there has been less institutional development of participation mechanisms. Most schools were part of local government and this provided a layer of local accountability in the school system with councillors represented on school governing bodies. This situation is shifting as the role of local authorities in school management diminishes. At school level, a number of stakeholders – staff, parents and local community interests – are brought together within governing bodies to provide oversight with scope to integrate user and worker involvement within school governance.
Pupils are not members of governing bodies, but they are involved in schools, shaped by four main influences. The first has been the increased interest in rights as exemplified by
Article 12 of the United Nations Convention on the Rights of the Child that states national governments should take account of the rights of children to express their views and ensure their opinions are taken into account in decisions that affect them. A second influence has been an emphasis on encouraging pupils to be active citizens. Mandatory citizenship classes and encouraging the establishment of student councils were integral to this approach
(Blunkett and Taylor, 2010). A third influence on the promotion of pupil voice stems from the school improvement agenda in which it is recognised that involving and consulting pupils on matters such as behaviour and attendance policy can have an important effect on the extent to which policies are accepted and adhered to, raising standards. Finally, the moves towards personalisation and an increased emphasis on the needs and attainment of each pupil, has brought a recognition that active pupil participation is necessary to enhance pupil performance (Whitty and Wisby, 2007).
Pupil involvement takes a number of forms but the most widespread is the use of student councils, present in almost 95 per cent of schools in England and Wales (Whitby and Wisby,
2007). Student councils are a formalised collective forum that uses indirect (representative) involvement to capture student voice. In most schools pupils are elected on the basis of
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form or year group to represent their peers and they meet with staff to express their views and assist with the development and implementation of policies such as the prevention of bullying. Student councils vary in effectiveness and this is often related to the importance that school leaders attach to their role. They tend to be less effective when they lack resources, do not include member training and are largely tokenistic, intended to meet the expectations of school inspectors rather than a genuine attempt to incorporate student voice (Bennett, 2012; Children in School/University of Edinburgh, 2010).
Parental involvement in schools is primarily individual and directly to the relevant teacher, but Parents Associations are widespread, mainly concerned with fundraising. The Coalition government has increased parental involvement in the 2014 OFSTED framework. Parents are invited to fill in online questionnaires under ‘Parent View’. OFSTED draw on parental and pupil views to inform inspection outcomes and, in extremis, parents can trigger an OFSTED inspection (OFSTED, 2014). Coalition government reforms, however, including reductions in the required number of parent governors in Academy schools, changes to the school admissions code and removal of duties on schools to promote community cohesion, may have diminished parental influence. As a trade union official commented:
On paper parents, it looks like, they should be having far more direct influence on what takes place in schools. For example, under this government, they’ve given the power to Ofsted, they’ve given to parents to generate an Ofsted inspection in schools. And that, I think, has been one of the major powers that they’ve actually done. So on paper, given how powerful
Ofsted is, the fact that a group of parents, a school’s got to have an eye on whether the parents are going to generate an Ofsted inspection, you would think has made parents more powerful. And yet what you often hear from parents is, and what we’ve experienced as well ourselves, is an increasing disenfranchisement of parents. I mean, for example when we were doing a lot of the things on academy conversion, the government did not make any specific requirements to consult with parents, saying how that should be done. So in many cases, we were coming across parents who were very anti the academy conversion. But the only consultation they had was to have a letter to tell them that the school was considering
academy conversion (I24).
School governance
Parents, unlike pupils, have a role as parent governors. Governing bodies remain the key forum for bringing together school leaders, parents, staff and community stakeholders to provide strategic direction, hold the headteacher to account and oversee financial performance. Governing bodies often use the school improvement plan as the basis for undertaking their role and also undertake annual or bi-annual surveys of parents, staff and pupils to gain a better sense of the challenges facing the school. With the increasingly diverse school landscape, types of school governing body functions vary, but the overall
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trend is towards increased local flexibility in the composition of governing bodies and increased responsibilities placed on them. The importance of this role is being reflected in the revised OFSTED inspection framework and since 2012, governors are being assessed on how well they support and challenge school leaders.
At the same time major questions are being raised about the effectiveness of school governing bodies in undertaking an increasingly demanding role. In 2013, the Education
Select Committee published a critical report on the role of governing bodies in England. It pointed out that governor vacancies were of concern and suggested that ‘The quality of governance in many schools is also inadequate’ (Education Committee, 2013: 3). A teacher trade union survey in 2014, generated 10,500 respondents about a range of issues.
Although the composition of the sample is not stated, respondents were highly critical of governing bodies:
Teachers are increasingly sceptical about their governing bodies, with more feeling that they do not do a good job (39%)… over half of teachers said they believe that their school’s governing body does not provide appropriate support and challenge to their head teacher.
This has increased by 6% since 2011. More than four fifths of teachers (84%) said that they believe their school’s governing body acted in the interests of the head teacher rather than the interests of the school (NASUWT, 2014: 7).
School governing bodies rely on part-time volunteers with variable skills, availability and knowledge amongst governors. In addition to governing body meetings, governors have key roles in school sub-committees that oversee the governance of pupil exclusions, staff recruitment and disciplinary matters, finance and increasingly the performance management of teachers, since the introduction of performance related pay for teachers.
Governors also often have links with specific departments enabling them to gain a better sense of the work of the school and may see teachers at work in lessons, but governors do not have a role in formal lesson observation (a key part of the performance appraisal process) and on occasions head teachers need to remind governors of the boundaries of their role.
Parent governors may have a good understanding of how a school functions from the perspective of their own child, but this may not always translate this into an effective overview of school governance. One difficulty for many parent governors, especially in larger secondary schools, is connecting to the parent body overall. Parent governors therefore like other governors become very reliant on the information and interpretation of developments as articulated by the head teacher. Staff governors, either teacher or support staff governors, confront related challenges. As staff members they are more integrated into the fabric of their school and can voice the views of staff, but they confront the challenge of aligning their role as a member of staff with their oversight role as a member of
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the governing body. Staff governors are not staff delegates and like all governors have a corporate responsibility to promote the success of their school employer. To prevent conflicts of interest staff governors are excluded from some activities and this can sometimes make staff governors feel less central to the deliberations of the governing body.
Responses of social partners to evolving systems and practice of user involvement
There is a clear recognition 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. 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 that result in less predictable funding patterns for organisations (reinforced by competition between providers) and enable service users to have a direct role in funding and employing staff; as well as tasking providers with being more open and accountable to service users. 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.
In terms of opportunities, NHS employers recognise that only the active involvement of patients, public and staff can bring about changes in the behaviour of patients (such as unnecessary attendance at A&E; lifestyle issues – obesity, alcohol intake etc). Encouraging more individual responsibility is an important motive for increased user involvement. In addition, policy makers are increasingly making the assumption that enhanced user involvement results in a better patient experience (see National Voices). Similarly in schools there has been increased acknowledgment over recent years that enhanced pupil involvement in their own learning and target setting enhances pupil outcomes.
In the NHS, post Francis, there has also been a strengthening of interest in patient quality and the patient experience that incorporates clinical outcomes and patient wellbeing. The extent to which patients feel that staff communicate effectively, exhibit genuine interest in their care, cede some control over key decisions are recognised as issues that require increased attention. NHS Employers also view opportunities for user involvement and coproduction to be more cost effective as voluntary sector organisation respondents noted: the other thing, possibly the biggest thing, is the money thing. So I think policy makers have increasingly started to co-opt a user involvement agenda because they think it is a way to
make the money go further (I30).
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Trade unions
Public sector trade unions identify opportunities in the increased emphasis on user involvement, but acknowledge that membership priorities revolve around the austerity agenda in terms of pay, jobs, restructuring and pensions. Despite these immediate pressures, there is some appetite within trade unions to engage with user involvement. This stems in part from a position of weakness because austerity measures have impacted on the membership and confidence of the trade union. As one official noted:
... the threats are so much greater now than they have been before. So you can’t afford not to… I think, you have to use everything at your disposal whichever side you’re on really.
Whether that’s a community group who uses the trade union’s ability to take out legal challenges or something, whether it’s a trade union working with a community group to
boost a kind of grassroots, ‘non-producer’ interest (I26).
These opportunities were viewed in in two main ways, firstly in terms of organising and campaigning and secondly in terms of member involvement. Reflecting long standing debate within the trade union movement about trade union renewal and coalition building
(Tattersall, 2010; Simms et al. 2013) there is some interest in community organising and community campaigning. Community organising seeks to move beyond the workplace and unite trade unions and community interests to organise on issues of mutual interest, but more narrowly it is intended to increase membership. This is achieved by reaching into communities that are receptive to union membership, in part because they contain workers that have exited from traditional industries (steel, mining etc) or contain ‘hard to reach’ groups such as migrants that work in public services.
Public service trade unions are working with faith and campaigning groups on issues such as living wage campaigns, but these are very diffuse and variable constituencies that can provide only limited support and traction for trade union goals. Community campaigning is viewed as more tangible because it seeks to generate alliances between trade unions and service users on current issues. This can occur at the level of the whole trade union, such as
Unite’s campaigning against NHS privatisation, or can be more localised, for example, against planned service reductions and reconfigurations. One of the most prominent and successful campaigns, resulting in a reversal of government policy, has been the Save the
Lewisham Hospital Campaign, but other hospital campaigns (e.g. in relation to Chase Farm in North London) were much less effective.
Many of the insights of mobilisation theory (Kelly, 1998) illuminate the differences in the effectiveness of these two campaigns. At Lewisham, a sense of unfairness, attribution of blame to the government and a sense that a campaign could alter the outcome were all present, with a strong sense of injustice that the public and staff connected to Lewisham
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hospital were being punished for the financial difficulties (arising from PFI) of another hospital. So both users and workers had an interest in joint campaigns. By contrast Chase
Farm Hospital, consistently labelled a failing hospital could not draw on extensive staff and user support.
The second main opportunity for trade unions arises from encouraging longer-term alliances and linkages with service users groups, although it is recognised that this is not straight forward. This involves encouraging members to become involved in governance structures and institutions of user involvement in health and education, such as becoming staff governors in schools and hospitals. The most common form of engagement with service users is during industrial action in which teacher trade unions have engaged in a more concerted way with parents than was the case in the past.
In some cases these initiatives involve trade unions, particularly in health, reaching out to users and incorporating them within their own governance structures. For example, amongst the professional associations, such as the British Medical Association, a Patient
Liaison Group has been established. Overall trade unions and employers have demonstrated caution in involving service users in their own governance structures, especially in comparison to many voluntary sector organisations. This is to be expected in the sense that many voluntary organisations were established by service users and despite formalisation and professionalisation of management structures, user control remains central to their ethos and governance.
Risks
The social partners also view increased user involvement as generating potential risks. This was an issue that arose less frequently for employers but some employers highlighted costs in terms of time and effort, with little return for the school or hospital. This was more of a concern in hospitals, taking account of the more complex governance structures of NHS trusts. Employers pointed to the increased regulatory costs of health reforms and service user forums, citing as an example, the costs of the Care Quality Commission inspection process that includes lay inspectors and events to gain feedback from service users on local services. In a period of straightened resources some employers expressed uncertainty about the ‘value added’ of broad and shallow local engagement as opposed to targeted feedback and involvement of specific patient groups.
In 2014, the NHS market regulator Monitor (2014b) reported that there are in excess of 2.2 million members in 147 Foundation Trusts, but this does not necessarily equate with providing patients, the public and staff with a meaningful say in how these organisations are governed. Participation in governor elections are low – around 20 per cent of trust members vote – and in a sample of 60 trust elections in 2013, half of all elections were uncontested
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(Democratic Audit, 2014; Simon, 2014). A survey of foundation trusts indicated that the costs of enrolling and servicing members are considerable, but only 13 per cent of respondents considered the impact of members to be ‘strong’ and just over 40 per considered it to be ‘weak’ or ‘very weak’ (Deloitte, 2013: 3). It is important to note, however, that NHS trusts may have failed in terms of enhancing democratic engagement via member enrolment and participation, but the council of governors and other forms of user involvement may still play a role in enhancing patient voice and communicating the patient experience within NHS trusts.
Trade unions also express reservations about the promotion of citizen engagement and service user involvement. First, the emphasis on personalisation in health and social care and shifts towards co-production are viewed positively in principle, but perceived as carrying risks because it can encourage further fragmentation of health and social care. The use of personal budgets facilitates the growth of casualised and low paid employment as budget holders became employers without recourse to effective HR advice and support.
There were also broader concerns about accountability, planning and the representativeness of ‘communities’, exemplified by the growth of free schools. In this type of context the interests of users, or specific groups of users, may be at odds with the interests of trade unions campaigning to safeguard existing (school) provision and models of service delivery.
Trade unions also raised more specific concerns about the consequences for their members of the turn towards user involvement. In the NHS, service users are more involved in recruitment and section within mental health rather than acute trusts. An issue that affects all hospital staff, however, is revalidation. Doctors are required to gather feedback from patients as part of the revalidation process and at present similar proposals are being considered for nurses in the revamping of nurse revalidation.
Service users tended to be most involved in relation to recruitment and selection, appraisal, training and in schools indirectly in pay via the role of governors ‘signing off’ on performance related pay increases for teachers. Many of these developments are viewed positively, for example, user led training. Less welcome are situations in which various forms of service user feedback are viewed as being used and abused by managers to performance manage and discipline staff. This issue has been investigated and analysed in some detail by the NASUWT, concerned that pupil voice activities are being misused by head teachers.
Activities that use pupils to observe teachers teaching, involve pupils in teacher selection, and garner feedback from pupils in a non-transparent manner are construed as disempowering and deprofessionalising for teachers. These concerns are documented in a
2010 dossier of 232 case studies Abuse of Student Voice (NASUWT, 2010). This led to a position statement on student voice in which:
Youngsters making judgements about the suitability for posts and competence in the classroom of those who teach them must be seriously questioned by the profession rather
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than accepted as either a natural extension of the concept of student voice or an appropriate interpretation of it (NASUWT, 2011: 2).
However, although the majority of the case studies raise concerns about student voice, there are some dissenting cases. For example respondent (case study) 226 states ‘student
voice does need regulation but the suggestion that it is widely abused is absurd’. The theme of services users, exerting too much pressure on teachers, however, is also resonant amongst head-teachers with concerns that ‘pushy’ parents may be fuelling a head-teacher recruitment crisis (Boffey, 2011). Other teacher union respondents also were cautious about an enhanced student voice in recruitment and selection processes: with appointments you have to be quite clear about who’s actually taking the decision for all sorts of employment reasons, you need to know who’s involved in the decision. And if there was discrimination or anything else you need to know who’s done it. So we don’t think it’s right that pupils should sit on an interview panel for example, but there’s no problem with teachers meeting pupils beforehand and pupils sort of giving a view or an impression, but I guess one lesson with a pupil isn’t necessarily going to be the be all and end all of you know,
whether someone’s right to be appointed or not (I25).
In summary employers and trade unions are engaging with the service user agenda but have distinctive agendas and these are shaped by the specific context and their members’ interests.
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4: Case studies of user involvement
Urban School
Background
Urban School has a commitment to involving a range of key stakeholders – staff, parents, pupils and governors and this is reflected in it being a member of the Co-operative movement of schools. It therefore embraces the co-operative values of self-help, selfresponsibility, democracy, equality and equity.
Urban is located in a diverse North London local authority and is a large school with over
1,800 pupils. It has expanded since 2011 to incorporate primary school provision to address shortages of primary school places in London. OFSTED rated Urban ‘good’ with some outstanding features in 2012. It employs 267 staff of which 124 are teachers and 143 are support staff and for the academic year ending 31 August 2013 the school’s total income was £13,148,158.
When the Coalition government took office in 2010, the issue of becoming an academy school became a prominent issue and this occurred in 2013. The main forum for executive management is the Senior Leadership Team (SLT) that meets twice weekly to oversee all strategic and operational matters of the school. The main link with governors is via the chair of governors who is in regular contact with the head teacher.
Trade union density at the school is high and in excess of 90 per cent of teaching staff are trade union members (mainly NUT). The main forum for local employment relations matters comprise the Joint Staff Governors Committee (JSGC) in which the recognised trade unions meet with senior managers, led by the head teacher and with a governor present, to discuss and resolve local issues, for example, the revamped pay policy. Relations between school management and workforce representatives are co-operative.
Service users: student and parent involvement
In addition to their involvement in their own learning, students are involved at Urban via the
Student Council that includes student leaders, peer nominated representatives of each year group and an assistant head teacher. The Student Council feeds back on: teaching and learning matters; school regulations, such as uniform rules; and has an important role in tackling bullying and encouraging high standards of behaviour. The Student Council can highlight staffing matters of concern. For example, when the School was using temporary
(agency) maths teachers because of shortages this was raised at the Student Council.
Student feedback is also obtained in the recruitment and selection process after candidates have taught a lesson as part of the selection process. Groups of students also meet with candidates applying for senior roles and ask questions of them. Students are not formally
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included in appraisal-related lesson observation arrangements, but some subject leaders use focus groups to gain feedback on teaching as well as looking at student books.
School-wide there are two main mechanisms for parental involvement: the Parent Council organised by the Parents Association and parent governors. Secondary schools are large organisations and interaction with parents is systematic but limited and there is a group of hard to reach parents that are difficult to engage, sometimes because they had bad experiences themselves at school. Targeted initiatives have been pursued, for example, inviting groups of parents into school for additional support for those parents whose children need more assistance, establishing a Somali parents group and arranging free counselling for parents with challenging children, although the uptake for the latter initiative has been limited. Urban employs three Parent Support Advisors (who do not teach) but are employed to support students, parents and staff to maintain high standards of behaviour and attendance – the school has a target of 96% student attendance.
School Governance: the role of governors
School governing bodies have overall responsibility for strategic direction, financial and managerial control of schools and holding the head teacher to account for the educational performance of the school. Governors have a series of supplementary roles in determining how a school’s budget is spent, appointing and dismissing staff; setting targets for the head teacher; serving on panels that hear appeals from students and staff, and devising and monitoring school policies across a wide spectrum of activities.
The fifteen person governing body of Urban comprises a mixture of parent governors (5), partnership and community governors (6), staff governors (2), local authority governors (1) and the Head teacher (1) and there is a clerk to the Board. The chair of governors is selected by the board on an annual basis and usually comes from the parent constituency. Three key issues that governors have been involved in, illustrate the connection between stakeholder and workforce involvement and the impact on school governance. These relate to academy status, disciplinary issues and pay and performance management.
Conversion to academy status
Urban as a Foundation School already had considerable managerial autonomy compared to maintained schools even prior to becoming an academy. The head teacher and governors were not ideologically committed to academy status but anticipated financial advantages from academy status, but also recognised staff opposition would arise, not least because trade unions were pursuing a national campaign opposing academy status.
Consequently discussions were held with staff representatives that pushed for guarantees that staff terms and conditions would not be altered and that that there would be a ballot of staff and parents. It was agreed that there would be no local changes to pay and conditions, even for new staff, and it was written into the constitution of the academy that the
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governing board can only alter terms and conditions of employment if 80% of the entire governing board support such a change. Although not obligatory a parent and staff ballot was held with a large majority amongst staff opposing conversion to academy status, but the result was open to interpretation:
One is that staff were genuinely against academisation …the second interpretation the staff were not particularly against academisation on principle but they were worried about their pay and conditions. The third argument is that they were voting that way in order to strengthen the hand of their union negotiators to get the best possible deal for staff post academisation. There was also a parental ballot and perhaps not surprisingly the turnout
was much much lower (I9).
Conversion proceeded in 2013 and neither staff nor governors could point to any significant changes as a result of academy status despite the concerns that it had engendered. Pupils and parent governors played an important but limited role in the discussion of conversion to academy status and did not question the decision to seek academy status. Despite the staff ballot even staff governors did not oppose academy status for three main reasons. First, staff and other governors argued that their responsibility as a governor was to act as individuals in the School’s best interests, they were not appointed just to act on behalf of their specific staff constituency. Second, they viewed trade union channels as the most appropriate and influential channel to deal with staff issues and that the governing body was not the place to address detailed staff concerns. Third, more generally, it was argued that it would be unfair to management and ‘stabbing them in the back’ to take staff related issues directly to governors.
Staffing matters: staff and student discipline.
A second main area of activity relates to staffing matters. Governors are routinely involved in the recruitment and selection of senior staff but their main role relates to staff and especially student discipline. Staff disciplinary matters, including dismissal recommendations, require governor approval. A panel is convened with trade union and legal representation, but in practice serious disciplinary matters are rare. More prevalent are student disciplinaries and three governors must sit on a panel if a 10 day or permanent exclusion is being sought. As a large school Urban has around 100 exclusions per year of which around 5-10 per cent relate to permanent exclusions. Governors invariably support the head teacher’s recommendation but governors have an important role in ensuring procedural fairness and making sure cases are well prepared. The school, however, faces difficulties in getting sufficient governors to serve on panels during working hours at relatively short-notice.
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Pay and performance management
Governors have an important role in pay and performance management because from
2013-14 a system of performance related pay is in operation for all teachers. To gain more than the national award, teachers are required to achieve their appraisal objectives and each appraisal report includes a pay recommendation. Each member of staff is set three objectives relating to achievements in teaching, linked to an attainment target for specific groups, a management target and a ‘softer’ professional development target. Data (pupil attainment) and lesson observation by line managers is used for the appraisal process. The senior leadership team reviews all recommendations with final decisions made by the governing body that has delegated the key responsibilities to the governor that chairs the pay committee. The Chair examines a sample of appraisal/pay decisions, especially the most contentious, and signs these off with the Head teacher before reporting decisions (i.e. broad distributions rather than individuals) to the governing board. Amongst teachers, the explicit link to pay is novel and there has been considerable uncertainty and anxiety amongst teachers about the process with the first cycle concluding by the end of 2014. In practice, only a small number of teachers did not obtain performance increases, although some may not have applied. Governors did not dispute any management pay recommendations, but these changes still enhance key governor’s role in the oversight of pay and performance management arrangements.
Discussion
A prominent issue in the case study relates to the role of the governing board in bringing together the interests of service users, staff and the school’s leadership to maintain excellent standards. The role and responsibilities of governors and governing boards are increasing as more schools become academies and OFSTED increases its emphasis on effective governance, but difficulties remain that limit the contribution of school governors.
First, there is the context in which governors operated. This comprises a complex and rapidly evolving educational landscape in which government policy alters frequently and governors are not always full aware of the implications of current government policy and practice, highlighting the importance of ongoing training and development. Second, governors are unpaid volunteers and this places constraints on the time that they have available for their role, the expertise they possess and the confidence with which they approach the role. The dilemma for the head teacher was that governors are: enthusiastic amateurs…your most able governors probably have least time. Your most
available governors are probably your least expert (I13).
Urban’s governing board recognised the importance of developing a clear set of expectations and standards for governors that were then then managed collectively by the board on matters such as attendance and participation in training activities. Related to this
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is the importance of realistic job-preview in which governors gain a clear understanding of what the role entails including its time commitment.
In recent decades government policy has emphasised that alongside traditional forms of employee voice and staff involvement, service users – parents, pupils and governors should have a greater stake in shaping workplace developments leading to empowered users and higher standards. These aspirations are certainly evident at Urban, underpinned by commitment to the Co-operative movement’s values, reflected in concerted attempts to involve students and parents in the life of the School.
Public policy support for enhanced user involvement is reflected in attempts to encourage parent, student and community involvement and these are well developed at Urban, despite barriers in involving ‘hard to reach’ groups. The one constituency that few governments have sought to involve more fully over recent decades has been the teacher trade unions. Ironically, however, their membership remains high and certainly in dealing with the concerns of staff about the shift to academy status, they had the most direct impact in safeguarding staff terms and conditions of employment.
Nonetheless, Urban like other schools is a complex organisation, managed by full-time professional staff who are publicly accountable for achieving demanding central government targets. Government policy over recent decades has increased the responsibility and influence of head teachers and policies such as performance related pay are simply a further iteration of attempts to reinforce managerial influence in shaping staff expectations and performance standards. It is therefore not surprising that although students, parents and governors can express voice in these managerial times the buck stops with the head teacher.
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City Hospital
Background
City hospital is a very large city hospital trust with more than 9000 staff split amongst several sites and providing acute services and some specialist services to a large catchment area in the South of England. It confronts similar challenges to many other NHS Trusts with rising demand for its services, especially in terms of emergency admissions, challenges in recruiting and retaining staff, necessitating high agency nurse costs, whilst at the same time it is required to generate ongoing efficiency savings and enhance quality standards.
Its governance framework comprises three elements a board of directors, a council of governors and members. The board of directors has overall responsibility for the strategy, performance and activities of the trust and is answerable via the trust chair to the Secretary of State for Health. It comprises executive and non-executive directors, the latter are appointed by the Council of Governors for a four year term and the governors also have the power to remove non-executive directors. The main organisational unit is the division that includes clinical and non-clinical with divisions headed by a clinical manager and other key departments include corporate affairs (that leads on patient and public involvement), finance, workforce, estates etc. There are series of key trust-wide committees replicated at lower levels within the organisation and include committees relating to: patient safety, quality and performance.
Second, the Council of Governors comprises 34 predominantly elected members drawn from patient, public and staff constituencies. Public governors, are the most numerous group (13) and are organised by locality, and there are also patient governors (six) and staff governors (six). The latter represent the main occupational groupings – medical and dental staff; nursing and midwifery, support staff, administrative staff and para-medical staff.
There also appointed stakeholder governors that include several local authority representatives and partnership organisations such as local university representatives as well as a governor from the trade union staff side organisation.
The council of governors has four main sub-committees: Membership and Community
Engagement that focuses on ensuring a representative and involved membership, Patient
Experience and Safety concentrating on the patient experience; the Strategy Committee that reviews City’s strategy and business plans; the Nominations Committee oversees the appointment of the Trust Chair and non-executive directors, making recommendations to the Council of Governors. Governors receive induction following election and there is a buddy scheme for new governors.
Patient feedback and Involvement
The Trust has a lengthy history of seeking patient feedback on the services they provide.
This predated national initiatives such as the ’Friends and Family Test’ and originated in
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concerns about Trust performance. An emphasis on customer feedback was reinforced by successive chief executives that had experience in the private services sector and put considerable emphasis on user feedback. The response of staff was largely defensive and negative with concerns that it would simply encourage complaints and there was much significant questioning of the reliability and validity of the survey instruments used. The response of senior managers was to embed patient feedback into the trust’s performance framework and to refine further patient feedback mechanisms. This included looking at the experience of other organisations such as Virgin, Tesco and Sainsbury’s and leading NHS
Trusts such as the Royal Marsden at how they encouraged excellent service and embedded these values into the behaviour of staff. In addition the Trust pursued a policy of transparency and openness with all results published that encouraged a culture of competition and peer pressure to improve results.
By 2014 the system that evolved to incorporate the FFT test (whether or not they would recommend the ward or A&E to friends and family if they needed similar care or treatment).
The implementation of the FFT during 2013/14 raised some challenges because in terms of resourcing it was not felt possible to undertake FFT and continue all the existing internal survey work undertaken as part of its ‘How are we doing’ patient experience work. In addition the Care Quality Commission undertake annual surveys of a random sample of patients for inpatients and maternity series and during 2013 the Department of Health commissioned an additional national survey relating to experience of cancer services. The trust also collects written comments and suggestions for improvement with feedback analysed by location and department and responses are categorised by patient/carer/visitor/trust member/member of staff. The trust aims for and predominantly achieves a response rate of 50 per cent.
The trust has a dedicated patient experience team that sits under the director of corporate governance and prepares the analysis. Each month a Patient Experience Report is prepared
(quarterly for the Board) that is reported by trust level, divisional level and ward level and comments are included on an anonymised basis. The data and comments are considered at divisional level and it is the responsibility of the divisional manager to address issues that may also be addressed at divisional performance meetings. It is acknowledged, however, that the responsibility for follow up lies very much with individual divisions, although the establishment of a trust wide lead clinician for the patient experience is expected to enhance further the profile of this activity.
The trust also undertakes extensive analysis and coding of complaints and the whole complaints procedure was reviewed and an action plan established in the light of the Francis
Report and the subsequent Clwyd and Hart (2013) review of NHS complaints. A serious complaints committee was established chaired by an NED and complainants were invited in participate in listening events. Post Francis the trust has placed much more emphasis on qualitative patient feedback and invested substantially in mainstreaming Patient Stories.
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These are frequently videoed and shown at the start of senior team meetings and generate lively discussion and empathy amongst staff. As the use of patient video stories has increased it has become much more normal and embedded within trust practice.
The trust has been less effective in mainstreaming patient voice within its organisational and governance structures and the main emphasis has centred on the involvement of trust members and governors. By contrast there has been limited support amongst senior managers and clinicians to involve patients within key committees and forums within the trust. For example, the Patient Experience Committee does not include lay patient representatives beyond governor representation. There is a tendency to assume that the presence of a governor on a committee is a sufficient form of involvement. Staff argue that their inclusion would compromise the openness of the discussion and issues of patient confidentiality also arise. There is also a sense that the Council of Governors has colonised the patient voice space and this is viewed as both helping and hindering scope for more embedded patient voice.
Patient voice in governance structures
As a Foundation trust City has a membership of almost 21,000 members with approximately
3,100 patient members, 7,900 public members and 9,900 staff members. Residents of the locality are eligible to be public members, patients treated in the previous 6 years are eligible as patient members and staff are also automatically enrolled as members. City maintains a data base that identifies the age, gender, ethnicity and seeks information on the level of involvement sought and the service(s) (cardiac, renal, elderly etc) that the member has an interest in. The membership is reasonably representative of the communities served, with the exception, like most trusts, of having few young members. The trust sends members a newsletter about the trust, organises bi-annual community meetings and annual meeting and this provides opportunities for members to meet governors and to have their say on issues such as discharge planning and the trust’s annul plan. Members are also used as a resource by the trust, for example, following training members participate in administering surveys (e.g. on food quality) on the wards and many volunteer in a variety of capacities.
The trust faces some tensions in managing it membership because servicing its membership requires considerable resources and time. Trust governors favour increased membership because they perceive themselves as akin to Members of Parliament with their own constituencies and governors associate larger constituencies with increased authority and legitimacy. Trust managers, however, are more concerned with the quality and representativeness of the membership rather than the quantity of members and are seeking to manage the costs of the membership base. The trust plans to move towards different categories of members, facilitating different levels of membership and engagement.
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The council of governors (COG) meets four times a year and run their own sub-committees.
The governors have a role as the voice of the patient and as critical friend and make a valuable contribution by challenging executive and non-executive directors. Many governors also bring the public and patient perspective to bear on trusts business, for example, by membership of procurement panel and the serious complaints committee. Governors also undertake a range of activities to promote the trust. At the same time, there is a degree of wariness about the role they fulfil. This is exemplified by the fact that governors can only attend the open (public) part of trust board meetings and the private (confidential) minutes of board meetings are not shared with governors, even though they all sign confidentiality agreements. This is in contrast to the practice in some - not all - NHS trusts and is a decision that is very unlikely to change. There is a tension between the elected COG and the appointed non-executive directors, reflecting inherent tensions within the foundation trust governance model and in addition servicing the COG and individual governors is time consuming for senior managers.
The role of staff governors is viewed as quite difficult because six staff governors are required to represent the whole workforce and the role is little understood by most staff, resulting in limited interest in standing as a staff governor. Nonetheless staff governors played a valuable role. For staff, their governors gained access to the chief executive and trust chair in a manner that was not replicated for staff side representatives within existing social dialogue forums. Staff governors were also able to bring insights from the workplace in a way that eluded patient and public governors. Staff governors became involved in a far wider range of activities than the much narrower agendas pursued within staff side union machinery.
Discussion
At City trust in a similar fashion to many NHS trusts, user involvement has gained a much higher profile than a couple of decades ago and the patient perspective is much more integrated into trust policy and practice. The most prominent component of end user involvement is the emphasis on gaining feedback about the experience of patient’s in terms of the clinical and non-clinical aspects of their experience. This data is collected systematically and fed back on a regular basis to staff, governors and board members at all levels in the trust. The government’s introduction of the Friends and Family Test may curtail some of City’s existing emphasis on user feedback as it redirects its attention to meeting the government’s FFT requirements. In addition and partly prompted by their response to
Francis, much more emphasis has been placed on capturing patient stories and feeding these back to staff. The particular model of user involvement, focused on service user feedback and the role of governors is separate from workforce representation through the
Joint Negotiation Committee (JNC) structure. In comparison to the school case study, there is no systematic trust-wide involvement of service users in recruitment and selection, appraisal or training, although service users do contribute to these activities on a local basis.
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City is also extending the work that it is undertaking on City values that include listening
(understand what matters to you); inspiring confidence in the care given, working together, aiming higher, and making a difference to the community. These values are increasingly being underpinned by behavioural statements that require evidence within the appraisal process, ensuring tighter integration of user feedback and staff performance management over future years.
Overall, the trust draws on a customer orientated model of involvement and has drawn on private sector experience to refine its approach. It has been much less proactive in engaging with service users and encouraging their involvement and participation in shaping service delivery. This stems in part from the nature of acute services in which many patients have a short-term and transitory involvement with the trust, but even amongst long-term conditions there is limited patient participation compared to some NHS trusts. This is attributable not only to the customer orientated model used but also to the role of the governors that have been viewed as the main vehicle for involvement and feedback in ways that both advance and curtail other forms of user involvement. Governors are viewed as critical friends, making a valuable contribution to the trust, but because their feedback can be challenging in some parts of the trust there is some reticence about increasing governor involvement. Staff governors bring a distinctive perspective to the CoG but the limited familiarity with the role amongst the workforce and the size of the organisation places constraints on the extent to which staff governors can represent the interests of staff.
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5. Conclusions
Service user involvement is attracting high-level policy interest in many global jurisdictions
(OECD, 2014) as governments alight on forms of user involvement and person-centred care as a key means to square the circle of providing more cost effective and high quality public services in ways that empower and liberate users. In the UK, putting the patient or pupil first is a very prominent component of the public services reform agenda and has moved from rhetorical aspiration towards institution building and embeddedness, but this agenda is still in its infancy as public sector employers and trade unions grapple with more immediate pressures arising from budgetary restraints, rising demand and the challenge of meeting government targets.
The mainstream political parties have engaged strongly with an agenda of putting the citizen at the centre of public services reform. For the Prime Minister David Cameron, it has been grounded in a narrative of voluntary action, mutualism and social entrepreneurship, initially badged as the Big Society whilst for Ed Miliband, the Labour Party leader there is a shift away from managerialism and ‘the untamed state’ towards an emphasis on user voice with concrete proposals to empower parents and patients (Miliband, 2014) as part of a shift towards the relational state (IPPR, 2012).
Service user involvement is therefore a significant public policy issue and has informed the reform of organisational structures in health and education (governance arrangements in foundation hospitals, establishment of free schools etc) and the establishment of institutional mechanisms in health and education (NHS Citizen, NHS Constitution, Friends and Family Test, student councils etc). The challenge is that many of these reforms are incoherent, cut across each and have been established in different time periods with distinct policy goals in mind. Significant barriers remain in shifting user involvement from policy aspiration and nascent institution building towards mainstreaming. As a voluntary sector patient representative commented:
Certainly there seems to be a willingness to involve patients much more now, put patients at the centre which is very much the rhetoric. We want to see that happening in reality more I think. Still I think often it’s an afterthought, involving patients too late. But there certainly is a shift and that’s been very good for us to see (I23)
Many of these barriers confront the social partners and impact on their willingness to assign a higher priority to user involvement. The diversity of terms used and their varied meanings has held back support for and the implementation of user involvement because the lack of clarity hinders advocates of this agenda. Despite these difficulties the overwhelming sense from respondents is that service user involvement has a legitimacy and acceptability that was not the case a decade ago. This recognition, however, is only been partially accepted by the social partners that have not incorporated it fully into their policy activities.
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User involvement is challenging to the social partners. They operate within organisations that are structured along managerial-professional axes in which influence ebbs and flows between two dominant groups – managers and professionals that traditionally have been viewed as the dominant and legitimate actors within hospitals and schools. Service user involvement provides explicit recognition that a third actor – the service user has a legitimate stake in shaping organisational practice – and whose needs must be addressed and satisfied. This challenges both managerial discourses that managers are the key custodians of the organisations they lead and professional discourses that professionals invariably act in the interests of service users. Consequently, whilst both groups recognise the potential and value added of service user involvement there is a concern that service users may be enlisted by policy makers, politicians (and employers) to supervise and redirect managerial and professional agendas.
Employers and trade unions acknowledged these concerns and also highlighted the ambiguities surrounding user involvement and this influenced how they and their constituents responded to user involvement. There is considerable uncertainty and a variety of competing policy agendas and priorities that are combined together and labelled as service user involvement. In practice this covers a wide and relatively diffuse agenda and this makes it challenging for employers and trade unions to identify priorities and appropriate models that will advance user involvement in ways that align with their interests. In a period when evidence based policy is the mantra there is an uncertainty about evidence and outcomes, enabling critics to discount the value of user involvement.
Employers have to gauge how far policy pronouncements are considered part of their core mission or are ‘worthy’ additional activity that can be ‘ticked off’ by relatively superficial initiatives. Whilst local responses vary from the highly committed to the tokenistic, in general both hospitals and schools are driven by targets and inspection and it is in the areas where clear targets exist, and policy agendas are prominent (focused on the patient experience) and the Friends and Family Test, that employers have concentrated their efforts, but this may lead to reduced emphasis on other forms of user involvement.
Consequently in Arnstein’s terms the dominant position is one of placation although there is some variation between sectors and organisations that reach into areas of partnership, but also towards less influential consultation.
In health employers in the acute hospital sector are focused on the patient experience which is a catch-all phrase that is centred on patient safety, quality and governance.
Employer’s are receptive to enhanced patient voice not as an end in itself in terms of
‘empowering’ users but as a means to enhance the patient experience and also assist in efforts to be more cost effective (e.g. by reducing hospital admissions). NHS employers are also seeking to ensure that staff adhere to values and enact behaviours that enhance patient care. Employers therefore are seeking to co-opt user involvement as a complement
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to broader agendas of service and workforce change. In schools, user involvement is a less prominent concern, reflecting the more informal ways in which feedback and involvement can be obtained in smaller organisations with a more long-term relationship with its main service users (pupils) and also the absence of high-profile failures that have confronted the
NHS. Employers, and headteachers, however, are alert to the importance of school governance, and the potential contribution of governors to school effectiveness.
Trade unions share much of this agenda and have also 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. For trade unions additional challenges arise because in general health and education trade unions have opposed foundation trusts and academy schools. Although this opposition is more muted than in the past, this stance leaves a legacy of distancing from these reforms, discouraging trade unions from actively encouraging membership engagement with school and hospital governance structures. Trade unions have therefore only sporadically 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, there are additional reasons why the social partners view user involvement with some indifference in terms of the direct impact on social dialogue. 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 and the links between user involvement and influence and social dialogue processes and practice continues to develop and evolve. In this evolving policy context, social partner indifference and lack of engagement with user involvement, especially on the part of trade unions, could prove to be short-sighted and a missed opportunity to combine enhanced workforce influence and to improve the responsiveness and quality of public services.
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Appendix 1: A note on Methods
This report is based on primary and secondary data collected between January and
December 2014. During this period 32 interviews were conducted with key respondents.
Excluding EU level interviews, 26 interviews were undertaken in the health and education sectors in England. In several interviews more than one respondent was present. Three main groups were interviewed. First, predominantly national level employer and trade union representatives whose role extended beyond traditional employment relations to include some responsibility for user involvement policy and practice in their organisation.
Second, interviews were conducted at workplace level with managers, union representatives and governors within the case study organisations. Third, interviews were undertaken with voluntary sector organisations that provide services and/or lobby for enhanced user involvement in the health or education sectors. Typically interviews lasted between 50 and 90 minutes and with one exception were digitally recorded and fully transcribed. Finally, fieldwork also included attendance at user involvement events in the health sector, including CQC public events prior to hospital inspection and public events for trust members at selected NHS trusts.
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Appendix 2: Examples of user involvement in the health and education sectors
Forum
Trust
Board:
Foundation
Trusts
Trust
Council of
Governors:
Foundation trusts
Sector
Health Single employer
NHS
Trust
Health Single
Employer
NHS
Trust
Healthwatch Health
Level
Locality:
Local authority
Status/ constitution and rights
Members: staff; users mandatory Corporate:
Exec/nonexec directors
Mandatory Mostly
Elected: staff, patient, public (+ stakeholder
- appointed not elected )
Mandatory Members not required
How elected
(and term)
Not
By trust members
What info provided to them?
Corporate
Public
Information
(they also have their own committee structures)
Appointed Information from local providers; own data generation
What issues can they address?
All
Patient experience issues and approval of some key decisions e.g. trust mergers
Local health issues of concern to local citizens varies User groups Health Service or condition specific
Governors Ed: school
Employer level
(school) varies – mandatory in maternity services varies
Mandatory Academies:
Parent, staff and community not
Parent
Association
Ed: school
Employer
Level
(school) voluntary but almost universal
Parents varies some elected: parents, staff; some appointed
Elected corporate varies – links with parent governors
Student councils
Ed: school
School voluntary: but very widespread
Mixture of staff and pupils
Mainly elected;
Varies all - but much work is carried out by subcommittees
Limited: events; fundraising
School policy
49