Utrecht June 6th 2014Research Partners Meeting

Service User and Workforce Involvement: The UK

Stephen Bach King’s College, London

Stephen.bach@kcl.ac.uk

With financial support from the European Union

Service user Involvement • Role of user involvement:

- many agendas – reaction against targets & markets- Coalition government: choice and voice

• Peripheral actors (parents/pupils/patients) mainstreamed- altered roles and expectations of actors - growth and influence of regulatory actors

• Components:- legitimation from above – government policy empowering and punitive e.g. parental responsibility- altered forms: individual v collective - responses of actors – employers and trade unions

Education v. Health Strong impetus in Health

• Potential impact on all citizens (compared to schools):- scale, service diversity, priorities

• Rich legacy of campaigning/advocacy organisations- Community Health Councils (1974 – 2003)

• NHS:- democratic deficit- professional dominance/hierarchy - NHS pivotal to future structure/role of welfare state

• Scandals…

Equity and Excellence: Liberating the NHS (2010)

• We will put patients at the heart of the NHS, through an information revolution and greater choice and control: a. Shared decision-making will become the norm: no decision about me without me.

• Choice of provider and reformed patient voice

• The health and social care system is not so good at listening. That is the lesson of Mid Staffs, Winterbourne View and Morecambe Bay. It is why the consumer or user is now being put centre stage and why Healthwatch has been created. It is time to do things differently. (Healthwatch annual report 2013: 6).

Forms of Involvement Industry level

• Pay determination (pay review bodies):- reserved for social partners - indirect link implementing Francis and 1% pay increase our first priority must be to ensure that the NHS can afford to employ the right number of frontline staff needed to ensure the safe, effective and compassionate care that patients have a right to expect [recommendations] are unaffordable and would risk the quality of patient care. (Health Minister, March 2014)

• NHS social partnership forum: - workforce consequences: whistle blowing

• Need to consider impact user involvement on the employment relationship not just social dialogue

Governance: Organisational stakeholders

Pupils, patients, parents, staff

Regulation/Inspectione.g. Ofsted; Care Quality Commission

NMC

Campaigns/Alliancessingle issue

campaignersTrade unions Local groups

Forms of involvement: Moving beyond direct v.

indirect

Governance in flux Hospitals and Schools

• Variable levels of formal autonomy:- academies: admissions, staffing, board composition

• Structure: - Foundation Trusts two-tier boards: governors not NEDs- Academy schools: usually single-tier - governing board

• Membership – different types of governor:- schools: parents, staff, community (LA/experts) - hospitals: patients, staff, community governors

• Appointment process –mixture election/appointment

Remit • Context: executive managers; centralised accountability

• Foundation trust hospitals:- can remove trust chair and NEDs- ability to challenge executive – don’t attend main board- specific difficulties of staff governors

• Schools: - appoint head teacher; performance manage head - staff governors - less central role? - parent governors - shortages and capability

Governance:Pupil voice

• School councils: >90% schools (voluntary)e.g. anti-bullying policy; fund raising; school meals

• Lesson Observation (NASUWT, 2013)‘meaningful lesson observation can only be undertaken by adults who are suitably qualified’ ‘Legitimises criticism of teachers’

• Staff recruitment: inappropriate to seek ‘the view of pupils on the relative merits of an applicant’s teaching’

• Consequences.....

2007-08* 2008-09* 2009-10* 2010-11* 2011-12 2012-13130230330430530630730830930

1030Nurses: Number of new referrals made

by public 2007-13

Member of public, service user or patient

* 2007-11 data refers to ‘public’ only; 2011-13 data to ‘member of pub-lic, service user or patient’

n

2007-08* 2008-09* 2009-10* 2010-11* 2011-12 2012-138

10

12

14

16

18

20

22

24

26Percentage of referrals made by public of

total 2007-13

Member of public, service user or patient

* 2007-11 data refers to ‘public’ only; 2011-13 data to ‘member of public, service user or patient’

%

48%

18%

13%

7%

14%

2011-12

Striking-off ordersSuspension orders Caution orders Conditions of practice orders Fitness to practise impaired – no sanction Fitness to practise not impaired

43%

18%

12%

12%

16%

2012-13

CCC and HC final adjudication outcomes

Responses of Actors • Employers: emphasis on patient experience

- workforce: values based recruitment/selection - service users as adjunct to performance management

• Service user involvement/alliances higher profile:- TUC work on co-production - lower priority than pay, jobs, austerity....

• Issues:- personalisation/personal budgets – casualisation - localism/communities: inequalities and accountabilities - must complement not erode collective voice

Consequences Responses of trade unions

• Governance: engage with new structures and institutionse.g. Foundation Trust (staff) governors

• Community campaigns v. community organising

• Community campaigns:- hospitals; station (rail) closures

• Issues:- effectiveness dependent on local factors e.g. Lewisham - NGOs: reluctance to be political ‘campaign fodder’ - service user criticism of workforce

Community Organising(See Wills 2013)

• Drivers: - limited results of organising activity - austerity – membership losses - overcome producer interests label

• Focus: Beyond the workplace

• Influence of Citizens UK:- Living wage campaigns

May 2010

(3 days before the election)

Community organising • Investment in community organisers:

Unite – 9 community branches ‘This is the real Big Society – ordinary people organising for themselves – in action’ Unite general secretary

• Unison, PCS (Living Wage) ad-hoc campaigns

• Challenges:- different aims (membership v. influence)- distinctive governance structures- beneficiaries? visibility/resources

Discussion • Tensions exist between user and SP involvement:

- differing aims, constituencies, funding

• Trade unions: - union decline may foster openness to new strategies - if public service users view services as producer dominated/self interested alliances are fragile/limited

• User involvement is increasing in importance in public services but more breadth than depth- shifting channels of ‘voice’ individualised via complaints

• Institutions are sticky: respond more slowly than actors

Coalitions - conditions:1. Shared concern & goals

2. Organisational capacity

3. Opportunity structures to change policy/practice

Employers (a)

Trade unions (b)

Service users (c)

Community coalitions (b + c)

Partnership [insider]coalitions (a +b)

Performance coalitions (a + c)

Grand Coalitions