the manager’s positive involvement in user consultation will make a major difference to the way it happens (Connelly and Seden, p42)
To discuss a subject is to examine it in detail or by disputation (Chambers, 1981). Charges have not unreasonably been levelled at the notion of user involvement as tokenism and of insincerity paid (Townson and Chapman, 2003; Leason, 2004). A report by The Sainsbury Centre for Mental Health declared that service users continue to feel uninvolved (Lipley, 2001). In different areas of care managerial initiatives to make user involvement central to a service may be more enthusiastic than others (Lipley, 2001), and for the purpose of this essay the area of mental health care will be used as the forum in which consideration of the topic will be made.
User involvement must be considered separately from consultation (Townson and Chapman, 2003). User involvement is the active participation in and direction of services (Beresford and Croft, 2003). Consultation on the other hand can mean different things to service users and to managers (Hickey and Kipping, 1998). To the former it is the active engagement of their views and experiences in order to develop the service – in the latter case it can mean a superficial method of pretending that users views have been sought and acknowledged (Beresford and Croft, 2003; Townson and Chapman, 2003). Some users report with despondency that they expect managers to disregard their views in the planning of a service (Connolly and Seden, 2003; Leason, 2004).
In fact, the topic for discussion assumes that user involvement and consultation are to be made central to a service. A plethora of directives from central government emphasizing the important role of service users and their carers in planning care services (Hickey and Kipping, 1998; Townson and Chapman, 2003; Beresford and Croft, 2003; Walker and Dewar, 2001), is not to be ignored. For Mental Health this is such initiatives as the National Service Framework for Mental Health (Department of Health, 2000), Modernizing Mental Health Services (1998) and Clinical Governance (RCN, 2003). National strategies inform corporate ones; and it is the role of the manager, whose role among many is as a form of filter between all interested parties (Aldgate and Dimmick, 2003), to drive the development of a service, so integrating the service user’s experiences and needs yet at the same time working according to corporate strategy.
Service users are increasingly becoming involved in the training and education of mental health workers (Beresford, 2003; McAndrew and Samociuk, 2003). Not only a raft of government legislation but also mental health service users’ lobby groups such as MIND (MIND, 2000) and Rethink (Rethink, 2002) strongly advocate for the direct involvement of service users in the planning and provision of care. One individual service user describes her struggle to be heard (MIND, 1999), a not uncommon experience (Connolly and Seden, 2003).
It can therefore be said that there are two main reasons for the implementation of user involvement and consultation being made central to a service. As well as the directives of central government, on a perhaps far more personal level is the idea of common humanity which informs care (Brechin in Aldgate and Dimmick, 2003), and the sense that those who use the service are in fact ‘just like [us]’ (Aldgate and Dimmick, 2003, p.8).
In order to make user involvement and consultation central to the service users themselves must be involved in varying and important ways – in one example (Connolly and Seden, 2003) service users drive the way in which evaluation was made of the project, they participate in steering groups with quality managers, canvass the views of service users, formulate questionnaires which makes sense to fellow service users, and are closely involved in training and service monitoring. Another report on the same project observes how service users initially encountered resistance from the service provider, but that the deployment of an independent evaluator gained the organization’s confidence (del Tufo, 2000).
Service user consultation also informs developments and improvements to a service. The input of many different sources necessarily involves flexibility and commitment (Connolly and Seden, 2003) in order to make it work. Consultation must not merely be a management exercise (Townson and Chapman, 2003).
Service users require motivation to participate in such initiatives, and ensuring access to involvement might mean practical support for people such as the provision of transport or of childcare, for example (Beresford and Croft, 2003). This might also mean presenting service users with the opportunities to develop themselves, such as opportunities for training and assertiveness. It is not unreasonable, for example, for service users to be recompensed for their involvement, say in the form of say travel expenses (Beresford and Croft, 2003). Occasionally this may even mean the payment of a salary (Read, 2003). Professionals and service users express themselves differently (Leason, 2004), so it is important for a manager to ensure that service users are not disempowered by the use of professional language which emphasizes the power base of a group (Holland, 2000). Many service users may find large groups intimidating (Leason, 2004).
Service users can be central to the process of staff selection (Beresford and Croft, 2003), for example forming separate interview panels or having a presence on interview panels alongside other care professionals.
Partnership is another essential means of how a manager can make user involvement and consultation central to the service. One advocacy worker describes the importance of strategic partnership with other groups and organizations in the field (Open University, 2003b). For some this necessitates a shift in culture and understanding. Calpin Davies (2004) describes the idea of partnership aimed at developing a service as “mutual investment” (p4), but emphasizes that traditionally the advantage in such partnerships has been to the service provider. It is the role of the manager to ensure that all parties are clear about their roles within the strategic partnership, and to keep all parties onboard (Open University, 2003a).
An important strategy in making user involvement and consultation central to a service is to involve staff. This can range from involving them in day-to-day working and decision making and cascading information to your staff team (Open University, 2003a), to facilitating opportunities for personal and professional development. Hickey and Kipping (1998) suggest that health care workers themselves need to feel empowered in order in order to empower users of the service. Such issues as training and support, openness, and staffing levels which enable staff to spend time with service users, are an indication of the level of commitment an organization has to put user involvement and consultation in place (Hickey and Kipping, 1998). The budgetary resources must be made available.
The notion of partnership can be taken to a more intimate level and seen in terms of relationship (Calpin-Davies, 2004), since partnership has an important human, face-to-face level. This will involve people skills (Woolf, 2002), for which a manager must be prepared. It is also vital for a manager to be fully aware of how many users of mental health services tend to be socially disempowered by reason of their mental health difficulties and the expectations of society as a whole (Dunn, 1999).
All of this needs to be placed within the context of existing budgets. The extent to which users can influence more strategic decisions in publicly-funded organization can be restricted (Hickey and Kipping, 1998). In many cases, agencies which act as purchasers of services are accountable for the ways in which resources are allocated. This means that such organizations retain their power in strategic decision-making, even though users of the service can be consulted when a strategic decision is made. Occasionally these decisions may limit the choices for users at the level of delivery of a service. In reality this might mean for instance that a service user is not able to access a day care facility because the purchasing authority does not have a contract with the service provider (Hickey and Kipping, 1998).
Service users must feel included from the start (Leason, 2004). In fact the process of consultation or of user involvement will be ineffectual if there are no clear aims and results. It is interesting to note that service users suggest that training is required for managers and for care professionals as much as for service users themselves (Connolly and Seden, 2003). Training changes the culture. Connolly and Seden (2003) also suggest several other ways of embedding consultation and user involvement in a service. These include flexibility and a diversity of approaches, to be willing to start small-scale and in an apparently obvious way and aim for small yet cumulative changes initially, increase the amount of information people have about each other, give service users the opportunities to speak directly to managers rather than through third parties, making sure that all staff are trained in new values as well as procedures so that any gains made can be consolidated, and to share learning and experiences with others. Managers need to be willing to take risks and to relinquish some of their power (Connolly and Seden, 2003). This might be difficult in a prevailing culture of defensiveness (Brown, 2003). Managers need to identify instances of good practice and build upon them (Connolly and Seden, 2003).
It is vital for a manager to ensure that the way in which users are involved in a service challenges instead of illustrates ways in which they are already excluded and discriminated against (Beresford and Croft, 2003). This entails that specific support is put in place so that service users can be involved on a level equal to others.
The task of making user involvement and consultation central to a service is not an easy one for a manager. There are many things of which to take account, and many nuances involving not only service users but also senior management, corporate strategy, and staff culture. Because they find themselves at the intersection of several discourses, the manager is uniquely placed to implement, sustain and develop this task.
REFERENCES
Aldgate, J. and Dimmick, B., 2003, ‘Managing to Care’, in Henderson, J. and Atkinson, D., Managing Care in Context, Routledge, London, pp. 3-26
Beresford, P., 2003, ‘Fully engaged’, Community Care, 13 November, http://www.communitycare.co.uk/articles/article.asp?liarticleid=42814&liSectionID=22&sKeys=beresford&liParentID=26, 12/03/04
Beresford, P. and Croft, S., 2003, ‘Involving service users in management: citizenship, access and support’, in Reynolds, J. et.al. eds., The Managing Care Reader, Routledge, London, pp. 21-28
Brown, M, ‘Shameful Act’, Society Guardian, The Guardian, Wednesday July 23, 2003, http://society.guardian.co.uk/societyguardian/story/0,7843,1003542,00.html, 12/03/04
Calpin-Davies, J., 2004, ‘Opinion Piece. Service user involvement: a new idea to revive an old failing’, Journal of Nursing management, Vol.12, pp.3-4, Blackwell Publishing Ltd
Chambers Twentieth Century Dictionary, 1981, W & R Chambers Ltd, Edinburgh
Connelly, N. and Seden, J., 2003, ‘What service users say about services: the implications for managers’, in Henderson, J. and Atkinson, D., Managing Care in Context, Routledge, London, pp. 27-48
Del Tufo, S., 2000, ‘Gaining the Inside View’, Community Care, October 25, http://www.communitycare.co.uk/articles/article.asp?liarticleid=28374&liSectionID=22&sKeys=gaining+the+inside+view&liParentID=26, 12/03/04
Department of Health, 1998, Modernizing Mental Health Services: safe, sound and supportive, http://www.dh.gov.uk/assetRoot/04/04/66/60/04046660.pdf
Department of Health, 1999, National Service Framework for Mental Health Executive Summary, http://www.dh.gov.uk/assetRoot/04/01/45/01/04014501.pdf
Dunn, S., 1999, ‘’All the lonely people, Health Matters, Winter 99/00, http://www.healthmatters.org.uk/stories/dunn.html
Hickey, G. and Kipping, C., 1998, ‘Exploring the concept of user involvement in mental health through a participation continuum’, Journal of Clinical Nursing, Vol.7 (1), January 1998, Blackwell Science Ltd
Holland, C., 2000, Reflections on empowerment, workplace language and literacy policy, and professional development in England, http://216.239.59.104/search?q=cache:cc4EZJwhy1EJ:www.rcvet.uts.edu.au/wkconference/working%2520knowledge30.pdf+empowerment+and+language&hl=en&ie=UTF-8, 12/03/04
Leason, K., 2004, ‘Are service users consulted too much, or should consultations be more selective?’, Community Care, 27 January, http://www.communitycare.co.uk/articles/article.asp?liarticleid=43535&liSectionID=22&sKeys=empowerment+&liParentID=26, 12/03/04
Lipley, N., 2001, ‘Mental health patients still not consulted about care [News]’, Nursing Standard, Volume 15 (19), 24 January, p.8
McAndrew, S. and Samociuk, G.A., ‘Reflecting Together: developing a new strategy for continuous user involvement in mental health nurse education’, Journal of Mental Health Nursing, Volume 10 (5), pp 616-621, Blackwell Science Ltd
MIND, 1999, User Empowerment 9: How I became a User Consultant, http://www.mind.org.uk/Information/Factsheets/User+empowerment/User+Empowerment+9.htm, 12/03/04
MIND, 2000, User Empowerment 4: Overview of Mind’s Policy on User Involvement, http://www.mind.org.uk/Information/Factsheets/User+empowerment/User+Empowerment+4.htm, 12/03/04
Open University, 2003a, ‘Creative Links’, Partners in Practice, Programme 1, Open University, Milton Keynes
RCN, 2003, Clinical Governance: an RCN resource guide, http://www.rcn.org.uk/publications/pdf/ClinicalGovernance2003.pdf
Open University, 2003b, ‘Open Minds’, Partners in Practice, Programme 2, Open University, Milton Keynes
Rethink, 2002, Rethink Policy Statement 50, http://www.rethink.org/news+campaigns/policies/50-empowering.htm, 12/03/04.
Robinson, R., 2004, ‘Guest Editorial. Patient and public involvement in health: the vitality of nursing’, Journal of Nursing management, Vol.12, pp.2-3, Blackwell Publishing Ltd.
Taylor, M., ‘Patient Care (empowerment): a local view’, British Medical Journal, Volume 320, 17 June 2000, pp. 1663-1664, http://bmj.bmjjournals.com/cgi/reprint/320/7250/1663?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&author1=Taylor&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1079308410953_13329&stored_search=&FIRSTINDEX=0&sortspec=relevance&fdate=6/1/2000&tdate=6/30/2000&resourcetype=1,2,3,4, 12/03/04
Townson, L., and Chapman, R., 2003, ‘Consultation: plan of action or management exercise?’, in Reynolds, J. et.al. eds., The Managing Care Reader, Routledge, London, pp. 29-34
Walker, E and Dewar, B.J., ‘How do we facilitate carers’ involvement in decision making?’, Journal of Advanced Nursing, 2001, Volume 34 (3), pp. 329-337, Blackwell Science Ltd.
Woolf, R., 2002, ‘User empowerment happens through good relationships skills not dogma’, Openmind 118, November/December, http://www.charts.force9.co.uk/current_projects/content/userconsultation/Open%20Mind%20article%20Sept%2002.pdf, 12/03/04
