Accountability to Welfare Service Users: Challenges and Responses of Service Providers

Influenced by the consumerist sentiment in New Public Management,the last decades have witnessed a revival of the call for accountabilityto service users in the public service sector. As an act ofaccountability, social care and health care professionals areincreasingly obliged to involve their service users in the serviceplanning and monitoring process. Despite the popularity of thisaccountability and user involvement rhetoric, critics have,however, been skeptical of the prevailing user involvement initiativesas an effective measure of accountability to service users (Barnes and Wistow, 1994a,1994b; Bowl, 1996; Peck et al., 2002; Rea, 2004). Based on astudy of user involvement in the welfare sector of Hong Kong,this paper argues that the discourse of accountability to theservice users can be a source of unrest for welfare professionals,in the manifestation of accountability as a power relationship.Their ensuing response is to accommodate the ensuing challengearising from the demand for accountability to service usersby manoeuvring the accountability discourse. It is the contentionof this paper that the institutional inclusion of welfare serviceusers into a discursive space is a necessary but not sufficientcondition for the realization of a mandate of accountabilityto welfare service users.     

Attitudes towards the welfare state have several dimensions

The dimensions and structures of opinions on the welfare state are not well known. This study distinguishes five dimensions based on previous literature: responsibility for welfare, financing of the welfare state, the use of benefits, the adequacy of the welfare state benefits and the effects of the welfare state. One or more attitude indicators are formed for each dimension by means of factor analysis of empirical material. Examination of the correlations between the dimensions and attitudes yields two opinion structures. A supportive attitude structure is founded on the concept that public authorities have responsibility for welfare services, a positive attitude towards public financing of welfare services, and on the concepts that the amount and quality of services and the level of income transfers is not adequate. The critical cluster of attitudes is formed by the reliance on private responsibility, negative attitude towards public financing and on the concepts that benefits are overused and that the welfare state makes its clients passive. Finally, the variation in attitudes among the population of Finland are studied by means of regression analysis. Social class, age and political party sympathies are the most important explanatory factors for a range of attitudes.     

Speaking in Tongues: Involving Users in Day Care Services

Correspondence to Dr Karen Ross, Centre for Policy and Health Research Cheltenham and Gloucester College of Higher Education, The Park Campus, The Park, P.O. Box 220, Cheltenham, Glos. GL50 2QF. Summary The new focus on the importance of user involvement within arange of public services, as witnessed by legislation and policysuch as the NHS and Community Care Act (1990) and the Citizen'sand other Charters, has significant implicaions for the wayin which users will be encouraged to have a voice in serviceplanning and delivery. A crucial factor in the success of participativestrategies is training for both users and workers, to enableinvolvement and participation to be something more than token.This paper is based on a study which set out to explore thereality behind the rhetoric of user involvement in day careservices. It found that the most significant factor in determiningthe extent of user involvement in day centres was the organizationalculture of individual establishents. Empowering strategies weremore likely to exist in those centres where staff felt valuedand where senior officers were committed to the principle ofpower-sharing and partnership between users and workers: trainingwas rarely provided for users and workers as a matter of routine.A number of suggestions are made as to ways forward, in thelight of research findings.     

Mental Health and the Asian Communities: A Local Survey

Correspondence to Barbara Hatfield, Lecturer in Psychiatric Social work, Department of Psychiatry, 12th Floor, Mathematics Building, Manchester University, Oxford Road, Manchester M13 9PL Summary The survey of people from the Asian communities in ‘Milltown’included people who used mental health services, family membersof service users, and members of the Asian general public. Personaland social stresses of the group were explored, as were theirperceptions of the ‘causes’ of mental ill-healthand appropriate responses. Although most people saw family andsocial stress as central, a religious dimension was also prominent,in terms both of causes and treatment of mental ill-health.There was no evidence of rejection of mainstream services becauseof a choice on the part of Asian families or communities tobe self-servicing. A range of issues identified by respondentssurrounded the cultural acceptability of services in ‘Milltown’to Asian people. A lack of knowledge of service availabilitywas also apparent, with a heavy reliance upon GP services formental health care in the community. The findings of the surveyare compared with similar studies, where available, which focuson indigenous white British service users. Some findings arecommon; other issues are specific to this Asian group.     

Responding to global shifts in social work through the language of service user and service user involvement

'Service user' advisory representation is required by law and/or regulation in British social, health and educational programmes. This is similar to client counsels or consumer groups in the USA, which are required in some, but not all, US social service sectors. Often users of welfare services are excluded from citizenship – both formally and in terms of actual restraints on their citizenship rights. There remains uncertainty, however, about how best to identify and enable such individuals to participate in service user involvement without continued marginalisation. This study seeks to contribute to our emerging understanding of service user initiatives by exploring preferred terms of reference and service user involvement from the point of view of persons often categorised as service users by social policy, health and social care providers and academics, but who do not necessarily take part in self-organised service user groups.     

The Impact of New Labour Health Policy on Social Services: A New Deal for Service Users' Health?

Summary The health policies of the Labour Government of 1997–2001included an increased emphasis on social services departments'(SSDs) contribution to promoting health. Three dimensions ofthis policy shift are discussed: first, the drive towards organisationalfusion between elements of the NHS and SSDs; second, the newmechanisms for conjoint funding of health and social services;and, finally, the new policy focus on tackling health inequalitiesby combating social inequalities on a national and localitybasis. In each case, the touchstone of our analysis is the consequencesfor the health and well-being of SSD service users as membersof socially disadvantaged groups. We conclude that New Labourhas taken some steps, particularly reducing child poverty, whichwill have long lasting health and social benefits for actualand potential service users. However, inadequate funding ofSSDs undermines their effectiveness as a partner in integratedhealth and social care. As signalled by service user initiatives,SSDs potential for promoting more equal chances of health andwell-being in ill-health will also not be realised without substantialchanges to current SSD policy and practice.     

Responding to global shifts in social work through the language of service user and service user involvement

'Service user' advisory representation is required by law and/or regulation in British social, health and educational programmes. This is similar to client counsels or consumer groups in the USA, which are required in some, but not all, US social service sectors. Often users of welfare services are excluded from citizenship – both formally and in terms of actual restraints on their citizenship rights. There remains uncertainty, however, about how best to identify and enable such individuals to participate in service user involvement without continued marginalisation. This study seeks to contribute to our emerging understanding of service user initiatives by exploring preferred terms of reference and service user involvement from the point of view of persons often categorised as service users by social policy, health and social care providers and academics, but who do not necessarily take part in self-organised service user groups.     

Accepting and Negotiating Service Users' Choices in Mental Health Transition Meetings

Across Western welfare regimes, policies emphasize that service users should have more choices regarding their services. This article examines how service choices are presented, responded to and decided in interactions between service users and professionals in mental health transition meetings. Choice is often associated with consumerist user involvement ideas, but in mental health choice also relates to the democratic user involvement approach and to shared decision making between professionals and service users. The results of the study show that professionals construct service users as consumers by offering service options in choice making sequences, expecting users to make appropriate choices. Service users mostly act like consumers by responding to these choice options. However, the study also demonstrates that the professionals do not always accept the user's first choice but respond to them as non‐preferred. Sometimes, they also suggest choices on behalf of the users. In these ‘non‐accepting’ sequences, choices are negotiated in interaction between the parties, rather than users acting as autonomous choice makers. The sequences are based on two kinds of professional reasoning: first, the professional‐led needs assessment and, second, the structure of the service package that the user is being offered. This negotiation has elements of shared decision making and the ‘logic of care’. But it also has elements of paternalist control which challenge both consumerist and democratic service user involvement and suggests consideration of more collectively oriented service user actions.     

Fathers' experiences with child welfare services

The lack of engagement of fathers by child welfare services is well‐documented in the literature as a serious problem. Towards addressing this problem, this paper reports the findings of interviews with 18 fathers about their involvement with child welfare services in Ontario, Canada. Qualitative analysis of the interviews yielded themes about what men saw as the positive and negative aspects of their involvement with child welfare. Positive aspects of service involvement for fathers included understanding and supportive workers, useful assistance from workers, being connected to useful resources and being given a ‘wake‐up call’. Negative aspects of service involvement included uncaring, unhelpful and unprofessional workers; prejudice against fathers; and experiencing the child welfare system as unresponsive, uncaring and rigid. Implications for practice are discussed with a view to improving the engagement of men in, and their experiences with, child welfare services.     

'Anti-oppressive practice': emancipation or appropriation?

Summary This article offers an initial critical discussion of the conceptof anti-oppressive practice - AOP - from the perspectives ofservice users. Whilst acknowledging the emancipatory aspirationsof anti-oppressive practice, it also considers its regressivepotential. AOP has become central in social work theory andpractice and indeed is sometimes presented as a key approachand theory of social work. This discussion highlights the failureso far significantly to involve service users and their organizationsin the development of anti-oppressive theory and practice. Itconsiders how the ideology and structures of anti-oppressivesocial work impact upon service users; the problems raised by'expert' appropriation of users' knowledges and experiencesand the issues raised by the failure so far to address the useof social work and social care services as an area of differenceand category of social division. Finally, the article examinesalternatives to existing notions of anti-oppressive practicebased on the equal involvement of service users.     

‘Like walking on eggshells’: service user views and expectations of the child protection system

This paper reports on a study of service users' views on Irish child protection services. Qualitative interviews were conducted with 67 service users, including young people between 13 and 23. The findings showed that despite refocusing and public service management reforms, service users still experience involvement with the services as intimidating and stressful and while they acknowledged opportunities to participate in the child protection process, they found the experience to be very difficult. Their definition of ‘needs’ was somewhat at odds with that suggested in official documentation, and they viewed the execution of a child protection plan more as a coercive requirement to comply with ‘tasks’ set by workers than a conjoint effort to enhance their children's welfare. As in previous studies, the data showed how the development of good relationships between workers and service users could compensate for the harsher aspects of involvement with child protection. In addition, this study demonstrated a high level of discernment on the part of service users, highlighting their expectation of quality standards in respect of courtesy, respect, accountability, transparency and practitioner expertise.     

Keyworkers Re-examined: Good practice, quality of care and empowerment in residential care of older people

Correspondence to Rosemary Bland, Department of Applied Social Science, University of Stirling, Stirling FK9 4LA, Scotland Summary Social work definitions of ‘good practice’ in residentialcare which were originally developed in work with children andyoung people have also been applied to residential settingsfor other user groups, including older people. However, anylink between such elements of practice and positive outcomesfor users has not always been demonstrated. The introductionof market principles and orientations into social welfare inthe 1980s re-defined the social work ‘client’ asa ‘consumer’ with the associated power to make choicesin the area of social care. The success with which such an approachcan be applied to services for people who are very often, notin a position to exercise much choice, is debatable. Alongsidethe notion of the ‘consumer’ or ‘user’of services has grown the ideology of ‘empowerment’of people who use social work services. Drawing on findingsfrom a recent study, this article explores the contributionof the keyworker role to good practice and the empowerment ofolder people living in residential homes. It concludes that,because their understanding of the concept and practice is largelyundeveloped, the role as currently interpreted is not consonantwith good practice and tends rather to reinforce the power ofstaff.     

User Involvement in Services--Incorporation or Challenge?

Correspondence to Joan Forbes at The School of Social Work, The University of Leicester, 107 Princess Road East, Leicester, LE1 7LA Summary In recent years, users of social work, like those of psychiatry,have been increasingly drawn into the organization and deliveryof social work and mental health services. This has been largelywelcomed as a desirable development by planners, academics andpractitioners in the field. In this article, we reappraise thebroad issues raised by user involvement and consider the implicationsof this trend. Despite the attractiveness of the user perspectivein the policy and delivery of social work and psychiatric services,we point to the dangers of incorporation and moderation of anoppositional position, from which, we argue, users can bestchallenge existing practices and connect with wider politicalstruggles.     

Service users' knowledges and social work theory: conflict or collaboration?

Summary So far, service users have not been systematically involvedin social work theorizing. However, disabled peoples's movements,mental health service users/survivors and other service usershave developed their own knowledges based on direct experienceand they have generated their own conceptual frameworks andbodies of theory. There are fundamental problems in social workseeking to interpret service user knowledges. Their developmentsand interpretation require the direct involvement of serviceusers and their organization in social work theorizing. Thereare strong practical, philosophical and political argumentsfor involving the knowledges and theories of service users andtheir organizations in the process of social work theory-building.This paper considers an inclusive approach to social work theorizing.While highlighting the importance of service users and theirorganizations being effectively included in social work theorizing,it also argues the need for them to have support and opportunitiesto develop their own prior and separate discussions about theory,including social work theory.     

Supplemental home care and topping‐up: A shift from service universalism towards a new and privatised public service model?

How does a public service model based on service universalism react to the introduction of market principles of topping up? In a recent so‐called Free Municipality Scheme (an experimental scheme that allowed for greater operational autonomy locally in an effort to reduce state bureaucracy), a number of Danish municipalities were for the first time ever allowed to compete with for‐profit providers of home care in selling supplemental home care services paid entirely by the user. The take‐home message from this experience is that the introduction of supplemental home care entails challenges and eventually wider implications for the public service model, on an economic, organisational and cultural level. Supplemental services represent a new and potentially powerful combination of market and state logics that eventually redirects away from the universalist welfare state and towards a new and increasingly privatised public service model – a model where the service level is determined by the user's capacity to purchase and pay for services. The introduction of such services therefore implies a change of the potential of the Nordic welfare state to ensure equal access regardless of class and income.     

Ambiguity and User Involvement: Issues Arising in Assessments for Young People and their Carers

Correspondence to Peter R. Day CRSP, Department of Social Sciences, Loughborough University of Technology, Loughborough, Leicestershire LE 11 3TU. Summary Issues for service users and professional staff arising fromcontemporary community care policies emphasizing user involvementare reviewed. Against the background of a key expression ofthese policies, the Disabled Persons' Act of 1986, methods ofproviding assessments involving young people with learning disabilitieswere analysed. Problems identified for further study includeddifficulties arising for young people due to lack of experienceand immaturity, the low expectations of their parents or carers,problems arising from the culture of services and how assessmentsmay be developed which provide seriously disabled users themselveswith ways of expressing their wants and needs.     

What do service users think of evaluation? Evidence from family support

Programme evaluators increasingly strive to capture how service users experience child and family welfare programmes. Yet user involvement is rare in a more routine form of evaluation: performance measurement. This paper considers how service users' perspectives can help improve the performance indicators that inform child and family service funding, management and planning. Qualitative research, conducted in family support contexts in New South Wales, Australia, identifies five user‐defined domains upon which indicators can be based. As well as showing how parents judge service quality and outcomes, the findings also show how they experience data collection, and how they prefer to participate in the routine performance measurement and monitoring that informs child and family welfare provision.     

Which Champions,Which People? Public and User Involvement in Health Care as a Technology of Legitimation

This paper concerns two practices, public consultation and user involvement, whose adoption has been urged upon the UK National Health Service in recent years. Public consultation is a local attempt to seek the views of a broad constituency of persons. User involvement is a local attempt to include organized groups of service users in the planning, and occasionally the management, of such services. The paper has four objectives. First, it locates the topic in the context of several related current debates. Second, it outlines the main findings of a recent empirical study of public consultation as they relate to the above debates. Third, it summarizes the relevant findings of an empirical study of user involvement. Finally, it examines these two practices as "technologies of legitimation" which can be seen as a means by which managerial legitimacy is maintained in the context of an increasingly pluralistic policy arena.     

Returning to Normality: Substance Users' Work Histories and Perceptions of Work During and After Recovery

Correspondence to Andreas Cebulla, National Centre for Social Research, 35 Northampton Square, London EC1V 0AX, UK. E-mail: a.cebulla{at}natcen.ac.uk Summary New service provisions designed to improve the employment prospectsof former substance users will enhance the roles and responsibilitiesof Drug Action Teams (DATs), Jobcentre Plus offices and otherproviders and co-ordinators of support services for substanceusers. This paper discusses the findings of a study of 30 currentand former drug and alcohol users, exploring past substanceuse histories and current employment aspirations. The researchinforms new policy initiatives designed to assist substanceusers’ entry or return to work. Differences in presentperceptions of work-readiness were observed, which reflectedusers’ perceptions of the nature of their addiction. Theattribution of blame for the substance dependency to either‘the drug’ or the individual’s psychologywas a critical influence on users’ work-readiness assessments.Work was perceived to benefit recovery from substance dependency.The evidence suggests that substance users’ return towork might be helped by their staged (re-) introduction to thelabour market as well as encouraging the primary labour marketto employ (more) recovering substance users. The research highlightedthe need for joint working between employment services and DATsto help substance users into work and to support their recovery.It also highlighted the need for mutual understanding and recognitionof each collaborator’s expertise.     

Service Users' Perspectives on the Benefits System in Israel: A Participatory Action Research

This article presents a position paper on Israel's benefits system. It was produced in the framework of a participatory action research with the collaboration of welfare services users and social welfare policy practitioners, academics, social practitioners, and social activists. Some 78 persons living in poverty, from various population groups, were asked, in group settings, to describe their experiences with the benefit system and services, their coping strategies, their perceptions and attitudes towards these services, and their recommendations for ways to improve them. The position paper which emerged from this process served as the basis for discussions between service users, social welfare policy practitioners, researchers, social activists and social practitioners at an academic conference. Issues such as benefits cuts, eligibility, and definitions of poverty are discussed and recommendations are presented.