Encuestas Dirigidas al Personal del Departamento Administrativo de International Forest Products del Ecuador S.A.

Internationally there are a number of policy documents that have influenced service user involvement both in practice and in professional education. Reform relating to service user involvement in the UK was brought about by the Health and Social Care Act 2001. This act planned to integrate the views of patients and citizens through every level of the National Health Service (NHS) by bringing the patients voice ‗inside‘ the NHS as opposed to keeping it ‗outside‘ (Department of Health 2001). Service user involvement in the NHS National Institute for Health Research has become a key issue, with the NHS making a national commitment to this. NHS trust policy documents support the involvement of service users. Policy documents such as ‗The NHS Plan‘ (2000) and ‗Research and Development funding in the new NHS‘ (2000) endorse the need for service user involvement. Recently, the aim of the operating framework for the NHS 2011/12 was to strive to improve service‘s ability to respond to and listen to the patients who use the services. Furthermore the publication ‗Real Involvement: Working with people to improve health services‘ (NHS 2008) helped the NHS to identify what they needed to do in order to have improved involvement practices.

According to Gregory (2007) the importance of service user involvement in healthcare began to be recognised in Australia during the 1990s. The Australian system for service user involvement has taken a different direction than any other country. Service

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users are seen as having a valid role at all levels of the health system in Australia. Most states have a consumer council and advisory committees on specific issues such as mental health. Consumer involvement is not treated as an add-on, but as an integral part of the health sector. Within the health sector, involvement is a fundamental part of the government policy development and a statutory obligation for organisations such as the National Health and Medical Research Council (NHMRC) and the Australian Health Ethics Committee (AHEC) (Horey and Hill 2005). In New Zealand important strategies such as its Health strategy (2000) and the Disability strategy (2001) promoted service user involvement. In New Zealand the Health and Disability Commissioner promotes and protects the rights of service users who use health and disability services. The Commissioner is informed by the work of a Consumer advisory group and health and disability representatives.

Canadian health policies have embraced service user involvement and the mental health strategy ‗Changing Direction, Changing Lives: The Mental Health Strategy for Canada‘ was published by the Mental Health Commission of Canada (2012). The experiences of mental health service users were involved in the drafting of this strategy, and the strategy stipulated the need for active involvement of mental health service users in decision making at all levels of the health system in order to promote meaningful change. In America the participation of service users is recognised as being of importance in all aspects of mental health planning, advisory and governance boards and is essential to the effective planning, delivery and evaluation of such services. Service users are seen to have a vital role in the development of policies that serve them. Examples of effective service user involvement include Mental Health planning and advisory councils which are mandated by federal law and service user involvement is strongly advocated by Mental Health America (MHA 2009)

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2.6.1 Ireland

In Ireland evidence of a discursive shift towards greater service user involvement is apparent in two major health service policy documents. In 2001 the Irish Government published a new strategy for the health service. Quality and Fairness: A Health System for you (DoHC 2001). The strategy emphasised the significance of patient-centred care. This policy document visualized community involvement in planning through consumer panels and regional forums. In 2004, the Mental Health Commission established a committee to consider the recovery model within the mental health services. A discussion paper, ‗A Vision for a Recovery Model in Irish Mental Health Services‘, was published to encourage and inform debate on establishing a recovery model. The paper discussed the international and Irish experiences in terms of moving towards recovery-orientated services and established the core elements of a recovery based mental health service (Mental Health Commission 2005).

The government policy document on mental health: A Vision for Change recommends service user involvement at every level of the mental health services and initiatives to develop service user run services (DoHC 2006). Essentially the policy document directive highlighted a vision that would essentially strive for equal partnership between service providers and service users; partnership in the relationship was described as fundamental. The document acknowledged that service users do have a unique insight in to the experience of mental illness; hence this expertise of mental distress is very different from the experience of other stakeholders. In addition the policy recommended education programmes to allow service users to represent themselves, and the establishment of The National Service User Executive (NSUE). The NSUE was formed so that service users could have a central role in the planning, delivery and evaluation of mental health services and to be a source of support for service users and carers. A ‗Recovery‘ approach, which prioritises user involvement in

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their treatment, is the foundation for A Vision for Change. Attempts at user involvement are recent and until the publication of the Vision for Change policy it lacked guidelines or standards and there was an absence of any coherent policy. The publication of the national strategy for service user involvement in the Irish Health service 2008-2013 (DoHC 2008) aimed to drive service user involvement in the Irish health services. The implementation of this strategy revolves around three levels of engagement: Firstly individual service users involvement in their own care, secondly the involvement of service users at a community level, in local services delivery and development. Finally, a national strategic policy informed through involvement of service user organisations in partnership with health care professionals.

The publication of the HSE‘s feedback policy to include comments, compliments and complaints is ‗Your Service Your say‘. The policy is provided to ensure that there is a structured system in place to respond to service user‘s feedback and complaints (HSE, 2009). This policy supports service user involvement and provides the service users with an opportunity to voice their opinions. The publication of the document titled ‗Service User Involvement Methods: A Guidance Document‘ (HSE, 2009) provides an overview of the range of different methods available for service user involvement, for example, service users panels, surveys, focus groups, consultation: written and online. The scope of the document is applicable to all service users and all professionals within health and social care services. The Health Service Executive (HSE) also published a guideline that strongly advocated for service user involvement. The document was titled ‗Best Practice Guidelines for Establishing and Developing a Service user Panel within a health setting‘. The purpose of the document is to provide a framework for the establishment and development of a service user panel within a health setting in an attempt to improve delivery and quality of services from the perspective of service users. (HSE 2010).

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The 6th Annual report by the independent monitoring group for a Vision for Change (Mental Health Commission 2012) report that some progress has taken place with regards to recovery and service user involvement. For example, the National Service User Executive (NSUE) and service user representatives are active in many national projects led by the Office of the Assistant National Director, Mental Health. Examples include: National Vision Implementation Steering Group, Forensic Reconfiguration Project Group, and Mental Health Act training with external partners (e.g. Gardaí).The role of the Expert by Experience post was independently reviewed and evaluated and the Office of the Assistant National Director, Mental Health and Dublin City University (DCU) has agreed to extend this project for a further 3 years. This decision indicates a commitment to service user involvement in mental health education. The HSE, in association with Atlantic Philanthropies, fund the Genio foundation which supports a number of person-centred initiatives promoting service user participation and capacity building initiatives (Mental Health Commission 2012). Also a key priority of The National Operational Plan was to develop service user and carer partnership by ensuring service user representation on Area Mental Health Management Teams (HSE 2013). It could be argued that this priority is tokenistic and simply ticking the box in terms of ‗having‘ service user involvement. The plan does not outline, or give detail on the role of the service user, it simply states to have service user representation. Service user involvement is about more than simply consulting, service users must be at the centre of decision-making.

A Vision for Change set out to reform the provision of mental health service in Ireland. There is no doubt that the implementation of the Vision for Change is slow, and a number of issues appear to be hampering its progress, namely cutbacks in the public service. It is apparent that steps are being made to strive towards greater service user involvement. However, it seems that policy makers need to recall why there is a

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greater drive and need for service user involvement, and that the basic premise of service user involvement is an intrinsic and social right justification. Compared to our international counterparts it has to be acknowledged that there has been limited progress made. Munday (2007) is of the opinion that service user involvement is something of a paradox in that, on the one hand, there is probably greater-than-ever public and policy commitment to increasing service user involvement. But, on the other hand real choice and involvement for service users in rarely available. This seems to be case in Ireland. Service user involvement is largely driven by government policies and imposed from the top down, rather than emerging from the service users themselves. Without meaningful and equal engagement with service users, and a genuine commitment to develop service user involvement, involvement strategies will remain largely disappointing.