A person centered approaches and services user involvement in health and social care

rachealbizz1

WK4-Theories-ModelsofInvolvement.ppt

Home >Nursing homework help >A person centered approaches and services user involvement in health and social care

Theories / Models of Involvement

WEEK 4

Bimpe Kuti

Review so far

PCA / SUI aim to ensure that patient experience sits as an equal partner in health and care service development, improvement or design of new care services
Over decades (as depicted in the historical timeline from week 2) PCA / SUI has become the centre of various national/local, organisational guidance and policy on how care should be delivered to patients and the public

Review so far

These policies have aimed to place people who use services at the centre of care, to understand their experience of services, to empower them to make decisions and to involve them in the design and delivery of care

Ongoing debate about PCA / SUI

Despite policy developments, there have been an increasing number of criticisms about the nature of PCA / SUI in practice.

There is uncertainty about how to do it well, in ways that constitute genuine partnerships and which involve a diversity of patients and the public, rather than a few selected individuals.

Ongoing debate about PCA / SUI

Some core issues around PCA / SUI that still requires further research and addressing are power inequities and discrimination. This has exposed PCA / SUI to criticisms of tokenism

This is seen as leading to a narrow model of involvement that fails to empower patients and the public in the involvement process.

Ongoing debate about PCA / SUI

The wider literature on PCA / SUI highlights the contested and bottom-up nature and drivers for involvement
Involvement at this level has, therefore, been criticised as providing little opportunity to influence decision-making processes in any depth, maintaining power differentials and the status quo.

Development of theories/models

These drivers have led to the development of theory, methods and approaches, particularly within health and care services in general, that have been used to develop wider involvement models and methods based upon co-production and partnership.

So what are the theories in undertaking PCA /SUI in health and social care

Concepts of PCA / SUI

A number of different terms are often used synonymously with involvement, such as engagement or participation, while the terms patients and the public are also used interchangeably with ‘citizen’, ‘consumer’, ‘layperson’ or ‘service user’.

These conceptual differences have emerged from different traditions, social movements, policies and practices to describe the involvement process.

Concepts of PCA / SUI

They have also been used to imply a greater or lesser level of involvement, power or influence in decision-making processes within an organisation.
However, this language does not always reflect the underlying ethos of these involvement activities.

Underlying ethos of involvement

This shift in involving service users as decision-makers in their health services has advanced for various reasons such as…

improving quality of care
ensuring health services are responsive to the needs of people

Underlying ethos of involvement

changing the ways services are delivered
to increase efficiency of services
promote fairness for all users
Promoting this type of recognition for patient-centered care underpins the principles that form the values and preferences of involvement, which should be central to discussions around care delivery at all levels.

Underlying ethos of involvement

This requires explicit focus on how service users can contribute to improving, developing or changing the quality of care

Principle of involvement

The core principle of involvement is influenced, not by a specific tool or approach, but by the relationships and how this is defined between healthcare providers and service users

This defines and impacts on the way service users engage with the involvement process, based on opportunities afforded for contributing to real change in care service

Four Models of involvement

Theories/models of involvement

Some conceptual frameworks for considering involvement processes are...
Arnstein’s ladder of citizen participation (Arnstein, 1969)

White’s framework of participation (White, 1996)

Cornwall’s dimensions of community participation (Cornwall, 1996)

The levels and degree of how SUI should take place as depicted by these concepts, in relation to the various national agendas now being promoted around SUP suggests that involvement has diversified and there are various contextual factors to be considered.

Arnstein’s ladder of participation

Remains one of the famous involvement tools that is at the heart of many approaches to PCA / SUI and adopted in conceptualizing what real involvement should look like

Its main appeal as a tool for participation is its ability to reveal power agendas in its representation of the degree of power.

It carries the notion that power shared is power gained.

The fundamental point of Arnstien’s criteria is that participation without redistribution of power is an empty and frustrating process for those who have no influence over power

(Arnstein, 1969).

Arnstein’s ladder of participation

Arnstein’s Ladder of Citizen Engagement (Arnstein, 1969)

Arnstein’s ladder of participation

The degree of participation is clearly depicted in the ranges on the ladder from manipulation through to consultation, with the highest level being citizen control.
Levels one and two on the ladder as attempts to ‘educate’ participants.
Levels three and four allow participants to hear and have a voice, but they have no power to ensure that their voice has influence.

Arnstein’s ladder of participation

Level five gives participant the opportunity to advise, but the right to decide is retained by organisation,
Level six considers partnership working as the most effective when participants have an organised and resourced base from which to work.
Levels seven and eight, participants form majority in decision-making arenas and hold managerial power.

Arnstein’s ladder - CRITIQUE

This linear conceptualisation of participation does little to emphasise the importance of either the process or the existence of ‘feedback loops’ (Tritter and McCallum, 2006).

Tritter and McCallum further point out that:

“A linear, hierarchical model of involvement – (such as Arnstein’s ladder) – fails to capture the dynamic and evolutionary nature of user involvement. Nor does it recognise the agency of users who may seek different methods of involvement in relation to different issues and at different times”. (Tritter and McCallum, 2006: p 165)

Arnstien’s ladder of participation does not acknowledge the fact that some users may not wish to be involved, or may wish to be involved in a different way other than as expressed on the ladder.

This is a potential risk for healthcare professionals who adopt a participatory process based on the simplicity of its format.

It could result in focusing on the interests of the professionals and overlook some of the pressing issues or interests that service users might want to express as important for their healthcare provision.

Cornwall’s participatory methods

Cornwall’s participatory steps (Cornwall, 1996, p. 96)

Mode of participation	Involvement of local people	Relationship and action to local people
Co-option	Token; representatives are chosen, no real input or power	On
Compliance	Tasks are assigned, with incentives, outsiders decide agenda and direct process	For
Consultation	Local opinions asked, outsiders analyse and decide on a course of action	For/with
Cooperation	Local people work together with outsiders to determine priorities, responsibility remains with outsiders for directing the process	With
Co-learning	Local people and outsiders share knowledge, to create new understanding, work together to form action plans	With/by
Collective action	Local people set their own agenda and mobilise to carry it out	by

Although Cornwall’s model of participation points out the impact of relationships between key stakeholders when planning a participatory initiative, it shows the importance of evaluating the initiative, to establish the level of its success.

CONRNWALL’S PARTICIPATORY - CRITIQUE

Similar to Arnstein’s model, it could potentially run the risk of professionals having a different view of which level the participatory activity should begin and service users having a different preference.

This raises the issue that distinct typologies of participation could exist within participatory processes, regardless of which participatory concept is adopted.

CONRNWALL’S PARTICIPATORY - CRITIQUE

This reinforces the argument that participation is an unfolding process not ‘fixed’ and which develops and then strengthens the capabilities of all actors to effectively engage meaningfully in the participatory process and if required to enhance or expand on its theoretical developments.

WHITE’S TYPOLOGY OF PARTICIPATION

White’s typology of participation (White, 1996, p. 144-146)

Form	Top-Down	Bottom-Up	Function	Example
Nominal Participation	Legitimation	Inclusion	Display	Group formed by government departments, for example women’s groups in local areas. However, their participation lacks any real substance, but women say they are members because they get to see their names on official books and it might give them access to other benefits such as to see if there are any new loans that are on offer.
Instrumental Participation	Efficiency	Cost	Means	People involved in infrastructure projects (for example the construction of a local school) to increase the efficiency of such projects for outside funders by better aligning supply with demand expressed through participation. For people, participation becomes a necessary cost for getting what they need, rather than valued in itself. Its function is to both achieve cost-effectiveness and the development of a local facility.

WHITE’S TYPOLOGY OF PARTICIPATION

White’s typology of participation (White, 1996, p. 144-146)

Form	Top-Down	Bottom-Up	Function	Example
Representative Participation	Sustainability	Leverage	Voice	Involving people in forming their own community base organisations for managing local development which can enhance sustainability. Present people with an opportunity to shape decisions in ways that meet their own interests and to ensure leverage. For example, local fishing families form their own co-operative for loans and fish marketing.
Transformative Participation	Empowerment	Empowerment	Means/ End	Occurs when external actors interact with people with the specific purpose of empowering them and equipping them with the capacity to bring about changes that matter to them. People are allowed to organise themselves and use opportunities to bring about the changes they desire.

This concept as depicted by White (1996) suggests that participation is a continuous long-term partnership as it talks about people having the opportunity to bring about changes, to shape decisions that meet their interests and enhance sustainability.

WHITE’S TYPOLOGY - CRITIQUE

This model on the surface appears like the successful approach to pursue in developing a participatory initiative that is service user led.

However, transforming participation by empowering participants does not always mean power shared by all stakeholders.

DYNAMICS OF SUI

How and why people participate varies immensely (Barnes 1999).
According to Birchall and Simmons (2004, p. 26), the motivations to participate depend on two approaches:
The individual thinker – ‘what do I get out of it?’
The collective thinker participates based on three variables:
Mutual needs that translate to common goals;
Feeling a sense of duty to participate as an expression of common values; AND

DYNAMICS OF SUI

Feeling a sense of community- identifying with and caring about other people who live in the same community or share the same experience.

Therefore, this insight into motivations for participation is important in understanding the events that take place during a participatory process.

Barne’s framework- sui

Based on the inference that no single method is best, rather a comprehensive strategy for public participation should recognise that there is the need for more than the use of one model or method for different stages.

Framework for participation. Adapted from Barnes (1997)

Whose participation is being sought?

Are people involved from a group of consumers also referred to as citizens living in a particular area, or are those who are often excluded from decision making the main group to be involved?

Type of knowledge to be accessed through the process of participation:

Knowledge in this aspect is categorised into four types the ‘expert’ – participation of people who already have knowledge about the subject under consideration, ‘interested’ – increase the knowledge of citizens generally through the process of participation, ‘informed’ – to access informed public opinion or ‘un-informed’ – to explore un-informed views of those have no knowledge and have not gained knowledge through the process of having their say.

The location within which participation is being sought:

This consists of various spheres within the public; through local community groups, voluntary or user groups…

Framework for participation. Adapted from Barnes (1997)

The objectives and purposes of participation:

This could vary from seeking change in services, to enabling citizens to take control over their lives, reduce social exclusion etc.

The degree of power sharing implied through opening up opportunities for public participation:

This could involve the delegation or sharing of decision – making process between people invited to take part and officials

The scope of participation and the level at which change may be achieved:

This could be: At group, community or neighbourhood level At particular social or health programmes level In individual decision making At policy making level In relation to particular organisations

Arnstien’s ladder of participation does not acknowledge the fact that some users may not wish to be involved, or may wish to be involved in a different way other than as expressed on the ladder.

This is a potential risk for healthcare professionals who adopt a participatory process based on the simplicity of its format.