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Constructing the 'service user' within UK mental health policy


Constructing the 'service user' within UK mental health policy

By Emma Perry

National Survivor User Network, London

The language used to refer to people who use mental health services has changed significantly over the past thirty years. Within UK mental health policy, terms such as 'patient', 'client', 'customer' and 'consumer' have been variously adopted and widely critiqued.

In recent years, the term 'service user' has come to occupy a central place within the dominant discourses of mental health policy and practice. A number of researchers (Cowden and Singh, 2007; McLaughlin, 2009) have drawn attention to the depersonalising, homogenising and reductive nature of the term. But despite these reservations, it is still in common usage and continues to be the most popular term used by policy makers and practitioners to describe those on the receiving end of mental health services.

'User involvement', the active engagement of people with lived experience in the development and delivery of services, has also been an emerging theme within health and social care policy since 1990 and is now enshrined in legislation.

My aim was to explore the competing and conflicting discourses of service user involvement and build on previous critiques by exploring conceptualisations of the 'service user' within UK mental health policy. My previous work has explored how offenders are constructed within criminal justice settings and I was keen to investigate whether similar constructions were operating within the area of mental health and service user involvement.

Theoretical Framework
I decided to use a post-structuralist theoretical framework in order to approach this topic. Proponents of post-structuralism take the view that reality is socially constructed in a variety of ways through language. As such, this approach can help to develop a greater awareness of how language shapes understanding through 'discourses' (sets of statements about a topic). It can also help us to question forms of knowledge that we might assume as being self-evidently true and challenge mainstream perspectives that are presented as being 'universal'. This can in turn create a space for more marginalised voices to be heard.

More specifically, I drew upon Foucault's concept of 'governmentality', whereby strategies of governance involve indirect rule of populations and individuals are encouraged to regulate themselves (1991). Rose (2000) argues, after Foucault, that in neo-liberal or 'advanced liberal' societies (such as the Thatcher and Reagan administrations of the late 1970s and 1980s) an indirect form of government emerged in which the role of the state was reframed 'not as the ultimate provider of security, but as a partner and facilitator for active and independent citizens' (2000: 186).

These 'technologies of freedom' (Rose, 2000) enable neo-liberal political regimes to 'govern at a distance', but in order to function effectively, they need to construct an idea of 'responsibilisation' amongst individuals and communities by encouraging self-regulation. As such, Rose argues that discourses of governance begin to emerge during this period that place a greater emphasis on personal choice, autonomy, responsibility and empowerment. Individuals are positioned within economic frameworks of active, entrepreneurial, responsibilised citizenship, and discourses of social inequality are replaced with those of personal responsibility. Those who do not advance within this system are therefore constructed as 'the blameworthy agents of their own misfortune' (Kemshall, 2002: 43).

The findings have been gathered through analysis of several sources:
ï‚· A compendium of UK health and social care legislation and policy, 1989 - 2013. (Perry, 2014a)
ï‚· Qualitative data generated as part of a review of values-based commissioning (Perry et al. 2013)
ï‚· A survey of National Survivor User Network (NSUN) members with regard to their preferred language in relation to their own identities and mental distress. (Perry, 2014b)
ï‚· NSUN's annual membership surveys.

I adopted a Foucauldian discourse analytic approach to language in order to draw attention to the complex, shifting and nuanced ways in which truths are socially constructed, and power operates within this context.

Key Themes
The service user is constructed within dominant discourses as:

An economic consumer of services
The NHS and Community Care Act (1990) is widely cited as the first piece of UK legislation to establish a formal requirement for user involvement in service planning. It introduced the idea of user-centred services and promoted the concept of the state as an enabler rather than a provider of care through the application of market principles and privatisation. This discourse was further reinforced by the Patient's Charter (1991), which emphasised the government's intention to provide 'patient-centred' care and positioned health care recipients primarily as neo-liberal economic consumers of services.

An involved and active partner
The phrase 'patient and public involvement' became one of the principal tenets of the Blair government's NHS modernisation agenda. Central to the emerging discourse of involvement was the positioning of the service user as an active agent working 'in partnership' with the NHS:
"Involving service users and carers is an important part of improving service quality in the NHS. Working with individual users and both local and national user groups can often provide a different view of problems and can lead to imaginative and innovative solutions" (Patient and Public Involvement in the New NHS, 1999: 3).

Such policies have paved the way for involvement initiatives and recommended a dialogue between user groups, clinicians, commissioners and policy makers. But in practice, genuine partnership working continues to be extremely difficult to achieve:

"I suppose there's that underlying thing about power, in that, yes, we can say what we like, but at the end of the day, they are going to make those decisions. The people who've got the purse strings." (Service user, VbC report, 2013).

"The people at the top will make the decisions they want to make, whether you agree or not…" (Service user, VbC report, 2013)

A responsibilised individual
The White Paper Equity and Excellence: Liberating the NHS (2010) mobilises discourses of 'choice' and 'control', promising an NHS that puts patients at its centre and provides personalised care that reflects individual needs. It foregrounds the principle of 'shared decision-making' under which patients make joint decisions about their care with their clinicians. However, the document also warns that:
"increasing patient choice is not a one-way street. In return for greater choice and control, patients should accept responsibility for the choices they make, concordance with treatment programmes and the implications for their lifestyle." (2010: 16)
Blame is located not with social inequalities that can lead to particular lifestyles and health problems, but with individuals who make the 'wrong' choices. Subtle distinctions are made between 'acceptable' citizens ('responsibilised' individuals who make the 'right' choices)
and the 'unacceptable others', the 'underclass of failed consumers' who are invariably positioned as being idle, selfish and violent (Bauman, 2005). Discourses of 'involvement' are therefore tacitly associated with discourses of 'compliance'.

Challenging naturalised assumptions of ethnicity and class
These dominant institutional constructions neglect and overlook the heterogenous and diverse subjectivities of people with lived experience. Instead, the 'ideal service user' is unproblematically imagined within a specific demographic - as white and middle class. The term 'hard to reach' has tended to be used as a way of describing marginalised and minority communities who are 'inaccessible to traditional and conventional methods' (Health and Safety Executive, p.8 2004). However, the term assumes homogeneity within disparate groups and locates the problem within the group itself rather than the approaches used to enable engagement (Kalathil, 2013). Meanwhile, many people from racialised groups and minority backgrounds continue to experience stigma and discrimination when accessing mental health services:
"I am an African woman, aged 54 years old and have mental health problems. As a BME I face daily discrimination because I am a migrant, and have suffered Race Hate/Harassment for many years… The mental health system stigmatizes us and does not treat us with the respect and dignity that we deserve […] Access to every service is fraught with barriers that exclude us as every term." (NSUN member survey, 2013)
Dominant discourses also overlook issues of social class and educational background that create and perpetuate barriers to involvement:
"It isn't just about cultural diversity. I think that there's a kind of a class/education dimension here. And regardless of the cultural roots of the person… if they have been given a certain education or social background you will see them filter through the door… But if they don't have that social background, they won't even know it exists." (Service User, VbC report, 2013)

Involvement tends to be measured by having a service user representative (or representatives) in attendance at meetings. People who are not used to attending meetings can find this an alienating and intimidating environment, not least because language continues to be used by clinicians and managers as a means of wielding and keeping power in this setting:
"A lot of the time you go to these meetings and they're coming out with a whole load of acronyms. And people are thinking 'I haven't got a clue what they're talking about!'" (Service User, VbC report, 2013).

Although policies relating to 'user involvement' have destabilised the traditional 'doctor/patient' power dynamic to a certain extent, the dominant institutional discourses that are currently in operation rely on naturalised assumptions that overlook the heterogeneity and diversity of experience, and issues of ethnicity, class, language and power. People who do not neatly 'fit' into the (primarily white, middle class) constructions of the 'ideal' service user as an active, responsiblised co-producer of services, are further marginalised. A discursive shift is needed in order to create and sustain mental health services that do not pathologise or label people who have experienced mental distress, and see 'service user involvement' as a more inclusive and radically transformative project than that currently envisioned within UK mental health policy.

Reference List
Bauman, Z. (2005) Work, consumerism and the new poor, 2nd edn, Berkshire: Open University Press.
Cowden, S., and G. Singh (2007) 'The "User": Friend, Foe or Fetish? A Critical Exploration of User Involvement in Health and Social Care', Critical Social Policy, 27: 5-23.
NHS and Community Care Act (1990) Available at:
Department of Health (1991) Patient's Charter, London: Department of Health.
Department of Health (1999) Patient and Public Involvement in the new NHS, London: Department of Health. Available at: http://www.xnn40.dial.pipex.com/Documents/PatientandPublicInvolvement.pdf.
Department of Health (2010) Equity and Excellence: Liberating the NHS, London: Department of Health. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213823/dh_117794.pdf.
Foucault, M. (1991) 'Governmentality', in G. Burchell, C. Gordon and P.Miller (eds), The Foucault Effect: Studies in Governmentality, Hemel Hempstead: Harvester Wheatsheaf.
Kalathil, J. (2013) '"Hard to reach"? Racialised groups and mental health service user involvement' in P. Staddon (ed) Mental Health Service Users in Research, Bristol: Policy Press.
Kemshall, H. (2002) 'Effective Practice in Probation: An Example of 'Advanced Liberal' Responsibilisation', Howard Journal of Criminal Justice, 41(1): 41-58.
McLaughlin, H. (2009) 'What's in a name: client, patient, customer, consumer, experty by experience, service user: what's next?', British Journal of Social Work, 19(6): 1101-1117.
National Survivor User Network (2014) Membership Survey 2013 Evaluation. Available at:
Perry, E. (2013) "We're not trying to turn them into middle-class Guardian readers": constructing the offender in the probation classroom, British Journal of Sociology of Education, 34(4): 525-542.
Perry, E., J. Barber and E. England (2013) A review of values-based commissioning in mental health, London: NSUN and NHS Midlands and East. Available at:
Perry, E. (2014a) Service User Involvement in Health and Social Care Policy, London: National Involvement Partnership/National Survivor User Network. (http://www.nsun.org.uk/assets/downloadableFiles/4Pi-SERVICEUSERINVOLVEMENTINHEALTHANDSOCIALCAREPOLICY.V62.pdf)
Perry. E. (2014b) The Language of Mental Wellbeing, London: National Involvement Partnership/National Survivor User Network. (http://www.nsun.org.uk/assets/
Rose, N. (2000) 'Government and control', in D. Garland and R. Sparks (eds), Criminological and Social Theory, Oxford: Oxford University Press.
Whitnell, S. (2004) Successful interventions with hard to reach groups, Basingstoke: Health and Safety Executive.

Emma Perry is Research Project Coordinator at NSUN. Emma's work for NSUN has focused on involvement in mental health commissioning. She has published a review of values-based commissioning in the West Midlands and worked with Mind to produce an accessible guide to values-based commissioning. She also teaches creative writing and drama at Crisis Skylight in Coventry.
Image on pg. 27 from Billionphotos.com

This article originally appeared in News & Views August 2016.


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