Changing Practice: Involving Mental Health Service Users in Planning Service Provision

David M. Rea, PhD

INTRODUCTION

The days when social work could practice independently as a profession–if they ever existed–have passed. Social work practice cannot be isolated from management and policy making. Accountability can no longer be restricted to professional accountability, but must also incorporate accountability to service users and a wider population.

This paper is intended to identify some of the more important management challenges arising from involving service users in planning mental health services. It focuses on user involvement which is often limited to consultation or to participation in decisions initiated by service providers. The focus here, however, will be on strengthening user involvement to the point where users actively take part in leading services towards change.

In the UK, as elsewhere, the challenges faced by management arise from national and local government policies which include user involvement in measures of performance, the desire of service users to have greater say in how the service delivers, and the willingness of managers and service providers to improve the quality of the services they provide. The will to involve service users is considerable and it is not new, although some might impatiently question why relatively little has occurred.

In some countries, where the state has taken less responsibility for provision and has encouraged private provision, service user involvement has sometimes progressed significantly beyond expectations. The virtue (and the vice) of private provision is that services can be developed ad hoc. However, the UK shares with many states a tradition of state responsibility and (at best) paternalism in service provision. While present policy developments incorporate notions of service, consumer, and responsiveness, mental health services are provided within a statutory framework that includes a high degree of compulsion. Within the contradictions of this framework, there are severe obstacles to user involvement and these can be presented–by service users as much as by social work practitioners–as reasons to do little or nothing.

This paper uses evidence from community-based mental health services (in Swansea, UK) to demonstrate some of the steps necessary to meet these challenges. Swansea is probably not typical. Judged by the evidence of recent social service inspectorate reports, Swansea is probably ahead of most in the UK (NAW-Social Services Inspectorate for Wales, 2001; NAW and the Audit Commission, 2000).

Elsewhere, a perceived lack of leadership, or the wrong kind of leadership, has increasingly concerned policy makers and service providers in health and social care. In Swansea, the Social Services Inspectorate also noted that user involvement developments were not widespread and occurred only where individuals took the initiative. This implies a similar diagnosis as elsewhere–that leadership is necessary before policy initiatives are taken up and incorporated into professional practice and managerial routines.

This paper seeks to contribute to this debate by identifying strategies that place service users at the centre of change affecting their services. Specifically, the paper argues that leadership needs to be conceptualised flexibly and needs to include team building, team-working, and networking where teams and networks include mental health service users who are empowered to drive forward change.

The needs of service users would lead the service and come to the fore through these networks. This concept of leadership is clearly distinguishable from concepts of transactional leadership or transformational leadership which focus on the leader as hero (Bryman, 1996). The importance of the concept of leadership is in the recognition that achieving (beneficial) change is what is not possible in conventional public sector bureaucratic structures, although their continued existence is probably necessary. User representation in these bureaucratic structures is unlikely to affect change. In the very recent past, public sector management has been in thrall to a singular model of management where a manager is defined as someone who imposes his will on others (Geenen, 1985; Pollitt, Harrison, Hunter, & Marnoch, 1991).

That this is an unlikely model for change has been recognised more recently by politicians and policy makers, as well as educationalists and trainers. They have re-discovered leadership. ‘Re-discovered’ because it is far from a new idea and has been around long enough for everyone concerned to know of its conceptual and empirical limitations (Bryman, 1996). But governments have recognised that issuing policy, providing financial incentives and penalties, and restructuring formal ‘authority’ in health and social care organisations is not sufficient. In the UK, the importance of leadership in health care has led to more policy documents (NHS Executive, 1999), expensive training schemes for executives, and the NHS Plan has promised a national Leadership Centre (DoH, 2000). Nevertheless, it remains difficult to detect what concept of leadership is being promoted by these initiatives.

Leadership, in this paper, is conceived of as dispersed among teams, ‘leading others to lead themselves’ (Sims & Lorenzi, 1992, p. 295), and more concerned with processes and skills than with who is formally designated as a leader.

So, the paper takes issue with much of the general management literature which is frequently concerned with role specificity (Carignani, 2000; IBM Corporation, 1993; Katzenbach & Smith, 1993; Margerison & McCann, 1985; Obeng, 1994; Ramcharan, Grant, Parry-Jones, & Robinson, 1999), while the presence of clearly defined professional boundaries and current legal requirements act to prevent the flexibility required for multi-disciplinary teamwork (Payne, 2000). Networking in a manner that allowed for service users to take a leading role would therefore pose enormous problems for public service accountability and for measuring the performance of those charged with providing services.

The aim of involvement where users are involved with leading the service is therefore likely to remain a distant prospect. The necessity for it, however, will be illustrated by the research discussed in this paper. Payne’s model of open teams and networking arrangements is the most promising model of leadership from which to proceed, and it will be used as a framework in the analysis that follows later. However, at this point, it may help to stress that open teamwork does not require new structural arrangements, but affects ways of working across existing structures.

Rather than outline this and other models of leadership separately from any empirical evidence, the paper seeks to examine teambuilding, networking and user-involvement, citing empirical evidence integrated within the discussion. It must be stressed that the benefits of this model cannot be demonstrated by this empirical work which only serves to indicate that further development is required. This can be understood if we first address the problems faced by further user involvement. In particular, there is an apparent dichotomy to be faced between an increased stress on leadership within the public sector, on one hand, and greater user involvement, on the other.

Before discussing this in more detail, however, the context of present policies towards measuring performance, involving users, and improving public sector management (leadership) can usefully be reviewed.

PERFORMANCE MANAGEMENT AND POLICIES TO INVOLVE USERS

User involvement–from involvement in deciding their own care through to involvement in policies and planning–has emerged in a distinctly modern form. Once associated with the radical movements of the 1960s, user involvement is now incorporated within what some writers have identified as the new public management (Barberis, 1998; Ferlie, Ashburner, Fitzgerald, & Pettigrew, 1996; Hood, 1991). Managers are made accountable for providing quality services with the money they spend (OECD, 1992). While policy directives insist that quality–as defined by service users–must be incorporated into measures of quality performance, definitions and measurements of quality still tend to be determined by providers, not service users.

Definitions of quality and the degree of user involvement remain contentious–this is an inevitable consequence of change. Practitioner, managerial, and user definitions of quality differ, as does its measurement. Involvement can vary from the minimum of consultation through to regular case reviews (for individuals) and routine structured representation.

Routine structured involvement has developed in the UK through joint commissioning of services involving service uses and voluntary bodies. A recent policy document, the NHS Plan (DoH, 2000), cites an example of joint commissioning from Somerset (p. 71). Other examples of ‘partnership’ trusts involving health and social care providers, with service users included in the decision making structures, are developing. At the time of writing, Norwich and West Sussex are two examples in England, while in Wales plans for partnership arrangements are out for consultation (NAW-Health Service Strategy Team, 2001).

The requirement to involve mental health service users in Wales is also evident in a raft of policy papers (NAW, 2001; Welsh Office, 1998a; Welsh Office, 1998b; Welsh Office, 1998c; Welsh Office, 1998d). The NAW’s mental health strategy said:

Current policies are enacted through the establishment of targets and standards against which performance is measured. The results or performance measures are publicized. Performance is also enforced through audit and inspection. This is a common approach within public sector management, whatever sector. The standards for mental health services are expressed through the Mental Health National Service Framework (DoH, 1999), which states as its first guiding principle that ‘People with mental health problems can expect that services will involve service users and their carers in planning and delivery of care’ (p. 4). Further, on p. 17, it states ‘All mental health services must be planned and implemented in partnership with local communities, and involve service users and carers.’ However, all the standards relate to individuals and their care, and no standard for user involvement is specified. So user involvement may be limited to the provision of evidence from surveys (graded as Type V evidence, p. 6).¹

In Wales, a National Service Framework for Mental Health has set December 2003 as a target by which all providers will have ‘introduced arrangements to ensure constructive user and carer participation in the planning, design, delivery and, monitoring and evaluation of mental health services’ (Welsh Assembly Government, 2002, p. 10).

However, it is not clear that user involvement for statutory agencies and service providers means the same as it does for service users (Barnes, 1999). Involvement can range from, at a minimum, the incorporation of a select number of views into policy and practice to, at a maximum, provider accountability to service users. There are difficulties in ensuring user representatives can adequately represent a diverse range of service user views (Bowl, 1996; Croft & Beresford, 1990). Any degree of representation may seem inadequate for service users who will argue that it may mean very little unless users are also involved in appointing staff (Brandon, 1992).

While the majority of staff welcome user input, some may take the view that service providers are unable to represent themselves adequately because their judgment is affected by their condition or by its treatment (Barnes & Wistow, 1994). Others may resist user involvement because they sense they are already over-burdened with work and that it has lesser priority than service provision (Dewa, Horgan, Russell, & Keates, 2001). It is also apparent that service providers have little of the skills necessary for systematic or meaningful research designed to establish what users want or what they think of the service (Rea, 1999). Under pressure for evidence, a ‘plethora’ of satisfaction surveys lacking theoretical foundation is of mounting concern (Edwards & Staniszewska, 2000).

Few providers budget to routinely measure service user views. Measurement of service quality poses a challenge to some mental health professionals who deny their work can be ‘reduced’ to quantifiable data. Others may accept the idea but see measurement too narrowly, in terms of clinical effectiveness (reduction of symptoms, of risk, or in the need for medication) (Rea & Rea, 2000).

These obstacles ensure that, because government policy requires user involvement, what little is done tends to be sporadic and the result of a few committed individuals. When social workers and other providers perceive links between finance and their performance, or when providers see that career opportunities depend on the public’s perception, bias is likely. Surveys may merely establish whether users were satisfied with services and whether the service was achieving the goals set by the professionals (Godfrey & Wistow, 1997, p. 326).

One alternative that seeks to avoid this bias is where service users themselves evaluate the service (Rose, Ford, Lindley, Gawith, & Group, 1998). While this should be empowering for the service users involved, there may too be questions about the commitment of the service providers to change as a result of this sort of involvement. This sharing of commitment is central if involvement is to be turned into action. The emphasis now placed on leadership development may address these issues provided leadership is defined as dispersed leadership. The next section illustrates what is meant by this.

LEADERSHIP AND EFFECTIVE USER INVOLVEMENT

These obstacles to user involvement are apparent in several local initiatives in Swansea’s mental health services. However, some progress is evident.

Mental health services in the Swansea are provided jointly by health and social services through four community mental health teams (CMHTs). In-patient beds are available, as well as a variety of day services, a resource centre, and specialist services. While the pattern of responsibility is changing radically, social services are an arm of local government while health services are provided through a national service, the National Health Service (NHS).

In Wales, this is complicated by the recent devolution of government to the National Assembly for Wales (NAW) responsible for health care policy. Local government and health authorities have both been reconfigured over the past five years–a process that is continuing with the abolition of health authorities. At present, social care staff are employed by the City and County of Swansea, and health care staff employed by the Swansea NHS Trust.

The lack of clear direction from the top–which may be viewed as an opportunity–accounts for local variations in service development and initiative. The CMHTs have devised multi-disciplinary working, some more so than others. The range of user involvement initiatives have been previously reported elsewhere (NAW-Social Services Inspectorate for Wales, 2001; Rea & Rea, 2000).

As elsewhere, the main focus has been on assessing service user views of the service, responding with information and policy changes, and followed by further user involvement in assessing user views.

These processes are highly reliant on the will of the individuals concerned and are not easily mapped onto the bureaucratic structures of health and social services. The process of policy change–in response to service user views–is not easily formalised. It relies on changes to professional practice, the willing adoption of changes to clinical practice and care management. It principally relies on communications and dialogue between service users and providers. Usually, however, user involvement is perceived as a structural mechanism.

Structures for User Involvement

An example of how user involvement is easily demonstrated in Swansea. The comment of a recent Social Services Inspectorate (SSI) report is worth examining:

To view involvement as occurring and existing though ‘mechanisms’ and structures of ‘wider representation’ is a product of a quasi-legal Inspectorate examining what is expected to be bureaucratic. Obviously, community mental health services are delivered through bureaucratic organisations, with a separate legal status, separate funding, and clearly demarked patterns of responsibility and accountability.

However, multi-disciplinary work, using a variety of agencies, can also be viewed as organised in ways that cannot be adequately represented as a hierarchical bureaucracy. It avoids the nature of the work CMHTs need to do to be an effective community-based team.

Payne’s idea of ‘open teams,’ for example, cannot be represented well as a bureaucracy (Payne, 2000). He represents open teams pictorially as:

(Payne, 2000, p4)

This is a diagram intended to show how teams exist in relation to other teams. There are many definitions of teamwork, but some characteristics are common to all definitions. A team is not a group. Nor is a team a group of people working to a common person in charge over them (McGregor, 1960). Teams have common goals. Its members share information, decision making, and responsibility. Its decisions are made to work. There is open criticism matched by trust. Everyone must lead, at some time or another. Drawing largely on Harrington-Mackin (1993), Payne argues that leadership roles must be shared, nobody can opt out, and they need to focus on administration, quality, production, processes, training, supplies, work environment, and service user relationships (pp. 205-210).

In community mental health work, teams must work with and relate to teams in other agencies. And there is every reason why these relations should be extended to include service users–whether as isolated individuals or as members of representative bodies.

Open team working and networks should allow people to work together, whether they are paid employees or service users. Of course, bureaucratic relationships co-exist, and it would be foolish to ignore them. However, user involvement is unlikely to be organised neatly in a way that dovetails with bureaucratic hierarchies. This is likely to concern some, because services and the extent of user involvement will vary. The SSI report on Swansea, for example, is concerned about the structural mechanisms which were said ‘to be inadequate and all planning partners recognised the need to develop a more innovative approach to achieving a wider representation of views’ (NAW-Social Services Inspectorate for Wales, 2001, p. 20). But, equally, service users are unlikely to be entirely comfortable with the hierarchies and bureaucratic arrangements that some service providers feel more comfortable with. However, as the examples provided below illustrate, service users can be involved as part of a network, taking the lead sometimes in service developments, provided the key elements of open team working outlined below are fostered.

User Involvement and Building Dialogue

In Swansea, one of the CMHTs has attempted to build a dialogue between itself and its users over the past three years using a process of surveying what users think of the service and feeding this into professional practice and information provision. This strategy has increasingly been recognised as enhancing dialogue and, in 2001, the process was extended across the whole area. Moreover, in 2001, the draft questionnaire was reviewed with service users and questions added or altered. The questionnaire was therefore the result of work by health and social service staff, service users, and this author.

It is important to appreciate that this survey should not only be assessed by its ability to represent user views accurately by means of an objective scientifically validated instrument. It does not offer comparison over time or with other services. Its importance is as a means of opening dialogue.

The results of the survey are made public knowledge throughout the service, including principally the service users. It is intended to be a document for them when they want to argue for change. Over subsequent years, they will be able to measure progress. It is also intended to guide policy and management decisions, and to ensure service providers know what service users want of them. It provides service providers with the information they need to act, but it will also make them accountable to service users.

Building a dialogue that both service users and service providers value takes time and leadership skills. It takes time because service users have to test that it is genuine and because service providers have to see that it is valuable to users, and not a threat to themselves.

When service providers are being compelled to listen to user views, then professionals and services users are likely to view a survey as merely a requirement of the system. It is extra work for service providers and service users, and they may think the only likely benefit is to the people at the top. Service users have to see the results. They have to be able to comment on the results. They have to be able to look back and see that beneficial change occurred and that it can be attributable to the information provided earlier.

While survey evidence requires some sensitivity in its interpretation, the CMHT survey does provide some evidence of the necessary dialogue. It is apparent in a number of key indicators. One straightforward indication that service users value the survey as a means of communicating their wishes is whether they take part–and continue to take part, although we might also expect people to weary of filling on forms. The first survey, in 1998, was limited to one of the four CMHTs, and the response rate was 63%. By 2001, this had dropped to 54%. But in 2001, the survey was conducted in all four CMHT areas for the first time and the average was 37.7%. These are ambiguous data; respondent fatigue may have caused the reduction in the first area. Workload pressures may have prevented the survey being administered fully in the other areas. However, the fact that 54% of service users were willing to take part in 2001 does indicate some measure of its perceived value to them.

In planning the first survey (1998) it was decided to ask whether service users had enough information about their condition and their diagnosis. Informally, some CMHT staff indicated reservations about this question and doubted it would be of value to ask about it. The survey revealed, however, that 68% felt fully informed of their diagnosis and that 78% of these respondents found this information helpful. More seriously, 31% said they had not been told their diagnosis, and of these 68% said they would find it helpful. Decisions to change practice were made, but in 2001 the survey reported that only 58% had information and 33% said they did not. There were more respondents in the later survey from this CMHT area, and people may have different expectations, but otherwise this has to be interpreted as a failure to amend practice sufficiently.

Similarly depressing figures emerged when users were asked about whether they had enough information about their treatment or the services available to them. In 1998, 82% said they had enough information about their treatment, and 83% said they had enough information about local services. By 2001, for the same area, 74% said they had enough information about their treatment, and 77% said they had enough information about local services. Again, these figures need interpretation–especially with the word ‘enough’ in the question–as expectations may have altered. In response to the first survey in 1998, leaflets have been issued about treatments and services. This may have affected service user expectations, but otherwise these figures are disappointing.

Direct comparison between surveys is otherwise impossible because the later survey has incorporated many more questions than its earlier counterpart. However, the comparisons above offer a salutary lesson that gathering information about what service users want from their service can only be regarded as a first step in the process of change. Need for further action has been clearly identified and one response by the providers is to devise an information strategy. Since the latest survey, service users have been active in improving the care management process, taking part in improving review procedures. They have also worked on user-focused monitoring: devising, administering, and analysing their own surveys. These initiatives illustrate that some progress has been made in confidence and trust building.

The paper now outlines what is necessary to ensure action follows.

Team Building for User Involvement

Confidence building and establishing a dialogue are necessary first steps, but others are needed. Following Payne’s discussion (on pp. 205-210), these steps are set out below. However, we should note that current job descriptions and performance management measures that stress the needs of the seriously mentally ill cannot assist in this kind of support. If it happens at all, it takes place outside of work hours.

Less optimistically, we can note that users were involved with staff appointments under previous organisational arrangements. The new unitary authority (City & County of Swansea) has adopted a fair selection policy, however, that requires training. Service users have not had any access to this training and so can no longer take part. Organisational boundaries and policies do not always allow for the sort of collaboration needed for open teams and networks, or respect the rights of service users to be involved in planning their service. So training needs also to cross those organisational boundaries and, in this example, would empower users significantly.

These are probably the bare minimum of what is required for service users to be involved and to participate fully in open networks. In Swansea, there is some evidence that some of these things are happening, but not all. Much more needs to be done. Moreover, Swansea probably provides one of the more advanced services in Wales. So, it is likely that further work is needed elsewhere.

CONCLUSION–RECONCILING POLICY AND MANAGEMENT IMPERATIVES WITH USERS’ EXPRESSED DESIRES

This paper has highlighted some of the difficulties inherent in involving mental health service users in service planning. Policy directives and modern forms of management are increasingly demanding they have a say. However, for service users to find their voice and ensure it is heard, further empowerment is required. Foremost among the steps that can be taken to empower them is the idea that they be involved through open networks. An opportunity exists in the UK for management of services to move in this direction, through the government’s recent stress on leadership skills. These have yet to be defined adequately by central government.

However, the definition of leadership does not have to come from central government. Managers, educationalists, service provider professionals, and service users can work together within this framework to encourage team leadership that involves service users in affecting change. A structure of representation can assist in this process, but it is not always required, and it is not all that is required. Far more important is that service users be empowered and encouraged. Their views have to be sought and acted upon, and be seen to be acted upon.

The kind of leadership necessary for these developments to occur is unlikely to be top-down leadership in the ‘hero’ mould. This requires that the accountability of those with formal leadership positions should specify what they have done to lead others to lead themselves, rather than what they themselves have achieved. Dispersed leadership makes accountability and responsibility difficult. But, leadership has to develop within teams of people working together across–or in spite of–formal organisational boundaries and financial systems. This development requires policy and organisational boundaries to be re-thought.

There are useful, even obvious, lessons to be learned from the concepts of leadership within teams, and Payne’s model of open teams provides a way in which user involvement can be developed in the future so that the service is user-led at appropriate times. Considerable problems have to be overcome, however, and the benefits of this model cannot be demonstrated empirically. However, it may provide a vision for future user involvement.

NOTE

^1. http://www.jr2.ox.ac.uk/bandolier/band12/b12-1.html

REFERENCES

Barberis, P. (1998). The new public management and a new accountability. Public Administration, 76, 451-470.

Barnes, M. (1999). Users as citizens: Collective action and the local governance of welfare. Social Policy & Administration, 33(1), 73-90.

Barnes, M., & Wistow, G. (1994). Learning to hear voices: Listening to users of mental health services. Journal of Mental Health, 3, 525-540.

Bodwell, D. J. (1996). High Performance Teams.

Bowl, R. (1996). Legislating for user involvement in the United Kingdom: mental health services and the NHS and Community Care Act 1990. International Journal of Social Psychiatry, 42(3), 165-180.

Brandon, D. (1992). Skills for people: Annual report and national conference report. Newcastle-upon-Tyne: Skills for People.

Bryman, A. (1996). Leadership in organizations. In S. R. Clegg, C. Hardy, & R. Nord (Eds.), Handbook of organization studies. London: Sage.

Carignani, V. (2000). Management of change in health care organisations and human resource role. European Journal of Radiology, 33, 8-13.

Chandler, J. (1996). Support for community psychiatric nurses in multi-disciplinary teams: An example. In M. Watkins (Ed.), Collaborative Community Mental Health Care (pp. 292-306). London: Edward Arnold.

Croft, S., & Beresford, P. (1990). From paternalism to participation: Involving people in social services. London: Open services Project/Joseph Rowntree.

Dewa, C. S., Horgan, S., Russell, M., & Keates, J. (2001). What? Another form? The process of measuring and comparing service utilization in a community mental health program model. Evaluation and Program Planning, 24, 239-247.

DoH. (1999). A National Service Framework for mental health: Modern standards & service models. London: DoH.

DoH. (2000). The NHS Plan: A plan for investment, a plan for reform. (Vol. Cm 4818-I). London: HMSO.

Edwards, C., & Staniszewska, S. (2000). Accessing the user’s perspective. Health and Social Care in the Community, 8(6), 417-424.

Ferlie, E., Ashburner, L., Fitzgerald, L., & Pettigrew, A. (1996). The new public management in action. Oxford: Oxford University Press.

Geenen, H. (1985). Managing. London: Granada.

Godfrey, M., & Wistow, G. (1997). The user perspective on managing for health outcomes: The case of mental health. Health and Social Care in the Community, 5(5), 325-332.

Harrington-Mackin, D. (1993). Keeping the team going: A tool kit to renew and refuel your workplace teams. New York: American Management Association.

Hood, C. (1991). Public management reform in the 1980s: Reflections on national variations. Paper presented at the Calculating health in the new public sector? Workshop on changing notions of accountability in the UK public sector, London School of Economics and Political Science, Department of Accounting and Finance.

IBM Corporation. (1993). Ideas on Teams and Teamwork: IBM Corporation.

Katzenbach, J. R., & Smith, D. K. (1993). The wisdom of teams: Creating the high-performance organization. Boston, MA: Harvard Business School.

Margerison, C., & McCann, D. (1985). How to Lead a Winning Team. Bradford: MCB University Press.

McGregor, D. (1960). The human side of enterprise. New York: McGraw-Hill.

NAW. (2001). Adult mental health services for Wales: Equity, empowerment, effectiveness, efficiency: Strategy document. (September 2001 ed.). Cardiff: NAW.

NAW-Health Service Strategy Team. (2001). Improving health in Wales: Structural change in the NHS in Wales. Cardiff: National Assembly for Wales.

NAW-Social Services Inspectorate for Wales. (2001). Inspection of adult mental illness services in the City and County of Swansea. Cardiff: National Assembly for Wales.

NAW and the Audit Commission. (2000). Learning the lessons from Joint Reviews of Social Services in Wales, 1999/2000. Oxford: Audit Commission.

NHS Executive. (1999). Leadership for health: The health authority role.

Obeng, E. (1994). All change! London: Financial Times/Pitman.

OECD. (1992). The reform of health care systems: A comparative analysis of seven OECD countries. (Vol. 2). Paris: OECD.

Payne, M. (2000). Teamwork in multi-professional care. London: Macmillan.

Pollitt, C., Harrison, S., Hunter, D. J., & Marnoch, G. (1991). General management in the NHS: The initial impact 1983-88. Public Administration, 69, 63-83.

Ramcharan, P., Grant, G., Parry-Jones, B., & Robinson, C. (1999). Roles and tasks of care management practitioners in Wales–revisited. Managing Community Care, 7(3), 29-37.

Rea, C., & Rea, D. (2000). Responding to user views of service performance. Journal of Mental Health, 9(4), 351-363.

Rea, D. M. (1999). Towards routine user assessment of mental health service quality performance. International Journal of Health Care Quality Assurance, 12(4), 169-176.

Rose, D., Ford, R., Lindley, P., Gawith, L., & Group, a. t. K. C. a. W. H. A. M. H. M. U. (1998). In our experience: User-focused monitoring of mental health services. London: Sainsbury Centre for Mental Health.

Sims, H. P., & Lorenzi, P. (1992). The new leadership paradigm. Newbury Park: Sage.

Welsh Assembly Government. (2002). Adult mental health services: A National Service Framework for Wales. Cardiff: Welsh Assembly Government.

Welsh Office. (1998a). Better health: Better Wales: A consultation paper. (Vol. CM3922). Cardiff: Welsh Office.

Welsh Office. (1998b). Improving local services through best value. Cardiff: Welsh Office.

Welsh Office. (1998c). NHS Wales: Putting patients first. (Vol. Cm3841). Cardiff: Welsh Office.

Welsh Office. (1998d). NHS Wales: Putting patients first: Local Health Groups preliminary guidance. Cardiff: Welsh Office.

David M. Rea is affiliated with the Centre for Health Economics and Policy Studies, School of Health Science, University of Swansea, Singleton Park, Swansea, SA2 8PP, UK (Website: http://www.healthscience.swan.ac.uk/) (E-mail: [email protected]).

The author would like to acknowledge the service users and staff whose support was invaluable to this research.

This paper is a revision of a paper presented for the Social Factors, Prevention and Empowerment stream of the 3rd International Conference on Social Work in Health and Mental Health, July 1-5, 2001, Tampere, Finland.

[Haworth co-indexing entry note]: “Changing Practice: Involving Mental Health Service Users in Planning Service Provision.” Rea, David M. Co-published simultaneously in Social Work in Health Care (The Haworth Social Work Practice Press, an imprint of The Haworth Press, Inc.) Vol. 39, No. 3/4, 2004, pp. 325-342; and: Social Work Visions from Around the Globe: Citizens, Methods, and Approaches (ed: Anna Metteri et al.) The Haworth Social Work Practice Press, an imprint of The Haworth Press, Inc., 2004, pp. 325-342. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. 5:00 p.m. (EST). E-mail address: [email protected]].