Of all the words and phrases that make me go hmmm, ‘service user’ is right up there. I actually cringe every time I hear anyone use it to define and describe other people. And I hear it a lot. And read it a lot too. So if it’s such a common term in adult social care, why is it so bad?
Identity: the same – but different
We describe people as service users whether they’re actually using a service or not. It’s become a generic term to define the people we might and do support. The NHS has patients. Adult social care has service users. But by describing people as service users, we’re defining people solely through the service they use and denying them an individual identity. We’re seeing a single element of a person rather than the whole person in the context of their whole life: who they are now, who they were and who they want to be. We’re ignoring the experiences, characteristics, relationships, connections and ambitions that make them people. Human beings.
We use the term service user to lump people together into a homogenous group – defined by the service they may or may not use. There’s an implication that everyone within that group is the same. Same label. Same needs. Same old service solutions. And because everyone in the group is the same, we’re keen to listen to their one sole ‘service user voice’. A token few service users are ‘involved’ or ‘engaged’ in forums and groups and committees. They are recruited (but not usually paid) to ‘represent service users’ and ‘ensure that service users’ voices are heard’. And those who are denied a service are denied a voice.
There is also the implication that if you’re in the ‘service user’ group you’re separate. Not a professional. Not part of the community, or a member of the public. Not an individual. Not even a person. There are countless examples of this. The Kings Fund has a web page called “Working with patients, service users, carers and the public” on which it describes a commitment to “developing a more collaborative relationship with patients, service users and individuals”. And NICE has a ‘Patient and public involvement policy’ which makes multiple references to “patients, service users, carers and the public”. In a recent call for views on civil participation, the British Association of Social Workers referenced the government’s Civil Society Strategy, suggesting it sets out important steps on “involving people and service users in services”. And the strategy it refers to mentions work to “support local authority commissioners to co-design and co-deliver services with local people, service users, and civil society organisations”.
Often the phrase is shortened just to ‘user’. And that term has the obvious associations with drugs and exploitation. Whether it describes an addictive or abusive relationship, it’s not a healthy one, and inevitably there is a destructive power imbalance in which one party is controlled by another.
In social care, the term ‘users’ suggests that people are passive recipients. Users of a service designed and developed and provided for them, rather than people identifying and shaping and controlling the support that they know will work for them. People who have direct payments even get labelled – without irony – as ‘direct payment service users’.
And all too frequently we add possessive pronouns like ‘my’, ‘our’ or ‘their’ when referring to service users – introducing an element of ownership and control, and reinforcing the unequal power dynamic. The professional and the service user. The provider and the recipient. The controller and the controlled.
Alex Fox claims that within the current power imbalances of our traditional public services, “detachment is the only manageable relationship one worker can have with numerous service users”. He suggests that our current approach brings together “two people in crisis: the personal crisis of the support seeker and the ongoing professional crisis of the hard-pressed public service worker”, and that “impersonality protects each from the other’s crisis”.
Our detached attitude is, to a significant extent, a symptom of our current ways of working. Indeed our sorting office approach relies on us keeping our distance. Maintaining our professional boundaries, and keeping ‘our service users’ firmly ‘over there’, helps us keep the show on the road. Identifying people as service users allows us to define our response to them in terms of services. As a service provider. It excuses the way we process people and pass them around. It makes it easier for us to deny their humanity, and to avoid our own humanity.
But while this othering, this separation, this indifference may help us cope, it’s dangerous. Really dangerous.
Death of a service user
When we stop identifying people as fellow humans, we’re failing to respect them. Failing to fight for their rights. Failing to believe in them. Failing them.
Reading Sara Ryan’s book ‘Justice for Laughing Boy’ I was horrified by the following cold, stark reference to Connor Sparrowhawk’s death in Southern Health board papers: “A Serious Incident Requiring Investigation (SIRI) occurred in one of the Trust’s learning disability in-patient facilities leading to the unexpected death of a service user. The post-mortem indicates the user died of natural causes…”
I only found out more recently that the Care Quality Commission has a regulation on the “notification of death of service user”, and countless other NHS trusts and care providers have their own ‘Death of a service user’ policies.
What does it say about our ‘care’ system when even in death we still refer to people as service users? When we continue to deny them an individual identity. When we refuse to refer to them by their name?
A better, brighter social care future
It’s easy enough (or should be) to talk about people rather than service users. It doesn’t take much to replace the term in a form or in policy or on a website. And that’s a start. But this is about so much more than just dropping one phrase and employing another in its place.
It’s not enough to make claims about person-centred working, and seeing ‘the whole person’, when the organisations we work in are designed around, and indeed rely on, us only seeing parts of people according to which box they or their diagnosis or their circumstances fit in to, and as such which service we assess them for.
We need to be much more ambitious, more radical than that.
First we need to acknowledge that there is no space for individuals in our current sorting office system with its standard pathways and generic processes that rely on us ‘doing to’ a homogenous group of service users, where our response is to give them a service – presented as a ‘package’, like a gift.
We need to accept that there is no place in our existing structures and hierarchies for people to be anything but passive recipients of services.
We need to recognise that the bureaucracies we’ve created to care for and protect and ‘safeguard’ people have become too big, too complex, too detached, and too dangerous.
And we need to be properly shocked by the fact that the only way we can continue to work in this way is to shut down our emotions and just keep ticking the same old boxes and filling in the same old forms.
Then we need to look at the alternatives. We need to value the trusted relationships, where people have time and space to work together as equals, and where barriers between ‘them and us’ are broken down. We need to tell the stories of difference, where honest conversations about what matters lead to support based around thriving rather than services designed merely for surviving. We need to celebrate the small scale, local, community-based innovations and allow them to develop and flourish without imposing top-down rules and red-tape.
We need to want to change.
Service user forums become redundant when we spend our time building better lives rather than commissioning better services. We don’t need experts by experience or service user representatives to speak on behalf of others when we actually spend our time listening to the individual voices of people and their genuine representatives, and support them to shape their own future. ‘Coproduction’ as an afterthought bolted on to our policies and plans becomes redundant when working together and trusting each other and listening and being kind becomes the core of everything we do.
In our better, brighter social care future, we recognise and respond to individuals. We value and respect difference, because we’re all unique – and that’s what makes us all human. But we also recognise that ultimately we all want pretty much the same. We all share a common desire to love and be loved. To have something to look forward to. To have hope and purpose and aspirations. To feel valued. To belong. And that’s what makes us all human too.
In our better, brighter social care future, our focus is on lives, not services. There is no them and us. There’s just us.
 Working with patients, service users, carers and the public The Kings Fund
 BASW would like to hear your views and experiences of civil participation British Association of Social Workers, 18 October 2019
 Civil Society Strategy: building a future that works for everyone Department for Digital, Culture, Media and Sport, 9 August 2018
 A new health and care system, Alex Fox, 2018
 Justice for Laughing Boy, Sara Ryan, 2018
 Regulation 16: Notification of death of service user Care Quality Commission