Assessing the consultation process - a critical analysis of

Liverpool City Council's adult social care provisioning and

accountability in the context of service delivery in an era of

local authority austerity

Ross Campbell

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ContentsAbstract Page 3

Introduction Page 31.1 Introduction Page 3

Literature Review Page 5

2.1: Local Context Page 5

2.2: What do we mean by ‘consultation’? Page 7

2.3: Consultation and ‘democratic empowerment’ Page 8

2.4: Consultation, the ‘market imperative’ and political interference Page 10

2.5: Impact of austerity on consultative service delivery Page 11

Methodology Page 13

3.1: Study Methodology Page 13

3.2: Data Analysis Page 14

3.3: Ethical Concerns Page 15

3.4: Sampling Page 15

Findings Page 15

4.1: Findings Page 15

(A) Defining the concept of consultation Page 16

(B) Pre-determination in the consultation process Page 17

(C) Council versus service user interests Page 17

(D) Risk to service users Page 19

4.2: Discussion of Findings Page 20

Conclusion Page 22

5.1: Conclusions and Recommendations Page 22

5.2: Study Limitations Page 23

References Page 24

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Abstract

The idea of consultation in the delivery and formulation of services in the field of health and social care is of growing interest to policy makers and practitioners. However, there remains much in the way of ambivalence over what the term actually means in practice, and this has resulted in discussions over how far the input of those being consulted extends to the outcomes of public consultations. The following dissertation reviews the literature on such consultation process and concepts and then describes how a qualitative research methodology was used to explore the experiences of two activists and two service users who were engaged in a consultation process with Liverpool City Council’s adult social care provision. The findings revealed a number of themes, including consultation as an ambivalent and ill-defined concept, evidence of pre-determinism within the consultation process itself, conflicting expectations between policy-makers and service users, and risks that were not explored by Liverpool City Council as a result of the process and the eventual outcome. The study concludes with a number of recommendations, including better mechanisms of engagement for service users and greater clarity of their specific role in the process, the introduction of independent advocacy in future consultations, and the incentive to undertake more research where service users are co-researchers.

Keywords: Consultation, service users, austerity

1.1: Introduction

In September 2014 Liverpool City Council invited members of the public to participate in a

six week consultation process as part of a broader reassessment aimed at addressing how to

reorganise local health and social care services following the imposition of spending cuts by central

government. Like all local authorities across the country, massive reductions to public spending

were deemed mandatory as a direct result of the Conservative-led coalition government’s 2010

spending review, which introduced new measures to “radically increase local authorities’ freedom

to manage their budgets”, but which also dictated that local authorities make “tough choices on

how services are delivered within reduced allocations” (HM Treasury, 2010: 8). Immediately

following the review’s publication, estimates emerged predicting that Liverpool City Council would

lose £45 million each year with a 7.25% cut to local authority funding, totalling £180m over four

years (Davies, 2010: 1) - an outcome dubbed ‘worse than the worst-case scenario’. Excluding the

possibility of putting forward and voting for an ‘illegal budget’, as Liverpool’s Militant Labour

council administration had done in 1985, the only other option available would be dramatically cut

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spending on local authority funded public services, either to be replaced with private or voluntary

sector alternatives, or simply not replaced at all.

Whilst there continues to be bitter disagreement between Labour, Green, Liberal and

Liberal Democrat councillors regarding the limited field of options available to Liverpool City

Council under such tight fiscal parameters (and specifically where the ‘axe should fall’), it

nonetheless remains true that this local authority, like many others, is now massively restricted by

austerity imposed by the UK Treasury – a reality now set to continue for the foreseeable future

under the Conservative majority government which was elected in May 2015. Writing for the

Guardian in 2011, a year after the publication of the coalition’s spending review, Liverpool’s Mayor

Joe Anderson explained the council’s position:

“We've made £30million in efficiency savings by reducing middle management, using what

reserves we can and cutting executive and performance related pay. Now there isn't any fat

left – only the flesh and bones of vital services… We will not let Whitehall mandarins come

in and set the budget for us. We will do what we've been elected to do: we will lead.”

(Anderson, 2011: 1)

In what ultimately amounts to a clear admission that central government spending cuts

would be adhered to no matter what the outcome, many questions regarding the legitimacy of the

consultation process must therefore be asked; specifically surrounding the impact that such

punitive budgetary decisions will inevitably have on democratic accountability, transparency, and

levels of pre-determinism regarding outcomes. Put simply, with Liverpool City Council fully

committed to implementing austerity measures and unwilling to entertain alternative spending

options a question arises as to; what value can be found from a public consultation process that

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might possibly result in dissenting viewpoints only likely be ignored or disregarded due to self-

imposed fiscal constraints?

In many ways an issue such as this feeds into a broader discussion of what ‘consultation’

really means, and for many years this issue has been the topic of much academic debate. One

question that immediately arises when we begin to consider the issue is whether or not the

purpose of ‘consultation’ is simply to gather information as part of managerial approach to

commissioning services, or whether it is instead a truly open and transparent process designed to

democratise and transform the decision-making paradigm itself. In addition to this, we must also

consider the extent to which the relatively recent phenomenon of local authority austerity has

impacted this process, and consider how far funding restrictions have altered this dynamic further.

The aim of this dissertation will therefore be to determine the definition of 'consultation' in the

context of public policy-making, and to assess whether Liverpool City Council’s adult social care

policy is an accurate reflection of public opinion or simply a 'tokenistic' gesture offering little in the

way of real substantial choice to participants.

2.1: Local context

In September 2014, Liverpool City Council outlined their proposals for discussion, with

mental health services to continue with two ‘hubs’ in the city, and with more of an emphasis

placed on recovery and rehabilitation. Continued council funding was proposed for The Lime

(physical disability and sensory impairment), Middleton (older persons/day services), Crown Street

(mental health), Amethyst House (mental health crisis support) Aigburth (alcohol), Sedgemoor,

Granby, and Venmore (older people) (Hunt, 2014: 1). Lancaster (learning disabilities), Alderwood

(learning disabilities), Parthenon House (mental health) and Geneva Road (homeless) were

earmarked to remain open but transferred to external organisations. Besford House (Belle Vale) to

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selected to become a specialist residential service for those with complex needs such as autism or

brain injuries, Norris Green (older persons/day services) to be relocated to Venmore and Speke

Day Centre to be closed completely (Hunt, 2014: 1). The proposals were offered to the public for

discussion as part of a consultation process scheduled to last for six weeks, following which a

decision would be made by the council regarding the outcome.

Following the six weeks of public consultation meetings with health and social care

professionals, service users and council staff, on 18th November 2014 Liverpool City Council's Adult

Social Care and Health Select Committee announced the outcome of the consultation monthly

public meeting, stating that they had, “considered a recommendation that the recommendations

set out in the report submitted be approved in order to achieve the changes required to deliver

£3.6 million Adult Social Care and Health Transformation & Efficiency proposals” (Liverpool City

Council, 2014: 3). The Council's decision revolved around a plan whereby a number of services

would remain publicly funded and available to the public as “in-house core specialist services”;

some of them to be consolidated and amalgamated or moved, and others to be “commissioned

externally”, or put out to tender (Liverpool City Council, 2014: 3). Changes specified by the Council

at this meeting included services at Lancaster (Walton) and Alderwood learning disability centres

(Speke), Parthenon House mental health centre (Norris Green) and Geneva Road homeless hostel

(Fairfield) being identified for outsourcing, and were therefore selected to be put out to tender to

external, private providers. Speke Day Centre was earmarked for closure, and Norris Green Older

Persons day service would be relocated to Venmore in Anfield, with services at centres deemed

‘’specialist’’ including Crown Street Mental Health Hub to continue to be run in-house by the

council as one of their “core services” (Brennan, 2014: 1).

Councillor Roz Gladden, Deputy Mayor and Cabinet Member for Adult Social Care and

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Health defended the Council's decision to act on their original proposals, specifying that their

decision was based on the need for a reduction in funding for Social Care from £220m in 2010 to

£134m in 2016/17, but this was criticised at the meeting by a member of the 'Save Our Sanity'

mental health campaign for failing to adequately address the views of service users who

participated in the public consultation (Liverpool City Council, 2014: 4). Regardless of whether this

accusation was true or not, there can be no doubt that the final plans agreed on by Liverpool City

Council were virtually identical to the proposals put forward at the very beginning of the

consultation process, and such we must critically consider the model of 'consultation' that

Liverpool City Council had in mind in this instance.

2.2: What do we mean by 'consultation'?

For decades the concept of consultation has been challenged for its ambiguity, and a lack of

an agreed meaning has arguably resulted in a dissonance of expectation between participants and

policy-makers. Importantly another voice, that of service user engagement in the delivery and

formulation of services has, since the 1980’s, been increasingly viewed as an essential component

of the conceptualisation of services (Barnes et al, 2006: 329). It was, however the New Labour

government that took office in 1997 who fully legitimised the idea of consultation as integral to the

development, implementation and evaluation of health and social policies in the UK (Cook, 2002:

516). In 2003 the concept of greater public consultation formed the basis of a major policy

announcement by Prime Minister Tony Blair, as he announced his government's 'Big Conversation'

exercise; explaining that, "big issues need real debate, a big conversation between politicians and

the people." (Trevelyan, 2003: 1). However, the policy initiative was shelved less than two years

later amid widespread criticism, with former Labour minister Roy Hattersley describing it as, “a

confidence trick in a good cause" (Leyden, 2003: 1). If nothing else, this failed policy exercise was a

very public demonstration of how those consulting and those being consulted can often have very

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different expectations regarding the issue of who ultimately has the final say in determining

tangible outcomes.

Cook argues that there is a widespread acknowledgement among those involved in social

policy-making that consultation is a crucial, yet “deeply problematic” process, with an official view

that the 'old' model of consultation, viewed as “tokenistic, unrepresentative and not engaging”.

These notions have been replaced with a more open, democratic and participatory alternative.

Nonetheless, some would argue that more user-responsive and democratised services have still

not been realised (Lewis, 2012: 279), and that authentic service user involvement in shaping those

services remains “a slogan, a concept with unrealised potential” (Leung, 2011: 43). One of the

main reasons for this is a fundamental ideological divide over what service user consultation and

engagement is, and what it should be in the future - with strong tensions between the consumerist

impetus of mainstream state-related interest in the issue, and the democratising and participatory

emphasis on service user movements themselves (Beresford and Branfield, 2006: 438).

2.3: Consultation and 'democratic empowerment'

Whilst the 1970's and 1980's were associated with a shift to the political right in the UK

resulting in a new market-driven consumerist approach to health and welfare, conversely it was

also a period when new organisations and movements led by service users began to develop

(Beresford and Branfield, 2006: 438). These have variously been defined as new social movements,

or protest and liberation movements aimed at redistributing the unequal distribution of power,

and their focus on service user involvement is based on a philosophy of democratisation and

empowerment (Beresford and Branfield, 2006: 438). This shift of emphasis from representative to

participatory democracy derives from at least two sources, the first concerning itself with the way

in which public services are managed and governed, with the primary focus on enhancing the

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responsiveness of services provided; and the second concerning itself with opportunities for the

authentic expression of lived experiences which have gone unheard or have been actively silenced

(Barnes et al, 2004: 93). Whilst the first addresses how the involvement of service users has the

potential to contribute towards the improvement of services at a structural level, the second

source perhaps holds greater significance as it seeks to redress the imbalance of power between

those commissioning services and those using them, and in the process open up the possibility of a

more democratic approach to the conception and delivery of those services.

The shift away from an old-style top-down to the formation and delivery of services is

highly significant, due to the fact that enhanced public participation is viewed as capable of

improving the quality and legitimacy of decisions in government, health services, local government

and other public bodies - as well as having the potential to address the 'democratic deficit' and

further develop community capacity and social capital (Barnes et al, 2003: 379). In short, a more

collaborative approach to creating and delivering services should, in theory, benefit everyone.

Other benefits include increasing options and broadening perspectives. Healy and Boyd argue that

this process is important because service users can often see the obvious in situations where

professionals “only see what they expect to see” (2011: 26), and their perspective allows for a

broader appreciation of the 'big picture'. In the context of the delivery of health and social care

services, improvements have also been observed in the co-ordination of care and in the

relationships between clinicians and those receiving treatment, and service user involvement has

also been associated with positive clinical outcomes including improved self-esteem and

confidence, and therapeutic benefits resulting from increased social interaction (Omeni et al, 2014:

3). Therefore, in theory at least, service user consultation as a genuine exercise in democratic

participation should be welcomed by all parties as a genuine method of improving services and as

a source of inspiration.

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2.4: Consultation, the 'market imperative' and political interference

It could alternatively be argued however, that consumerist thinking in recent decades has

resulted in a view of client-participation that lacks the capacity for legitimate service user influence

on organisational decision-making, despite progress made by radical service user groups in the

interim period (Leung, 2011: 43). This is reflected in the way in which dominant managerial and

bureaucratic approaches to service user involvement have attempted to 'graft' their participation

onto existing policy-making structures (Lewis, 2012: 279). Assuming this is the case, much of the

involvement on offer to service users is therefore not based on a desire to open up, or democratise

services, but instead based on a consumerist model of involvement operating as a form of market

research – which for many service users, can feel little more than tokenism, or a box-ticking

exercise rather than genuine partnership decision-making (Beresford, 2010: 499). This effectively

reduces the role of the service user to little more than information providers, with commissioners

free to regard them as ‘customers’ rather than true equals in the decision-making process

(Beresford, 2007: 309)

Barnes argues that another potential reason for the exclusion of service users from

legitimate decision-making in the context of a consultation process is due to the process itself

often proving uncomfortable for professionals unused to being questioned by their clients or

patients (1999, 81), which in turn can lead to participants feeling peripheral to core activities and

priorities, and in some cases feeling undervalued, undermined and used (Cotterill et al, 2010: 166).

One result of this is that service users increasingly complain about consultation fatigue, a

frequently negative response resulting from the perception of their input having little if any

discernible effect on the outcome of consultative involvement (Beresford, 2010: 497). Despite

decades of attempts to achieve more user-responsive and democratised services, it can still be

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argued that there remains a large implementation deficit due to the rigidity and inflexibility of

professionals and institutions to alter their working practices and accommodate a more

collaborative approach to delivering services (Lewis, 2012: 279).

Another barrier faced by service users is the potential for special interest and party political

groups to distort the outcome of public consultations for their own ends (Barnes and Coelho, 2009:

228). Holden et al compiled a study in 2001 investigating the public perception of the development

of secure mental health facilities in Rotherham, where the local health trust conducted a public

consultation process in relation to the proposed development of a medium secure mental health

unit in the local community. The findings suggest significant discrepancies between the perceived

fears identified by local residents due to a lack of understanding regarding the nature of and

purpose for the facility, and Trust managers who felt that their risk assessments were adequate,

and this tension was compounded further by local politicians playing a very influential part in the

consultation process (2001: 513). Holden points out that the public consultations took place

around the time of local or general elections, and that this was believed to have heavily influenced

the way in which the politicians dealt with their constituents' concerns (Holden et al, 2001: 518).

When the public consultation took place, one Trust manager described, “mass hysteria, shouting

abuse... it was like something out of a film” (Holden et al, 2001: 519). Whilst the consultation

process in this instance might have had a constructive and collaborative outcome, ultimately this

case study can be seen to illustrate how there are often competing agendas at play within the

context of a consultation process, and how this can lead to “conflict as well as collaboration”

(Beresford, 2010: 500).

2.5: Impact of austerity on consultative service delivery

If it remains the case that public consultation continues to fall short of the fully-realised

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exercise in democratic participation envisioned during the New Labour years, then we must also

consider the impact that the 2010 Spending Review has had on this relationship. In December

2010 following its publication, the Communities Secretary Eric Pickles stated:

“Taxpayers are no longer prepared to write a blank cheque for the public sector. But they do

want less interference in their local communities from Whitehall government. So the

coalition government is delivering the most significant shift in power from officials in

London to elected local councils in a generation."

(Curtis, 2010: 1)

However, by 2014 the National Audit Office reported that half of all Councils in the country were at

risk of financial failure within another five years as a direct result of the 2010 Spending Review.

Margaret Hodge, chair of the Public Accounts Committee reported that, “local authorities with the

highest level of deprivation have seen the biggest cuts, potentially putting vulnerable people at

risk” (Syal, 2014: 1), with Liverpool among the worst affected local authorities in the country.

Whilst the Coalition government's rhetorical approach to local government had emphasised the

devolution of power to communities and promise of greater grass-roots democratic control over

how services are formulated and delivered, the reality of a substantially reduced budget has

arguably resulted in less control for local communities and fewer options as well. Noble and

Henrickson argue that it is futile to assume that an unfettered free market can replace the state

and provide for all the needs of its citizens (2011: 128), and that the rise of the neo-liberal

economic model over the past several decades coupled with higher levels of inequality in societies

that have implemented more radical free market reforms clearly demonstrates this. The result of

this ideological trend has resulted in a structural decline in the quality and quantity of local

authority health and social care services, and this has accelerated since 2010 as a direct result of

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the Spending Review.

The outcome of this has led to government calls for service user involvement to be met

with increasing suspicion, with these unprecedented spending cuts being made in the name of

“reducing the public deficit” having brought the previously held ambiguities of service user

consultation into sharp focus (Beresford, 2010: 52). Service users and their allies meanwhile have

increasingly adopted alternative approaches to making their views heard, using social networking,

demonstrations and direct action, through collective action and organised marches, nationally and

locally to express their opposition to austerity (Beresford, 2011: 1). Whilst in one sense this

approach can be viewed as a political response to the democratic deficit in the decision-making

process, it could also be argued that austerity has strengthened and radicalised service user

movements aimed at demanding change in a way that was not evident during the New Labour

years.

3.1: Study Methodology

The study described below involved interviews with key stakeholders to critically examine

the consultation process involved in restructuring mental health services in Liverpool City Council.

Rather than conducting case studies, questionnaires or organising focus groups to gather

information, the study sought instead to carry out interviews with a small number of mental health

service users, as well as members of the Health and Adult Social Care Select Committee,

campaigners and other local residents, with the primary objective of gaining a greater

understanding of their experiences and points of view regarding the process, and to obtain more

detailed information regarding the specific circumstances surrounding the consultation process

itself. One of the limitations of the study, discussed below, was that, despite concerted attempts to

encourage these stakeholders to participate, in the end only two service users and two

campaigners who had been involved in the consultation process, agreed to be interviewed. In

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order fulfil the aim of the study, a qualitative, interpretive phenomenological research

methodology was used. This allowed for a subjective exploration of experience from a participants'

perspective (Roberts, 2013: 215). The interpretive phenomenological approach departs from

‘simply raising awareness about a phenomenon’ through simple description, in favour of wanting

to ‘attain a broader and deeper understanding’ of what the phenomenon means to those who

experience it in their own social-cultural contexts and realities, including how the experience alters

their entire being (Matua, 2015: 24).

Given that much of social work is concerned with holistic well-being and service user-led

agendas, particularly in the context of anti-oppressive practice (Dominelli, 2009:49) it was felt that

this approach would be particularly appropriate given the context and the underlying power

structures inherent to the consultation process that took place. This approach proved useful for

identifying common scenarios that participants experienced throughout the consultation process,

and allowed me to gauge the level of engagement felt by participants. I met with participants for a

semi-structured interview, utilising directed questioning, but with enough flexibility to allow for

open questioning and follow-up responses that might result in more detailed data collection. A

number of questions were asked of participants to fulfil the aim of the study, including what they

understood the term 'consultation' to mean, the extent to which they felt decisions had already

been made before the process began, what they felt the key issues to be, how they felt the process

did (or did not) address latent underlying power structures, how they felt service user sensitivities

were addressed, and the extent to which they felt policy-makers had addressed the risks posed to

service users in the event of services being lost.

3.2: Data Analysis

A thematic approach to the analysis of the data was used in the study. This helped in

identifying, analysing and reporting patterns or themes within the data, whilst simultaneously

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facilitating the search for, and identification of, common threads that extend across an entire

interview or set of interviews (Vaismoradi et al, 2013: 400).

3.3: Ethical Concerns

From the outset of the data collection process, the study complied with the BASW

professional code of ethics, through commitment to human dignity and worth, social justice,

service to humanity, integrity and competence (Horner, 2003: 135). Confidentiality agreements

were presented to all participants ahead of their interviews, and a clear explanation regarding

their role in the participation was also provided. Due to the fact that the nature of the research

was based on policy and procedural issues rather than exploring the life experiences of service

users, there were no major ethical concerns flagged up at panel as likely to adversely affect either

the research itself, or the well-being of participants. The study received ethical approval from the

University’s ethics committee.

3.4: Sampling

A convenience sampling approach was used in the study. Despite invitations being extended to a

broad range of individuals involved in the public consultation process, including service users,

academics, anti-austerity campaign groups, members of the select committee in the form of

councillors and health commissioners, and the P.R. consultants responsible for hosting the

consultation events, the only participants who agreed to be interviewed were two mental health

service users, and two campaigners.

Participant 1 Mental health activist/campaigner

Participant 2 Service User

Participant 3 Mental health activist/campaigner

Participant 4 Service User

4.1: Findings

Of the four participants interviewed there were a number of consistent themes and issues

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that emerged: Defining the concept of consultation; Pre-determinism to the consultation process;

Council versus service user interests; and Risks to service users. These are now described using

illustrative participants’ quotations.

(A) Defining the concept of consultation

When asked about what they believed the definition of a consultation process to be, some of the

participants expressed the belief that consultations should be open and democratic in theory. Thus

P4 believed that consultation, “implies a shared decision-making process”, and that it represents,

“the underlying idea that the original idea can be changed and adapted to take into account the

differing voices”. P2 explained that they felt that a public consultation was, “supposedly a two-way

thing”, and P3 described that process as, “the underlying idea that the original idea can be

changed and adapted to take into account the differing voices”.

However, P1 expressed cynicism over the likelihood that this might be possible, questioning

the legitimacy of the process from an ideological perspective;

“Are the outcomes of this process pre-determined by government ideology? Things like a

commitment to the free market, commitment to austerity and so on? Or is there genuine

scope for citizens to shape the outcome of debates around the nature of service provision

through a consultation? I don’t think that processes in and of themselves allow us the

democratic space to regroup, and genuinely produce democratic outcomes.”

P4 was concerned about the gulf between what they believed the terminology to mean and what

they believed the outcome to be in reality, describing it as, “basically just an explaining of what’s

going to happen in the future, with very, very little ground for manoeuvre from that”.

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(B) Pre-determination in the consultation process

The interviews were used to explore whether participants believed or did not believe that the

outcomes of consultation might be pre-determined. They were therefore asked if they felt that

they were active parts of the decision-making process or not during the six week period. All four

participants felt that to varying degrees that they believed there was at least some element of the

outcome being fixed ahead of the public consultation, and a few described how they came to

believe that this was in fact the case. P2 described their personal experience of the process as

follows

“We were supposed to have received letters from the council that nobody actually had,

telling us that we’d had a previous meeting that made us feel totally delusional, because

none of us could remember it… The thing is, meetings were arranged between the council

and the service users at Crown Street… The email address was dodgy - nobody could book a

place through the email. And the phone number was not on an answer machine, it just

never got answered. So it was almost like they were wanting as few people there as

possible.”

P1 explained that they became aware of the proposals, “on the basis of a leak from someone who

was working within services that suggested cuts, outsourcing and potential closure of day services

and resource centres was coming down the line”, and P3 described the entire process as “fairly

meaningless”. When discussing the level of inclusivity they felt they experienced participating in

the public consultation, P2 explained that they felt the “lack of compassion was almost blinding”,

and P3 described the process as “fairly meaningless”.

(C ) Council versus service user interests

Another issue that emerged was a degree of scepticism over whether the interests of the

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Council were in conflict with those of service users. In relation to the council's motivations for

holding a consultation in the first place, P2 explained that they believed the Council, “desperately

wanted to put the two centres, Parthenon House and Crown Street out to tender”. P3 agreed,

stating, “it's quite simple, it's economic”, and P4 described the process as “capital-driven”. P1

further commented:

“Clearly the key issue for the council was that it was seeking to make £156 million of cuts,

and it was seeking to make £42 million of those cuts in social care… to my mind, it doesn’t

make much difference to me whether it’s a party making cuts with a heavy heart. If you’re

making cuts, you’re making cuts. And the question for me is, “are you part of the problem,

or are you part of a solution to that problem?”

When discussing how the consultation process addressed latent underlying power structures

between ‘professionals’ and ‘service users’, P2 argued that:

“What they did was very much divide and conquer, it was as if the staff were told to tell us

absolutely nothing as service users. We couldn’t talk to them, the staff couldn’t come to our

meetings, or when we were organising campaigns against the proposed tendering out and

stuff. So they kept us very, very separate, the service users and staff. And I think they still

kept the staff in the dark about a lot of things as well, but it was very much a divide and

rule.”

P1 responded along similar lines, explaining that, “that was flagged up as an enormous

problem from the start,” and that staff members working at the day centres were initially

instructed not to inform service users of any changes to the services. P3 explained that they

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believed the Council were effectively incapable of delivering a consultation that addressed latent

underlying power structures in an competent way, arguing that, “people with power don’t know

how to given up that power and consult in democratic ways”, and P4 described service users as

“just being pawns in this game”.

Participants also questioned how the Council had approached the public consultation from

the perspective of recognising sensitivities specific to mental health service users. P1 explained

that, “the shape of the proposals did not recognise or acknowledge what service users felt was

important about how those services operate,” whilst P2 explained, “I don’t think they care”, P4

expressed the belief that, “either [policy-makers] haven’t [displayed a knowledge of service user

sensitivities], or they’ve just buried their humanity”, and P3 described their approach as a

“bastardisation of the democratic process”.

(D) Risk to service users

All four participants expressed scepticism over whether the council were aware of potential

risks to service users if the day centres were to be closed completely as a direct result of local

authority cuts. P2 explained;

“That was one of the things that came up again and again – that they'd not really done any

proper risk assessments. We were saying to them, “Please tell us when this has happened in

the past, what the result was – when you've done this with day centres, were there more

suicides? Were there more hospitalisations? But we never got any facts and figures, and

that was our concern”.

P1 asked the question, “where is the research, the evidence base to give us confidence that the

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situation for these people hasn't deteriorated because of the removal and closure of these

services?”. P3 explained that they suspected very strongly that there would be, “significant

heightening of risk, and maybe even the loss of life as a consequence”, and P4 described the

Council's approach as, “worryingly socially Darwinistic”.

4.2: Discussion of Findings

McLoughlin argues that consultation is often viewed a usefully ambiguous term that is open

to abuse, due to the fact that it can mean nearly anything to anyone. As such, it could also be

argued that consultation does not require those who are consulting to act on any of the

consultee's views, only to hear them (2009: 152). Reflecting on the findings from the research

conducted for this dissertation, it seems reasonable to deduce that this view is broadly shared by

all of the participants, and that their experience of participation within this particular consultation

process was marginal at best. It is also true that local authorities including Liverpool City Council

are facing greater pressure and demands on their services at a time when central government

support is being scaled back. It is precisely the more disadvantaged local authorities with greater

concentrations of households in need and levels of deprivation that are being disproportionately

affected by reductions in government expenditure, with third sector agencies that provide support

for hard-pressed households also facing significant financial reductions given their greater

dependence on statutory funding (Kennett et al, 2015: 640). This has arguably forced local

authorities to take a utilitarian approach in recognising that at a time of fiscal constraint, it

becomes more important to utilise scarce resources well (Staniszewska et al, 2011: 631), and on

the basis of the findings from this research, it would certainly seem to be the case that Beresford is

correct when he asserts that service user involvement may, in effect, 'have had its day' (2011: 6).

These findings would appear to demonstrate that whilst most of the participants entered

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into the consultation process in good faith with the assumption that their contributions would be

acknowledged and even addressed at some level by policy-makers, all of them then went on to

assert the belief that that they did not feel the process was open and democratic, and that they

perceived the outcome of the consultation to be fixed before the process even began. As discussed

earlier in this dissertation, the final outcome of the consultation announced by the Council in

November 2014 was virtually identical to the proposals discussed back in September 2014 when

the process began, and this certainly lends credibility to their arguments. McLaughlin argues that

what he describes as 'tokenistic involvement' occurs when the researcher claims to be involving

service users but manages the research in such a way that the involvement is a mere facade (2009:

152), and the consensus from participants involved in this particular consultation would appear to

be that this was in fact the case.

Another trend that emerged from each of the research interviews was the recognition by

participants that the Council's priorities were not the same as those of service users and members

of the public, and that the Council's primary aim of reducing the running costs of health and social

care services due to economic necessity was very much at odds with the aims of service users

wishing to retain those services in their current form at any cost. They also expressed feeling a lack

of control over how the event was organised, they did not feel that the Council effectively

recognised specific mental health service user sensitivities, and they also suggested that the

Council may not have fully assessed risk before putting forward their initial proposals. Croft and

Beresford argue that we can identify three models for user involvement. The first of these is the

market research approach, aiming to collate data information and gather information. Service

users serve as a source of data which may be of value to the agency hopefully enabling it to

provide more efficient and appropriate services. The second is the consumerist approach, whereby

service users or clients are now conceived of as consumers and issues re-framed in terms of

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consumer choice and opportunity – an approach largely an extension of the market research

model and its links with an expanding commercial welfare sector and an overtly "mixed economy

of care" are easy to recognize. Last is the democratic approach. Here the aim is to enable the

involvement of service users so that they may have a greater say in and control over services (Croft

and Beresford, 1990: 62). On the basis of this research it would seem that this consultation falls

firmly in the first category due to the lack of true democratic participation, and it is also debatable

whether or not participants could even be considered consumers in this context when so little

choice was available.

5.1: Conclusions and Recommendations

In conclusion, this dissertation illustrates how service users were not effectively consulted

on Liverpool City Council's proposals to reform local authority adult health and social care services.

Research participants expressed frustration at the low level of engagement on offer from policy-

makers, and whilst this does illustrate the ambiguous nature of consultation as a concept, it also

leaves the Council open to accusations of 'tokenism'. Participants also addressed concerns

regarding 'pre-determinism', and the perception that the Council's plans to reform adult health

and social care services were finalised in advance of the consultation process taking place. Whilst

this was no doubt a response to the finalised plans bearing strong similarities with the original

proposals put forward in September 2014, another important factor to take into consideration is

the economic reality of local authority austerity, and the likely prospect of local councillors being

motivated more by economic necessity than through a desire to deliver democratically formulated

local services. Whilst arguably an unavoidable consequence of the 2010 Spending Review, it

nonetheless remains the case that service users and other participants who took part in this

consultation process are documented as expressing disenchantment and marginalisation with the

process, and one particularly significant issue that was not effectively addressed throughout the six

week consultation process was whether a comprehensive risk assessment had been conducted.

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Participants were not convinced that it had been, and raised concerns that the outcome of this

consultation could lead to a decline in the mental health of many service users, or even potentially

an increased risk of self-harm or suicide. This dissertation makes a number of recommendations to

improve future consultations, including the implementation of better mechanisms of engagement

for service users, and greater clarity regarding their specific role in the process. In addition to

successfully addressing feelings of powerlessness and disenfranchisement, this would allow service

users to enjoy a much greater level of involvement within what is effectively a technocratic process

that many people may find difficult to fully understand. One possible mechanism to improve

engagement might be the introduction of independent advocacy in future consultations, and this

would be one method of addressing the latent underlying power structures inherent to the

process. Another recommendation that might possibly improve future consultations would be for

service users to participate in future academic studies in the role of co-researchers, and this would

provide another constructive way for policy-makers to address deficiencies within the consultation

process as it is currently conceived.

5.2: Study Limitations

The study described in this dissertation used a small, unrepresentative sample so the findings

cannot be generalised to other populations. This type of interpretivist, qualitative approach to data

collection is prone to researcher bias, however care was taken to transcribe and analyse the data

as described above.

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ReferencesAnderson, J. (2011). The more deprived you are, the bigger the cuts you've got. Available: http://www.theguardian.com/uk/the-northerner/2011/nov/11/liverpool-localgovernment. Last accessed 7th July 2015.

Barnes, M. (1999). Users as Citizens: Collective Action and the Local Governance of Welfare. Social Policy & Administration. 33 (1), p73-90.

Barnes, M, Newman, J, Knops, A and Sullivan, H. (2003). Constituting 'The Public' in public participation. Public Administration. 81 (2), p379-399.

Barnes, M, Knops, A, Newman, J and Sullivan, H. (2004). The micro-politics of deliberation: Case studies in public participation. Contemporary Politics. 10 (2), p93-110.

Barnes, M, Davis, A and Rogers, H. (2006). Women's voices, Women's choices: Experiences and creativity in consulting women users of mental health services. Journal of Mental Health. 15 (3), p329-341.

Barnes, M, and Coelho, V S. (2009). Social participation in health in Brazil and England: inclusion, representation and authority. Heath Expectations. 12 (1), p226-236.

Beresford, P. (2007). User involvement, research and health inequalities: developing new directions. Health and Social Care in the Community. 15 (4), p306-312.

Beresford, P. (2010). Public partnerships, governance and user involvement: a service user perspective. International Journal of Consumer Studies. 34 (1), p495-502.

Beresford, P. (2011). User involvement is dead. Community Care. 1878 (1), p6.

Beresford, P. (2012). From 'vulnerable' to vanguard: challenging the Coalition. Soundings. 50 (12), p46-57.

Beresford, P and Branfield, F. (2006). Developing inclusive partnerships: user-defined outcomes, networking and knowledge - a case study. Health and Social Care in the Community. 14 (5), p436-444.

Brennan, C. (2014). Liverpool Council approves another £3.6m in social services cuts. Available: http://www.liverpoolecho.co.uk/news/liverpool-news/liverpool-council-approves-another-36m-8068957. Last accessed 19th July 2015.

Cook, D. (2002). Consultation for a Change? Engaging Users and Communities in the Policy Process. Social Policy & Administration. 36 (5), p516-531.

Cotterill, P, Harlow, G, Morris, C, Beresford, P, Hanley, B, Sargeant, A, Sitzia, J and Staley, K.. (2010). Service user involvement in cancer care: the impact on service users. Health Expectations. 14 (1), p159-169.

Croft, S and Beresford, P. (1990). Listening to the voice of the consumer: A new model for social services research. Convergence. 23 (4), p62-68.

Curtis, P. (2010). Eric Pickles unveils biggest council budget cuts in recent times. Available: http://www.theguardian.com/politics/2010/dec/13/eric-pickles-council-budget-cuts. Last accessed 19th July 2015.

Davies, C. (2010). Spending cuts: Liverpool facing 'worse than the worst-case scenario'. Available: http://www.theguardian.com/politics/2010/oct/22/spending-cuts-liverpool. Last

2

accessed 7th July 2015.

Healy, K and Boyd, C. (2011). Seeking and Using Service User Input to Improve Clinical Services. Group Analysis. 45 (1), p15-27.

HM Treasury. (2010). Spending Review 2010. Available: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/203826/Spending_review_2010.pdf. Last accessed 7th July 2015.

Holden, C, Lacey, A, and Monach, J. (2001). Establishing secure mental health facilities: The outcome of public consultation exercises. Journal of Mental Health. 10 (5), p513-524.

Horner, N (2003). What is Social Work? Context and Perspectives. Exeter: Learning Matters. p135.

Hunt, H. (2014). Massive mentally-ill and elderly day services shake up planned for Liverpool to save £3m a year. Available: http://www.liverpoolecho.co.uk/news/liverpool-news/massive-mentally-ill-elderly-day-services-7699954. Last accessed 19th July 2015.

Kennett, P, Jones, G, Meegan, R and Croft, J. (2015). Recession, Austerity and the ‘Great Risk Shift’: Local Government and Household Impacts and Responses in Bristol and Liverpool. Local Government Studies. 41 (4), p622-643.

Leung, T. (2011). Client Participation in managing Social Work Service - An Unfinished Quest. Social Work. 56 (1), p43-52.

Lewis, L. (2012). 'It's People's Whole Lives': Gender, Class and the Emotion Work of User Involvement in Mental Health Services. Gender, Work and Organisation. 19 (3), p277-305.

Leyden, J. (2003). Critics turn a deaf ear to Blair's ‘Big Conversation’.Available: http://www.theregister.co.uk/2003/12/01/critics_turn_a_deaf_ear/. Last accessed 19th July 2015.

Liverpool City Council (2014), Adult Health and Social Care Select Committee, 18th November 2014. Liverpool: Liverpool City Council.

Matua, G A. (2015). Differentiating between descriptive and interpretive phenomenological research approaches. Nurse Researcher. 22 (6), p22-27.

McLoughlin, H. (2009). Researching social work. In: Adams, R, Dominelli, L and Payne, M Social Work: Themes, Issues and Critical Debates. 3rd ed. Basingstoke: Palgrave Macmillan. p143-155.

Noble, C and Henrickson, M. (2011). After neo-liberalismand postmodernism, what next for social work? Journal of Social Work. 11 (2), p128-131.

Omeni, E, Barnes, M, MacDonald, D, Crawford, M and Rose, D. (2014). Service user involvement: impact and participation: a survey of service user and staff perspectives. BMC Health Services Research. 14 (1), p1-23.

Roberts, T. (2013). Understanding the research methodology of interpretative phenomenological analysis. British Journal of Midwifery. 21 (3), p215-218.

Staniszewska, S, Adebajo, A, Barber, R, Beresford, P, Brady, L, Brett, J, Elliott, J, Evans, D, Haywood, K, Jones, D, Mockford, C, Nettle, M, Rose, D and Williamson, T. (2011). Developing the evidence base of patient and public involvement in health and social care research: the case for measuring impact. International Journal of Consumer Studies. 35 (1), p628-632.

Syal, R. (2014). Half of councils at risk of financial failure within five years, say auditors. Available: http://www.theguardian.com/society/2014/nov/19/councils-risk-financial-failure-auditors. Last accessed 19th July 2015.

Trevelyan, L. (2003). Blair launches 'Big Conversation'. Available: http://news.bbc.co.uk/1/hi/uk_politics/3245620.stm. Last accessed 19th July 2015.

Vaismoradi, M, Turunen, H and Bondas, T. (2013). Content analysis and thematic analysis:

2

Implications for conducting a qualitative descriptive study. Nursing and Health Sciences. 15 (1), p398-405.