Foundations for self-directed support in Scotland
Foundations for self-directed support in Scotland

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Foundations for self-directed support in Scotland

1.7 Understanding personalisation: where next?

The term ‘service user’ more or less replaced ‘client’ in social work and social care by the first decade of the twenty-first century. It is also a term sometimes used by health care professionals to replace the term ‘patient’, although one might well argue that a ‘service user’ in principle is no less or more passive than a ‘client’ or a ‘patient’.

Some people are still unsatisfied with the term ‘service user’ – partly because it doesn’t tell us what service users ought to be or to do, except be users of services. People who ‘use’ services have plenty of other roles too – as parents, pupils, employees, club members and neighbours, for example. And where does this definition leave people with disabilities who are unable (or choose not to) access services? Or people who are unwilling ‘service users’ – that is, people who are detained in hospital or children subject to compulsory supervision orders because they are considered to be at risk of harm?

So, just as the term ‘client’ once obscured reality in one way, the term ‘service user’ might obscure reality in a different way. Nevertheless, ‘service user’ is the term that is now currently in use and will be used, alongside 'citizen', in this course to describe people who were previously or may still be described as ‘clients’ or ‘patients’ of health and social care services.

It’s important to note that the terminology may have to change again as personalisation – and, as an expression of this, self-directed support – becomes an increasingly influential force in Scotland. We will begin to explore how personalisation and self-directed support may well soon be making us think again about the language that we use, but first take this opportunity to review your reflections about ‘what’s in a name?’

Activity 1.6: What's in a name? Sara and her family

Timing: (25 minutes)

Now that you have had an opportunity to explore some important changes in the context for health and social care in Scotland and the rest of the UK, let's return to Sara and her family who you met in the introduction.

Figure 1.12

As you have seen, different terms – patient, client, service user, consumer, citizen – have different meanings to different people. The use of particular words can change the way people are seen by others and themselves. Using your learning log [Tip: hold Ctrl and click a link to open it in a new tab. (Hide tip)] answer the following questions:

  • How might each term highlight or conceal different aspects of the needs of each family member?
  • Do you have a preference about what you would like to be called? Why?


It seems likely that Sara and her grandparents will be very familiar with the role of ' patient '. The term tells us something about their need for health services, including medical and nursing expertise, but less about their other needs – social, emotional or economic, for example. ‘Patient’ originally meant somebody who suffered with calmness and composure, and it still suggests a degree of passivity, of 'being treated', which may be very far from, say, the way that Gita or Samuel may wish to engage with their GP or district nurse.

The word ' client ', suggests, as we've seen, that the individual is seeking some kind of expert service from someone who 'knows best' about what they need. This might be true, for example, of the advice and support Sara and her family are given in relation to Sara's continence needs. But the term obscures the ways in which Sara – as well as other family members – is an expert too. She is an expert in how she wants her continence difficulties managed, and who she is happy to have help her with intimate day-to-day support. Lela, as Sara's mother and principal carer is an expert too. She will have been making decisions for Sara, since she was a baby. Sara's grandparents are also very involved in her care and will have a wealth of knowledge of what she likes and what upsets or worries her. So, rather than just identifying Sara as the client, perhaps it is the whole family that is the client? Some practitioners argue that much of their work with children and young people focuses on sustaining the family as a whole because their needs are so closely inter-related.

Sara undoubtedly could be described as a ' service user' of additional support in her school as well as of health and other services. But this only tells us about the nature of just some of the services she uses, not about how these services can help her to achieve what she wants from them, or about other public services, such as the local leisure centre or library. And how do the many 'services' that the members of this family provide to each other fit into this description?

And what about the term 'customer '? This implies a degree of power and choice, which may feel empowering for family members. But what are, for example, the options available to this family if budgetary cuts result in a reduction in the support Sara has at school? Or Gita waits for months to be assessed at the local hospital? Being a customer implies having money in your purse with which to make a choice, but these are often not decisions that individuals and families have the power to make.

It is perhaps easier to see all four family members as ' citizens ' – and indeed, it's likely that Sara has been learning about her role as a global citizen at school. The term suggests equal rights and the power to take action to secure these rights. However, whether each family member will believe themselves to have these rights – or indeed are regarded as 'citizens' by others, including the UK government – we can only speculate.

There are, of course, other terms you might have thought about too. At school Sara is a 'pupil', Lela is an 'employee' at work and a provider of care to the rest of her family, and Lela's parents are both 'pensioners'; all these terms also carry a wealth of meaning and assumptions about people's behaviour, attitudes and roles in society. You may well have concluded that no one term is sufficient to describe the relationship between the individual and health, social care and other services. However, it is likely that you will have some preferences about how you would like to be referred to by doctors, nurses, social workers and other professionals. You may want to come back to this activity and your reflections on Sara and her family from time to time as you work through this course to see if your opinions have changed.

This short activity is a reminder that the language we use to refer to others has more weight than its dictionary definition. It also suggests that language is important to our understanding of who we are, and who has the power to make decisions about individuals and families.


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