The relationship between those who provide health services and the people who use them is a changing one. Most writers link this to other economic and social changes, such as a rise in consumerism associated with the growth of market-based societies which produces rising expectations in the context of scarce resources (Abercrombie 1994; Mechanic 1998; Mays 2000). Falling levels of public trust due to increased media coverage of healthcare scandals, such as the lack of appropriate screening of blood products in France in the 1980s or the Bristol cardiac surgeons in the UK, and greater explicitness about the way care is resourced or rationed have also been cited (Davies 1999). Within this context, many governments have introduced health policy that increases the importance of user perspectives and involving users in decisions. The form this health policy takes varies between countries but there are some common elements. For example, many European countries have developed policies for protecting patients rights (e.g. Finland) although in some countries these rights are not enforced by legislation (e.g. the UK Patient s Charter). Other countries have carried out national consultation about health priorities (e.g. New Zealand, UK) or have citizen involvement on local health organisations (e.g. Israel, New Zealand, UK) and in most countries there have been surveys to find out users' views (Calnan 1995, 1998). Few countries make involvement in health decision making a legal requirement apart from the UK (Health and Social Care Act 2001).
The issue of user involvement is complex but in this chapter it will be broken down into four main areas. The first section examines evidence about whether user perspectives are different from those of the health professionals and managers and what is known about influences on these perspectives. It also considers the different aims and objectives of user involvement and the advantages in taking a strategic overview to ensure that involvement is integrated into the organisation. The second section looks at the involvement of users in choices about treatment and care, identifying the reasons why this is considered important and ways of