MEMORANDUM BY SOPHIA R CHRISTIE HEALTH
PARTNERSHIP DEVELOPMENT MANAGER, SANDWELL
PUBLIC INVOLVEMENT IN HEALTH
PERSONAL STATEMENT
I am a NHS general manager with 14 years experience.
For the last 18 months I have been working across the Health and
Local Authorities in Sandwell reporting equally to both chief
executives. I have extensive experience in a variety of forms
of public involvement in health and other public sector services
including:
— Formal NHS closure consultations;
— Informal time-limited consultation
seeking input and advice from specific client/community groups
on both general and service specific issues;
— Ongoing, developmental relationships
with particular client or community interest groups; and
— One-off measures seeking information/opinion
in specific areas using market research techniques.
I believe in the value of public participation
where a basic organisational infrastructure is in place to respond.
EXAMPLES OF
PARTICIPATION EXPERIENCES
Formal
Closure of poorly performing single-handed general
practice: Bangladeshi GP serving Bangladeshi population who travelled
considerable distance to see him. SHA recommended closure and
dispersal to neighbouring practices. Significant opposition from
practice population. Led to debate about what they valued about
practice (cultural accessibility and relevance) and professional
concerns re effectiveness and efficiency of service. Resulted
in maintaining practice on the site but new GP with clear professional
links through to neighbouring multi-partner practice.
Closure of hospital serving deprived population
in inner city: HA seeking to concentrate acute hospital services,
including A+E onto 2 of 3 sites across city, including teaching
hospital in centre. A+E in West End used as primary care site
by local population, hospital had developed positive systems for
working with deprived, multi-lingual population. Teaching hospital
had no track record in responding to needs of this population,
and no history of interest in attempting to do so. Consultation
clearly dominated by medical academic politics rather than needs
of local population. Negative experience provided stimulus to
primary care investment in community development approach, which
has gone from strength to strength and now provides basis for
excellent community involvement work.
Informal
Over 400 local people involved in group discussions
to identify priorities for HAZ programme in Sandwell: led to recognition
of "determinants of health" issues which would not have
been identified within a professional agenda but which are emerging
as important pieces of work.
Focus group type approaches working with stable
membership over period of time to explore issues of specific interest
to that group, where opinion and experience not readily available
within NHS; e.g groups of mental health services users, single
sex groups drawn from different ethnic groups experiencing CHD
or diabetes, identification of health priorities by people living
in deprived neighbourhoods.
Can participation make a difference?
Positive experiences suggest that it can improve
range of information available to inform decision-making, relevance
of subsequent decisions, and process of implementation. Success
entirely dependent on attitudes and values dominating the culture
of the lead organisation.
Do organisations change to accommodate consultation?
Work on community development suggests that
it require a parallel track of organisational development if it
is to bear fruit. If organisations are not able to respond flexibly
to findings then consultation will not make a difference. Organisations
need to have a value base which means they are motivated towards
making change happen in response to consultation—even if
that means a fight internally with certain professional power
bases or externally with funders/performance managers. Must be
committed to participation, and have invested in organisational
understanding of why this is important.
Key issue is time-scale—government tends
to impose consultation times which do not allow for real participation,
lack of understanding at regional level means that where longer-term
information is available it is rejected in favour of the project-specific
consultation, which is more likely to reflect public prejudice
than informed opinion.
Do non-elective bodies take a different approach?
Yes and this has positive and negative aspects.
Local government typically has greater history
of investment in consultation/participation, but has had to tread
carefully in arena where "representation" rather than
participation is given greatest status. Frequently called upon
to work on behalf of organisation or individual members to undertake
consultation work in the interest of the organisation or election
play rather than with focus on identifying real issues for local
people and responding to them.
As health bodies are not elected there has been
greater onus to seek other forms of legitimacy. Where participation
processes have developed they have tended to be quite sophisticated
and required investment over time, with the emphasis being on
developing long-term influencing relationships rather than one
off consultations on specific issues. Experience in this area
tends to be limited to certain Health Authorities and Health Promotion
departments; there is generally a low base of skills and understanding
within the broader service.
DIFFICULT TO
REACH GROUP
Need to recognise the diversity of "publics"
which exist. NHS/local government do not serve homogenous communities.
Often the interests of these diverse communities may be perceived
to be in conflict eg mental health service users seeking community-based
services, local residents concerned about house prices, consultant
psychiatrists concerned about medical status and access to in-patient
beds. Difficult to reach groups are often also socially-stigmatised
groups and different opinion groups have differential access to
power and influence.
By definition require sophisticated approach,
grounded in long-term investment. Need to provide training and
accreditation and support to participation and commit time to
developing relationships and trust.
Unlikely to be reached effectively in any one-off
consultation approach and debatable whether required investment
would be worth outputs. Social exclusion will be tackled by creating
the potential for participation not by consultation.
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