Select Committee on Public Administration Minutes of Evidence




  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.



  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.


  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.


  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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