Select Committee on Public Administration Minutes of Evidence



  My perspective on the topic comes from 15 years involvement in research and development in relation to user involvement and public participation in health and social care. I am currently leading work in community involvement in the national evaluation of Health Action Zones, and have just started a project on public participation and social exclusion in the ESRC Democracy and Participation research programme.


  The following factors are important in considering the nature and purpose of public involvement in health and health service decision making:

    —  There is no system of local democratic accountability in the NHS.

    —  The health service is one of the biggest and most popular public services.

    —  Most people use the NHS as some stage of their life.

    —  There is increasing organisation amongst health service users seeking to influence both policy and practice.

    —  It is a service dominated by professional power and authority. Medical professionals are well organised and very successful in securing sympathetic media attention.

    —  It is a highly diverse service, delivered by a wide range of practitioners operating in different organisational systems with different accountability arrangements.

    —  Advances in health technology are raising ethical questions which require wide public debate.

    —  The NHS has responsibilities not only to provide services to people who are ill, but also to contribute to health improvement and the reduction of health inequalities.


  Different purposes for involving "the public" in decision making need to be distinguished. These can include:

    —  To draw on the knowledge and insights of people who have used services, and those who have experienced living with illness or impairment, to improve the design and responsiveness of services.

    —  To enable marginalised and excluded communities to play an active part in defining health problems and developing solutions to them.

    —  To prompt informed debate about health services and health policy amongst citizens.

    —  To develop systems through which public servants can give account and be questioned about their plans and decisions.

  Effective strategies for public participation need to reflect these different purposes. The methods adopted and the groups targeted for "participation" will likewise vary. There are examples of methods of involvement intended to address each of these purposes, eg

  1.  User representation in bodies commissioning health services. For example, mental health service users in Nottingham play an active part in service planning and have been involved in contract specification.

  2.  Community development methods to engage local people in defining health needs. In St Peters in Plymouth Rapid Appraisal methods were used to identify local health needs. Practical projects were subsequently developed which responded to problem issues identified and involved local people in their delivery.

  3.  Citizens' juries and citizen panels which aim to inform citizens and develop capacity for deliberation, as well as to inform policy making. Citizens' juries have been held to promote informed debate on issues such as: the future organisation of health and social care services (Belfast); policy relating to mental health services (Kensington and Chelsea); preferred models of palliative care (Walsall).

  4.  Local health strategy panels. As part of their community involvement strategies a number of Health Action Zones are setting up systems to ensure that priorities and plans are influenced by local people and that they can also be involved in monitoring and evaluating the effectiveness of strategies. For example, Walsall HAZ is linking with local committees established by the local authority and supported by SRB funding. They are also developing Health Watch Groups, run by the Community Health Council, whose remit includes monitoring local health care and services.


  As in other areas of public policy, public participation in health is seen as a means of delivering policy objectives: including reducing social exclusion and creating more responsive, higher quality services. Public participation within a health context has to be seen in the context of significant change in the organisation and governance of health services, and in the context of the objective of achieving more effective partnership working on cross-cutting policy issues.

  Key aspects of this policy context are:

    —  The emphasis of primary care as a location for both service deliver and commissioning, including the establishment of Primary Care Groups and the pursuit of innovation in service delivery as a result of the 1997 Primary Care Act. There is evidence that it can be particularly difficult to develop public participation within a primary care context.

    —  An emphasis on the public health objectives of achieving improvements in the overall health of the population and a reduction in health inequalities. This is being pursued through HAZs, Health Improvement Programmes, Healthy Living Centres. All require collaboration across agency boundaries and the active participation of the public. They require joint action in relation to involving the public as well as the co-ordination of policies and services.

    —  Clinical governance—opening up the practice of clinicians to scrutiny. There are examples of user involvement in clinical audit, but also strong professional resistance to lay input. The quality of clinical practice is a matter of concern not only to direct users, but also to citizens generally.

  There have been significant developments in public participation in the NHS during the last 10 years, but there remains the need for the implementation of a coherent strategy—not only throughout the service, but also in the context of emergent governance arrangements which cross the boundaries of different public services.

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