Select Committee on Public Administration Minutes of Evidence



Examination of witnesses (Questions 367 - 379)

TUESDAY 15 FEBRUARY 2000

DR MARIAN BARNES, MS SOPHIA CHRISTIE, DR SUE BROWNILL, MR NEIL MCINROY and MR DANIEL DOBSON-MOUAWAD

Chairman

  367. Can I welcome you here this morning to assist the Committee with its inquiry into innovations in citizen participation. We are taking evidence from a whole range of people, but you are an important additional element in the evidence that we are taking. We are grateful to you for coming. Thank you for letting us have some preliminary papers. I am assuming you were going to say a few words about these papers to start with. Dr Barnes, would you like to say something first?
  (Dr Barnes) I am here to talk about public participation in the context of the National Health Service and more broadly in the context of health policy. My perspective comes from working in a research and development capacity on this sort of issue over about the last 15 years. I am not a practitioner; I am primarily a researcher, but I have been involved with some initiatives where I have been working with people helping them to try and develop some participation initiatives, and I have also been involved in the evaluation of some of them. I understand there was reference in a previous session to some of the work in citizens' juries and I have been involved in the evaluation of some of the citizens' juries for IPPR. I know you have had previous discussions about the importance of distinguishing some of the different purposes for public participation and also the implications of that for identifying the different publics who might be involved. I guess that is really where I want to start, specifically in the context of health. In doing so, I also want to recognise that the influence and impetus for increasing public participation is coming both from within the National Health Service itself where, over at least the last 10 years, there has been a growing commitment to public participation as an important plank of policy- making and service development; but there is also pressure from below if you like, from service user groups, health consumer groups, communities, the public generally no longer being satisfied to leave it to the experts but demanding a place at the table, demanding that their voices are heard. It is also important to recognise that there can be tensions if not conflicts in some of the objectives of officials working within the NHS and user groups, community groups, the public who are seeking to have their voices heard. I would like to distinguish four different purposes for involving the public within a health context. The first is to inform the development of health services to ensure that they become more responsive, more sensitive to the needs of people who use those services. In this context the public are primarily people who have experience either of living with illnesses or particular health problems or of using the health services and therefore have experiential knowledge on which to draw which is a valuable resource to people involved in developing services. The second purpose relates to some of the broader responsibilities of the NHS in partnership with other public bodies to contribute to health improvement and to reducing health inequalities. Here there is a purpose of enabling particularly marginalised and excluded communities to be able to play a part in defining health problems and an active part in developing solutions to them, community development type approaches which enable people on the wrong end of the health inequalities divide to play a part in seeking health improvements. The third purpose I identify is to prompt informed debate within the public generally about health service and health policy issues, to raise the level of knowledge and understanding within citizens generally to enable a high level, more informed debate to take place. The fourth purpose is to develop systems by which public servants—in this case working in the health context—can give an account of and be challenged on their decisions by members of the public. In that context it is important to recognise the different government structures of the NHS in comparison with local government. There is no local system of elected representatives in relation to the National Health Service and therefore there is a need to establish systems whereby health decision-makers at a local level also can give an account of and be challenged on their decisions by local people. I would identify those four different purposes, each having a slightly different definition of who the public are and seeing those as the building blocks for the development of effective comprehensive strategies for public participation in the context of health services.

  368. Thank you very much indeed for that. I am going to ask Sophia Christie to say a word because of the health connection.
  (Ms Christie) I am coming from a slightly different perspective, being a practising manager in the health context, having had experience both in managing service provision and also in commissioning health services and currently managing the Health Action Zone working across the council and the Health Service in Sandwell. The point about the different publics that Marian has made is important. The other thing I would throw into that complexity in an NHS context is that the NHS is not a very homogeneous organisation. One of the other things to bear in mind is the different structural levels within the health service. The context in primary care and individual general practices is quite different in terms of public participation in relationship with a largely patient-based public from the sort of relationship that large service providers like an acute hospital would have or the commissioning relationship that a health authority or in the future primary care groups would have. There is the further developing relationship in the partnership context of how health services sit at a local level in relation to local government and the good opportunities for a new way of relating to the public, building on those relationships in a shared investment in community development and participation. Bearing that in mind and again what that implies in terms of how we relate to different publics and the kinds of structures and tools that we might use to do that is an important aspect of the rest of the conversation. The other point I would make is that we are likely, during the course of the conversation, to use different terminologies, and the overall term that we have is participation, but that can get interpreted as meaning lots of different types of processes. When I am talking about participation I tend to be thinking about a longer term relationship with a group of people that I would get to know over time rather than a one-off consultation survey, a more limited panel type of approach. When I am talking about participation it is at that end of the spectrum rather than the consultation end.

  369. Thank you. Could I ask either Sue Brownill or Neil McInroy to move us into the regeneration area and say a brief word based upon your paper to us?
  (Dr Brownill) One of the issues that we know the Committee is concerned about is non-elected agencies in governance. In regeneration the partnership has become a major vehicle for the delivery of the regeneration. That is a partnership between the public sector, private sectors, the community sectors, most of whose representatives are not elected. What we have tried to highlight in the paper is that there were some pros and cons of those kinds of agencies, that you can have advancements in participation through closer relationships with communities, through structures like community forums to get people represented, but there is also the downside aspect of that about their being non-elected, about the speed of operation and about a very output- driven culture that is across the board in regeneration and increasingly in public services. That was one issue that we wanted to highlight. Coming from that, what is important is to look at the processes. Participation is a process; it is not just about the structures, about who sits on what committee. It is about how they operate. What we have tried to do also in the paper is indicate where you can have some forward strategies to try and make sure that the process of consultation and participation is part of the whole stage of regeneration and possibly in other areas of government. The second point is underlining what Sophia Christie said about being clear about whether or not consultation is happening, whether or not participation is happening. The distinction I would draw is about levels of power: how much power is being devolved to people to influence decisions; and experience in regeneration shows that it is very important to be clear. If you are really just asking people's opinions on a decision that has already been made it is no good saying, "We are asking you to participate" because people will quite rightly spot that and they will feel that they are having the wool pulled over their eyes. Finally, there are barriers to participation. Some of those we have tried to identify, about the fact that there are a lot of different publics, that the way agencies operate can exclude some and include others. There are practical ways to overcome these and there is good practice which exists which again we have highlighted in the paper.

  370. Thank you very much indeed. Finally, again on regeneration as a particular example, Daniel Dobson-Mouawad, you are from the London Thames Gateway Forum. Would you like to add a word or two?
  (Mr Dobson-Mouawad) First of all I would like to thank the Committee for inviting me to participate in this inquiry. I am the head of a non-governmental organisation servicing communities throughout the Thames Gateway, encompassing a catchment area of approximately two million people. We service that catchment by servicing directly over 550 community and voluntary sector organisations. Please note that we do not state that we represent them. We purely service their interests. That is very important, particularly when we come on to the issue of discussing the levels of participation and at what point you can differentiate between a mandate or purely an indication of which way a process should be taken forward. The clear aspect here is that we are practitioners at a grass root level but we also translate those issues to a strategic level and we try to bring pressure upon the process, particularly the governmental process, to bring about positive change for the inclusion of communities in the regeneration process. We are practitioners in several programmes, European and national programmes, and we have already submitted some written evidence to identify some of the major barriers that communities face in the process, and I am here at your service to answer any questions.

Mr Oaten

  371. I have a general question and then I want to home in with a few questions on the health side. My sense of the public is that they have not got a clue who runs the police, health, education, no idea, and why should they? But what they do feel frustrated about and what they always say is, "They have made that decision". They are not sure who "they" are. One of the most interesting things that somebody touched on was how do we get consultation and participation which break down all those barriers and mean that folk can come along and give their opinions on police, education and health, whatever it may be, possibly all at the same time rather than expecting them to be engaged in the different exercises which local authorities, counties, health authorities, social services, put in place? Are there any models which have achieved that and is it something which we should be doing?
  (Ms Christie) In terms of the partnership, that is an issue that some organisations have been quite conscious of and certainly in the health context there is a long history of health authorities doing consultations but of flagged-up issues about housing, crime, and then the health authority has not known where to take that and has not been able to make a very effective response and you get a lot of disgruntled participants. One of the approaches that we are looking at in Sandwell—and this is at an early stage so I would not be able to say it is the way to do it—is bringing together those key organisations, so it is the West Midlands Police with the local authority, the health authority, the TEC, the voluntary sector, umbrella organisations and a local ethnic minority forum as a civic partnership that also includes the Chamber of Commerce; and within that umbrella framework we have been looking at how we can adopt more consistent approaches to participation and we have just accepted a common framework for community involvement, that all the partnership organisations are signing up to. We are in the process of working through the development of the idea of a kind of consultation clearing house where we would have a central point with people checking out who is doing what on what kinds of issues and whether we can do that consistently. We have also got a common residents' panel where we are collaborating across the partnership to look at the sorts of questions that are being asked so that it has a single identity and people are not being bombarded with similar questions from different organisations.

  372. So a one-stop-shop participation consultation process would be the way of describing that process?
  (Ms Christie) That is the vision. We are working towards it.
  (Mr Dobson-Mouawad) Of course there are implicit problems with that approach. The problem is that not everybody wants to be consulted on all issues. Clearly the process that we get engaged with quite often is to differentiate between different issues, different approaches or different elements of the process and only engage those who most want to be engaged in those particular elements. There would be no point in having major consultation exercises that tried to cover everybody on all matters because clearly what would happen is that people would be biting off more than they could chew and inevitably they would choke on that.
  (Ms Christie) As a point of clarification, they are not all done at the same time. The clearing house in particular is to try and avoid a situation where the same people are being targeted by three different organisations within a four month period asking either different or similar areas of questioning, but it is about trying to get some consistency.
  (Dr Barnes) There is another way of looking at this, which goes back to what I was saying about needing to look at the way in which communities and groups of people collectively are saying, "You need to come and talk to us. You need to come and hear what we have got to say." There it is not about public agencies going out and saying, "We want to talk to you about X, Y or Z." It is about groups of people who either share a common identity or who live in the same area collectively organising themselves and saying to whoever, "there are issues that we have identified that are a problem for us. We want to engage you in a dialogue about them." That can work in all sorts of different ways. I am thinking about one particular example of work supported by Age Concern in Scotland, working with frail elderly people exploring their experiences of what it is like to grow older and using that as a basis for saying to the health service, to the local authority, to the local transport services, "These are the issues that this group of old people are concerned about. Can we talk about this?"
  (Dr Brownill) In the regeneration area there is the example of New Deal for Communities which is very area-based but is trying to do exactly what you are saying, bringing together all the agencies involved in delivering services and forming plans in that area and trying to ensure that there is a common route into them and that decisions are made in tandem and are complementary rather than different agencies doing separate things.

  373. It seems to be at early stages yet and no real evidence to see whether it has worked or not. Can I come on to the health service? There seems to be a general view amongst politicians when they are not in front of the cameras or in the chamber that there needs to be a grown-up, mature debate about the health service, and most politicians gather in a room and start talking about rationing, charging, things like that, but will never say that outside of that room. If the politicians cannot have that grown-up, mature debate, do you think the public are ready to have that grown-up, mature debate and understand some of those issues, or would you say that there are frankly some things which it is inappropriate to get to the public on within the health service?
  (Dr Barnes) I would say it is possible to have that grown-up, mature debate if you provide the appropriate environment in which it is possible for it to take place. There is not a lot of point using things like opinion polls or surveys to ask the public about complex issues of rationing, complex issues about value based decisions, about the development of genetic therapies or whatever the current issue is, but that if you provide people with the opportunity to become informed, to have the space and the time to debate and deliberate with each other amongst groups of citizens and with health service officials, you do get a much more informed, much more mature debate developing.

  374. But you could not take a community with you on that. You could only take a number of informed citizens whom you have been consulting with for a six-month period, or can you expand that to a community to engage in these issues?
  (Dr Barnes) I think you can. The issue is whether you are prepared to invest the time and resources that are necessary to do that.

  375. Who should be doing that? Is it a role for the primary care groups to be doing this, to be having that debate, and have they got the equalities and the ability to do it? Or is it the Community Health Council? They seem to be patchy up and down the country with regard to their respect in the area, so who is doing this? Who is going to have that role?
  (Ms Christie) There may be two questions that come before that. One is, why is it that the politicians do not feel comfortable about having that debate in public? It is because the consequences for potential re-election feel very uncomfortable because if the debate is had with an uninformed public then we know what the knee-jerk reaction is going to be, which to me begs the question how can we not have that debate in public because otherwise we are never going to be able to have that debate? That then leads to the question of how you invest in having that debate properly. I think it is less of a question about would it be a PCG or would it be a CHC because in different parts of the country in different boroughs it will be different places. In some places you have very strong assertive CHCs who are very engaged in community development, public participation, who would be ideally placed. In other places you have very conservative CHCs who see their roles being about complaints which would be the last role you want to give them. PCGs have an absolutely immense agenda of basic operational structural change to deal with. At the moment you would completely disable them if you asked them to take on a role like that, but in the future, if you invested and provided the infrastructure to allow them to do it, then they may be able to. The key question is, where is the investment coming from in time, resources and skills that would allow there to be people on the ground who facilitate that?

  376. To summarise in the last question, in a sense what you are saying is that before we even begin to think whether it is a good idea or whether it is possible that we actually want to listen to the public, even if we did decide that we wanted to do that, there is no real mechanism at the moment which exists which is capable of being able to do that.
  (Ms Christie) I think there is a diversity of mechanisms that are specific to time and place and having an edict that said, "The way you will do this is that you will get your local CHC to do it" or "You will get your local PCG to do it", would not be the most effective way of using the skills and resources on the ground. In some places it might be best done through the voluntary sector. In other places it might be best done through a team of community development workers. It will depend on local situations. It would be more important to define what you wanted to achieve by it and to have some resources available to support it and then looked to the local situation as in that political and local context for what is the best way of addressing that.
  (Mr Dobson-Mouawad) I would like to put an addendum to that. We obviously tackle social regeneration, economic regeneration, physical regeneration. It is not purely the physical regeneration that people normally associate with regeneration programmes. We tackle the root of it which is quite often social. There are clear causal links between such things as poverty and health, and quite often what we are finding is that we are having multi-agencies trying to tackle essentially what is the same problem in one localised area but in fact all these agencies are coming at it from a different perspective, engaging in a different process, and essentially bringing in to the equation overkill of the consultation and participation process. What we have to do is ensure that there is a mechanism that brings together these agencies, perhaps suggesting one of the examples that have already been mentioned, and ensuring that there is clarity of process and objectivity in what is trying to be engaged and who is trying to be engaged and for what purpose. As far as this discussion is concerned that politicians cannot seem to have, I can tell you that communities can have those discussions because they are not tainted if you like by short term gains that they have to accrue over a couple of years. They have to view their involvement clearly in the longer term perspective because they are after all the people who have to remain living in an area, who have to bring up their children in an area, who have their economic and social welfare already invested in an area, so their interest is in the long term. Where the political aspect conflicts with that is quite often when there is a short term dimension to trying to engage the community and this is where we have some conflict.

Mr Townend

  377. Do you really think there is a demand for participation from the public?
  (Dr Barnes) Let us go back to the need to distinguish different publics. There is certainly a demand coming from people who are either long term users of health services, people who have chronic health problems, which means that they are using health services for long periods of their lives and for whom the services are absolutely significant and who are strongly motivated to becoming involved in ensuring better services both for themselves and other people in their situation. If you are saying is there a strong desire from the public generally, the answer is probably no, but the evidence is that if you provide people with the opportunities, if you invite them to take part in some of the intensive forms of deliberation that have been developed, people really value that experience. It is beneficial for them. They value the experience in terms of what it can do, in terms of developing their sense of themselves as citizens, and they enjoy it. It is not just a question of saying, "Is there a demand coming from the publics?" It is about saying, "Do we think that increasing public involvement is a good thing in its own right? If so, how can we enable a broader number of people to experience that benefit and to contribute to a high level debate about policy issues?"
  (Mr Dobson-Mouawad) The question, sir, is `Are you asking the right question?' If you ask a member of the community do they care about their future, do they care about the environment in which they live, would they like to influence what happens on their doorstep and what happens to their communities, the majority of respondents would say yes. If you then took that one step further and said, "These are the key points where you can influence that process and these are the mechanisms which will help you participate", then what we are finding is that the majority of people do want to accept the invitation and participate because we are supporting their participation. Where they are not interested in participating is where they suspect that the root of the exercise is purely giving the whole issue lip service, where it is not genuine, where they believe that their involvement is not going to make any significant change to what is already decided or what is already going to happen. To that effect you get marginalised communities because they do not believe they can influence the process. There is another dimension to this which is that too often there is an over-reliance on stating that the community is not interested in participating because there is a poor electoral turn-out. Indeed, if you think it through logically, those people who are now making the decisions have got their mandate from the majority of the minority who have actually voted for them in the locality. The critical aspect here that we have brought forward is that the communities are and want to be involved and want to be franchised into the process and that the poor electoral turn-out does not necessarily reflect a disenfranchisement with the regeneration process that communities want to be involved with.

  378. You ask the question to get the answer you want. Secondly, it strikes me that part of this is to by-pass the electoral system. I am one of those few MPs who is the local MP. I have lived in my constituency all my life and I was the leader of the county council and before that I was Chairman of the finance committee of a large city. I am not in the clouds. I have to tell you, and I do not know if you would agree, that if you said to my constituents, old people for instance, "Do you want to have more consultation and more participation or do you want more money spent on the health service?", they would say, "We want more money spent on the service, not on participation." If you said to them, "What is it really that you are worried about?", what they really want is an adequate complaints procedure, that they can get things put right that are wrong, if they are not getting the right service from their doctor, if they are not getting the right service from the police, and so on. They are not really interested in public participation about policy. Do you use focus groups in your public participation?
  (Dr Barnes) I will pick that up but I want to disagree with you. Having been involved in working with groups of frail older people who are heavy users of health and social care services, one of the key things that they will say in the course of their discussions is that they simply would not complain, that they were concerned about the likely implications of a complaint when they were heavily dependent on the quality of care that they were being provided with. What was coming out of the opportunity for older people collectively to share their experiences of using services was something that went well beyond complaining about what was going wrong, but actually coming up with creative solutions about what it would look like if it worked right. There were some very practical things: coming up with a 14-point good hospital discharge plan, what would a good process of hospital discharge actually look like, built on a collective experience of things that had gone wrong, moving away from saying what this is about is complaining to saying, "What we want to do is to be part of the solution here." The possibility of doing that was because you had groups of people meeting together over a period of time, not a one-off focus group. A one-off focus group is very limited in terms of its capacity not only to explore the issues but also to come up with solutions. What we are talking about here and what Sophia was talking about in terms of participation is a longer term active involvement in the process whereby people can be contributing ideas as well as reacting and saying this was wrong.
  (Ms Christie) I have a group of old people I am working with at the moment and I do not know if you know about Sandwell but it is the seventh most deprived borough in the country; it is a very disadvantaged area; people have low levels of educational attainment; it is the kind of classic area where there may be assumptions made about people's ability or willingness to participate. We have a process called Age Well which is a collaboration with older people in the borough in which a number of old people have come forward to give quite significant amounts of time to help facilitate the involvement of other older people. The response to that has been a very positive one in terms of people welcoming the opportunity to come up with ideas, not to complain but to make suggestions about how things could be improved. Last year we had a conference day that 200 old people were involved in. They identified 13 challenges to the chief executives of the health authority and the council, which were then fulfilled over the year. They ranged from very practical issues like a better response to repairs for older people in housing through to some work that took longer that was about how we can get an approved list of builders of people who are safe for older people to invite into their own homes. I do not think the chief executive of the health authority, left to his own devices, would have thought that that was a hugely important issue for older people, but older people were able to tell us that yes, actually that was one of the things that made them feel confident about staying in their own homes and continuing to live full lives. There is a positive process of engagement. It does depend on what question you ask. If you ask them, "Do you want to be involved in making decisions about health services?", then, going back to Daniel's point, they will not know what you are asking them to do. If you ask them what their ideas are about how they could live fuller and more fulfilling lives, they have got lots of ideas about how we can support that. The other thing I want to do is respond to your question about do people want participation. All you have to do is announce that you are thinking of closing a ward or an accident and emergency department and you have the answer to that question. People want to know what is the decision-making process that lies behind that kind of decision and want to have an opportunity to influence it at an earlier stage in the process. We learn to our cost that if we do not invest in that kind of involvement and participation then we will be hung, drawn and quartered.

  379. But are you not just trying to by-pass the democratic system?
  (Ms Christie) Personally?


 
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