Evidence submitted by Professor Celia
Davies (PPI 157)
Background
1. Interest in creating new forms of direct
public participation in politics and policymaking is now prominent
across political parties in the UK and a theme in political activity
internationally. This has been prompted by growing concern about
levels of political disaffection on the one hand, and an attempt
to respond to social changes, including growing cultural diversity,
rising educational levels and continuing social inequalities and
social exclusion, on the other.
2. The rationale for encouraging greater
public participation across different areas of public policy stems
largely from an assumption that engagement with a more active,
informed and involved citizenry will:
(a) help to broaden the range of options
under consideration;
(b) have the potential to be generative of
novel solutions;
(c) enhance the legitimacy of solutions which
are proposed (both because citizens have been involved and because
subsequent argumentation can reflect likely concerns); and
(d) facilitate social inclusion, social solidarity
and citizen growth.
3. There have now been multiple initiatives
in public participation across sectors and at different levels
of government and undoubted successes. Citizens' juries in particular
continue to draw enthusiastic comment and local government has
instituted a wide range of measures (Lowndes 2001). The issue
is being addressed in parallel in other fields, for example, in
public engagement with science. The Power Commission (2006) has
recently distilled lessons. The evaluation literature, however,
is of variable quality and work is often remains small scale and
carried out by scheme advocates and initiators.
4. A volatile emotional charge frequently
surrounds citizen participation initiatives. This is certainly
the case in health where activist critics see repeated organisational
reforms as having no clear evidence base and at to have been detrimental
to experience built up under previous arrangements. Public sector
agencies and organisations are looking for political leadership
on this and this initiative on the part of the Health Committee
is to be welcomed.
Context of this Submission
5. The points below arise from experience
with a study commissioned by the NHS R&D Methodology Programme
in England with the support of (what is now called) the National
Institute for Health and Clinical Excellence (NICE) to evaluate
the establishment of a Citizens Council in NICE. The full study
is published in report form www.pcpoh.bham.ac.uk/publichealthnccrm/publications.htm
and in a book-length study published as Celia Davies, Margaret
Wetherell and Elizabeth Barnett Citizens at the Centre: deliberative
participation in healthcare decisions Bristol, Policy Press,
2006.
6. The Citizens Council of NICE is a group
of 30, recruited to reflect the diversity of ordinary people who
meet twice a year, to discuss the values underpinning the decisions
that NICE makes. Formed in 2002, the Council represented an addition
to the Institute's Partners' Council and to representation of
patients on its work groups charged with evaluating drugs and
devices and making recommendations as to their efficacy and cost
effectiveness to the NHS in England and Wales. Council meetings
take place over a working week-end, supported by independent facilitators.
They address a question set by NICE and report back to the Board.
Audio-visual recording of these events and transcription of tapes
make the evaluation study probably the most in-depth study to
date of citizen participation in action .Three themes arising
from this study are briefly highlighted below for consideration
by the Committee.
The Potential for an Engaged and Informed Public
7. This study suggests that approached in
the right way there is a large pool of citizens who might be interested
in engagement with NHS policy. Potential members of the Citizens
Council responded in very large numbers to publicity in the national
media and an advertisement under the banner "Do you want
to improve the NHS?" There were 35,000 initial expressions
of interest and almost 4,500 people completed application forms.
Those recruited spoke of wanting to help with the challenges of
today's NHS, of a sense of public duty, and of wanting to grow
develop and be stretched. While most were nervous of what was
going to be required of them and concerned about conflict, almost
all enjoyed participation, most reporting that they would look
for new forms of participation when their terms of office ended.
8. In seeking to provide balanced and effective
information for citizens, however, participatory initiatives,
must be realistic both about levels of information and understanding,
and about citizen capacity. On the one hand, members of the public
are not blank slates—they are already influenced by personal
experience and especially by the media. On the other hand, they
do not necessarily bring fixed attitudes and opinions. The most
successful moments for the Citizens Council were those where they
heard speakers who were passionately and differently positioned,
and where they became emotionally engaged in working out their
own individual and collective positions in response. It is more
helpful to think about the development of citizen potential through
well designed modes of participation, rather than to make assumptions—positive
or negative—about fixed citizen capacity.
The Challenge of Creating a Space for Dialogue
9. The Citizens Council was based on a deliberative
ideal—asking what a diverse group of people would decide
might be the public good, when exposed to relevant information
and given the chance to question and debate. This demands interaction
between people who would not have met in daily life, and requires
them to take positions using unfamiliar language and information.
The practical difficulties of this were apparent in early meetings
where at best only fragments of deliberation occurred. Appropriately-crafted
questions, imaginative facilitation (using role-plays, dramas,
case studies and games), alongside continued feedback and support
for individual members is required. A high degree of sponsor commitment
and a sustained allocation of resource is also vital. For practice
to develop, a new cadre of facilitators with opportunities for
training and support probably now needs to be nurtured.
10. If citizen participation is to achieve
the results than are intended, it is also vital that minority
viewpoints and what theorists have termed oppositional or anti-hegemonic
discourses are fully heard. The evaluation study provides evidence
on the inadequacy of assuming that individuals will be willing
and able to articulate minority viewpoints and that these, even
if articulated, will get a sympathetic hearing. There is an urgent
need to develop additional mechanisms in this area—such
as ensuring that organised lobby groups and minority identity
groups are heard in evidence and utilising facilitation techniques
that encourages articulation of minority views even where these
are not expressed (eg the "empty chair" technique).
Integrating the Results into an Expanded Political
Process
11. The results of an exercise in citizen
deliberative participation need to be seen by citizens to feed
back in a highly transparent way into a decision-making process
and to affect outcomes. Sponsor organisations need to be clear
at the outset how the results will be used and to provide an adequate
timetable for meshing them with and taking them forward through
existing forms of governance. Some commentators argue that results
should be binding. I do not agree. The contentiousness of such
a position was exposed in debates in the host organisation in
the evaluation study; there was questioning of the process and
its "representativeness", and querying whether poll
data were not more "robust". Interestingly too, while
Council members were alert to the possibility of their deliberations
being merely "cosmetic", they wanted their views to
be taken into account, without these being binding on NICE.
12. A number of doubts about the idea of
a Citizens Council out the outset of this study were found among
organised patient group members. Such groups are alert to dangers
of incorporation and well aware of the challenges of securing
independent and balanced information for those drawn from the
public in general rather than from patients with direct experience
of a matter under discussion. Organised patient groups are now
strongly established in the political decision-making process
in health. Initiatives in patient and in public involvement need
to be clearly distinguished in a new phase of policy development
and integrated more successfully together. Alongside its necessary
work on the detail of the new LINks scheme, a vision from the
Health Committee of and expanded political process and the orchestration
of its different elements would be particularly welcome and serve
to minimise misunderstanding and conflict. A discussion of the
requirement for consequent changes in the role of the state at
the centre is provided by Fung and Olin Wright (2003).
Conclusion
13. My conclusions from this study are:
— that the involvement of citizens—not
only at local level in issues that directly involve their lives
but at national level in questions of strategy and direction of
government policy—is a feasible goal;
— that the multiple forms of and
levels of participation need to be clearly mapped, related to
each other;
— that involvement of all kinds
cannot be achieved without strong support from the top, continuing
support for citizens, and imaginative and informed facilitation;
— that creating circumstances
in which citizens are able to contest received ideas and challenge
dominant discourses and enable fragile counter-arguments to emerge
and be heard is a central challenge of participatory initiatives.
This process is not yet well enough conceptualised or understood;
and
— that the integration of participation
initiatives into a wider vision of democratic governance needs
urgent attention.
14. There is a further point. The academic
world, attending rightly to the voices of service users, has for
long couched debates around citizen involvement in terms of a
power struggle between officials reluctant to hand over power,
and service users whose ideas about change are all too often marginalised
by a process of consultation which falls short of full participation.
A "ladder of involvement" model has dominated thinking
(Arnstein 1969). We need to make the growing use of the term "engagement"
signal a real change away from characterising disappointment with
forms and towards embedding processes and practices that generate
active dialogue and creating what we have called "expertise
spaces" for citizens.
REFERENCES
Arnstein, S (1969) "A ladder of citizen participation",
Journal of the American Planning Association, 35, 4, 216-44.
Fung, A and Olin Wright, E (2003) Deepening Democracy:
institutional innovations in empowered participatory governance,
London: Verso.
Lowndes, V et al (2001) "Trends in Public
Participation", Public Administration, 79, Nos 1 and
2 pp 205-22, 445-55.
The POWER Inquiry (2006) Power to the People:
Report of POWER: an independent enquiry into Britain's Democracy.
York: York Publishing Services.
Professor Celia Davies
London School of Economics
January 2007
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