Richard Norris, Visiting Fellow, Academy of Government and Director of Scottish Health Council
A recent seminar organised by the Academy of Government, Healthcare Improvement Scotland, and the Usher Institute, explored the issue of public engagement in health service change. We had a mix of academics and researchers, policy people and practitioners, including the third sector. Bringing together this mix of people is a rare event, and we wanted to explore some key issues, including how Scotland compares with other parts of the UK, and what we expect public engagement to achieve.
Dr Ellen Stewart shared findings from some recent Health Foundation-funded research looking at policy and practice in engaging with the public on healthcare service change across the UK. We heard about the difficulties encountered in reaching a common understanding between NHS organisations and the public they serve on models of service provision and how they should change. I talked about the evidence base for participation: when it is likely to be more successful, and also the occasions where the end result has still been an impasse.
Everyone agrees that engaging with the public about healthcare services is important, but why is it important?
Looking at various policies and guidance over the past 15 years the list of reasons for involving the public includes:
- Improving the health of the public
- A catalyst for change
- Achieving improvement in services
- Strengthening public confidence in the NHS
- Demonstrating the NHS listens and takes into account public views
- Making services more efficient and effective
- Building community skills and confidence
- Boosting democratic participation
- Better outcomes for communities
- Recognising people’s ‘right to be involved’
These are the reasons set out in policy documents and guidance, but what do the public see as the benefit of participating in healthcare decisions? Looking at research into public views, and comments made by community and campaigning groups, these can be summarised as:
- To improve services
- To have a say
- Understand why things are changing
- Feel more involved in healthcare issues
- Develop skills
- Influencing / lobbying e.g. for resource
- Preventing proposals which are unpopular
An important issue is the difference between service users and carers being involved in the development of a particular service, and much more wide-ranging public engagement exercises around hospital closures or centralising services. Not surprisingly the latter can be far more contentious, and what is seen as a good outcome for some may not be a good outcome for others. To many it seemed that the difference between say, engagement with service users about a local mental health or diabetes service, and engaging with the wider population about relocating an Accident and Emergency department was not just a difference in scale, but a difference in type. In the smaller and more local exercise, engaging with the public is about getting user and carer views and experience to inform how to improve the service. But in other, population wide, cases, it will be more about meeting democratic expectations and making decisions that are seen to be legitimate.
Particularly in the more challenging areas of relocating or centralising services, the evidence that good public engagement necessarily leads to decisions that command greater public support is not as clear, although some public engagement is a lot more likely to produce a greater level of support than no engagement at all. There are case studies (for example on the NHS Confederation website and Scottish Health Council reports) that give examples of where public engagement has led to decisions that command greater support. But there are also plenty of examples where public engagement has not resulted in proposals that command broad support. In some cases, NHS organisations have pushed ahead, against public opposition. In other cases, plans have been changed, or halted. Either way the result has not been strengthened public confidence in the NHS, or a consensus that services have been improved.
Maybe as well as getting a local perspective which provides essential evidence to inform the best decision, it is important to ensure that people have the chance to give their views because they have the right to be heard, for differences of opinion to be aired, and NHS organisations to gauge the range, and strength, of public views. In this scenario there are no right or wrong answers, but there are good or bad ways to make the decision.
Deliberative approaches (like Citizen’s Juries), where a small number of the public spend time hearing evidence and discussing alternatives, offer some options for reaching better decisions. But this is best done before issues become too polarised, and may not always find a consensual way forward. A recent review of 66 Citizen’s Juries around the world that were about healthcare found that few Juries’ rulings were transferred into policy and practice. However this remains an area worth investigating as a way of exploring alternative options to unpopular proposals.
Four key points came out of the discussion:
- We should learn where we can from other parts of the UK but also bear in mind that Scotland has a clear legal structure and policy direction in terms of public participation, and the creation of Health and Social Care Partnerships is a huge opportunity to make more progress.
- Participation may not create consensus, but it will provide an opportunity to explore and understand different points of view. Professionals do not have a monopoly on ‘rationality’, expertise or evidence. Community concerns about transport (for example) are very rational. What the public brings to discussions is important evidence. Sometimes people talk about the public having an emotional investment, but so do professionals.
- Decisions may be wrong, and should always be subject to review. The world is messy, not linear. It may be difficult to have conversations about unsafe services, but risk is subjective. Decisions to close hospitals can transfer risk to different parts of the system, e.g. primary care.
- In Scotland there is a protectiveness and defensiveness around institutions and there is a need for a more open culture. And the ‘politics’ of service change should not be underestimated. People’s lives are political, and conflict can be a good thing.
So no easy answers, but if we can be realistic about the prospects of public engagement achieving consensus, it perhaps focuses us more usefully on how to develop processes that are open, transparent, and seen to be fair.