Big conversation, small talk

The problem with consulting the public is that’s all it is: an exchange of views on the chosen topic. Big conversations can turn into small talk when the topics are all chosen by one side, which listens as much to its own views as to those of the other discussant. There is no doubt who is in charge, and no doubt who makes the final decisions. Consultation is very much a professional’s approach to getting patient opinions, represents a huge power imbalance, has enormous potential to be patronising, and has little to offer health policy.

It need not be like that. We know enough about methods that foster participatory democracy to correct the democratic deficit in public services. This does not mean creating public forums as adjuncts to hospital trusts or PCTs, but moving public involvement to the centre of the NHS. This can be done by creating management bodies recruited from local government, civil society and NHS staff at each level of the health service. The strategic health authorities should satisfy their strategic management board (and ultimately regional government) rather than the Department of Health, primary care trusts should refer to augmented local authorities, hospital and other trusts should be steered by elected representatives, and consultation and information-giving roles should be relegated to the work-unit, whether ward or health centre.

Citizens’ juries can be recruited and serviced at local level to enrol the public in complex decision making, and could even become a civic duty, like serving on a court jury. Standing conferences of voluntary bodies can review health policy and debate options for service development, diverting some of the effort currently squandered on ‘multiple projectitis’. Focus groups, public opinion surveys and patient participation methods can be used at micro-level to clarify choices and validate plans.

Such changes would strengthen local government and help restore the civic pride eroded by a centralised state. They would fit perfectly with an enabling and regulatory role for the Department of Health, the Commission for Health Audit and Inspection, and other quangos, for these bodies would set the framework within which an increasingly democratic NHS could work. But it would not fit with a command-and-control culture where centrally determined targets are conveyed to the public along an administrative transmission belt.