NHS Citizen team went to Newcastle last week to present our project to a conference organised by the Participatory and Deliberative Democracy group. The theme of the conference was the impact of social and technological innovation on democracy. Although this was primarily an academic conference (where theoretical frameworks and normative standards kept popping up into panel discussions as well as coffee break conversations, baffling some of my colleagues…) there were also a few other practitioners and policymakers. To be fair, most presentations described inspiring empirical case studies of local and national level democratic innovations, as a testimony to the fact that academics are increasingly engaging with institutions, not only to test their theories in the real world, but increasingly to co-create innovation with people and policy makers. And if normative standards will (rightly) continue to guide academic work on deliberative democracy, the focus is increasingly on instrumental incentives for policy makers to support and champion participatory processes. At the conference we even discussed the idea of starting a new forum on deliberative democracy where practitioners, policy makers and academics can meet and work together.
Our panel, “Deliberation in Public Policy and Administration”, offered a good mix of case study analyses. Oliver Escobar’s ethnographic research focused on the micro-politics of practitioners’ work as they engaged stakeholders in a Scottish local authority. His work problematised the very notion of the public: this is not a pre-existing entity, as we’d like to think, but is instead contingent, context-dependent and is continuously (re)constructed around specific claims.
Vanessa Liston had the privilege/ onus to present two papers! The first one was a fascinating study of a new software that facilitates the process of public submissions to local authorities. The paper described how this software was successfully tried out in a local authority in Ireland, smoothing the process for councillors and citizens and allowing for speedier feedback on submissions and more effective monitoring. Her second paper, co-authored with Clodagh Harris (also presenting) and Mark O’Toole described how Q-method can be used to address opinion noise and polarisation before the referenda.
Mary Houston’s work offered important insights on government-sponsored online participation in the national level policy process. Her study focused on civil servants’ perceptions of e-democracy, showing a variety of “types”, from the enthusiastic champion of innovation to the sceptic who doesn’t see the point. She highlighted how the mainstream narrative of participation in government remains, however, centred around the idea of the citizen as primarily a consumer.
All these insights ring a bell with our work on NHS Citizen, as we engage with stakeholders, ordinary citizens and policy makers to shape an ambitious, bold even, deliberative system in a highly challenging context of macro and micro politics. Anthony and I presented this dynamic process designed in an open, transparent way with everyone that wants to be engaged, and I felt the idea(l) of NHS Citizen really captured the imagination of our audience. Yet the challenges ahead are many and several difficult questions were raised over issues of inclusiveness, agenda setting, ensuring a coherent system where citizens can genuinely become coproducers of solutions and influence decisions.
The most difficult question (one that we have been asking ourselves all along) was raised by Stephen Coleman: how does NHS Citizen fit within the continuing process of marketization of the NHS? Will NHS England buy into the process if citizen-driven agenda setting challenges their vision and direction of the NHS? NHS Citizen is a courageous decision on the part of NHS England, but one that is necessary, as they understand very well, in a context of democratic deficit and a lack of political accountability (with the 2012 reform the Secretary of State has effectively abdicated his responsibilities over the running of health services). Managerial accountability on its own can’t fill this void and this is why the role of NHS Citizen will be crucial. The instrumental incentives for policy makers are many: renewed legitimacy, better policies that truly address the needs of the citizens, coproducing solutions to problems that often depend on people changing their behaviour. For this people’s role has to be central.
NHS Citizen shouldn’t have predefined normative values (either set by NHS England or by NHS Citizen team). It should be an impartial process, which can enable citizens to deliberate together and open a dialogue with the different tiers of the NHS, from CCGs and Health and Wellbeing Boards to the NHS England Board. We can’t predict which issues or solutions will emerge. We’re all taking a risk – as well as full advantage of an opportunity – but one that cannot be avoided. Academia can play an important role here, in helping us shape an inclusive and open process that create incentives for both citizens and policy makers to engage, while continuing to probe critical self-reflection.