Published on January 28, 2014

NHS Citizen: Designing democracy in the light

NHS Citizen

By Simon Burall

Simon Burall is a Senior Associate of Involve. He has extensive experience in the fields of democratic reform, governance, public participation, stakeholder engagement, and accountability and transparency.

Diagram showing the state of the NHS Citizen system as it currently is. Three layers are shown: on the outside Discover; in the middle Gather; and in the middle the Assembly Meeting. There are times, very rare times, where a part of government decides that it needs to develop a new structure to give citizens more power to hold it to account.

When this happens, the usual way it is done is that a large consultancy or corporation, or the politically orientated flavour of the month thinktank, is sent away to work in a darkened room. They then emerge six months later with a shiny new organisational structure that they guarantee will change the balance of power. Only it doesn’t. Either it doesn’t work, or it doesn’t do so in a way that more than a few dozen people outside government have heard about and so changes nothing for most citizens.

So I’m really excited that we are involved in a radical approach to designing a new system for holding the Board of NHS England to account. In partnership with Public-i, Demsoc and the Tavistock Institute, working with the NHS England Public Voice team, we are developing an open process to answer the what, why and how questions which surround something as challenging and huge as the design of a new democratic mechanism for the NHS.

We are calling this NHS Citizen.

This post is intended to give you a high-level summary of what we plan to do, and how we plan to work. At the bottom I suggest a number of ways you can follow our progress and get involved.

How are we going to design NHS Citizen?

The mandate for this work comes from a decision of the NHS Board in early 2013 to develop citizen voice within the decision making process and to better hold the Board accountable. Following the decision, several hundred people participated in two workshops, held in July and October 2013, to begin the design process.

Both workshops were live streamed and brought twitter and other forms of online engagement into the room. At its height, over 700 people were following the live stream of the October workshop, with many of these engaging in the debates with those in the room. This something we aim to build on as we scale-up the design process.

The current model of NHS Citizen that we are exploring and testing envisages three interlinked spaces, Discover, Gather and the Assembly Meeting. It is during the Assembly meeting that the NHS Board will meet face to face with citizens. While the workshops held to date have begun the process of shaping NHS Citizen, they also identified a series of, as yet, unresolved tensions and unanswered questions arising from the way the system might work.

The programme plan that we have developed with NHS England consists of nine workstreams which have been designed to refine and test the model and start to resolve the tensions and questions. We expect this process to resolve some issues, but surface others.

Processes of institutional design like this not only normally happen in darkened rooms involving small numbers of professionals, they are also nearly always delivered against rigid project plans.

We will be working differently as we aren’t setting the next year in stone.

Instead, we will be drawing inspiration from the agile model of software development. We will be using an adaptive programme management process (described here in outline) which holds the vision and model, the research and learning questions and the programme’s critical path in public, refining and adapting them at the end of two-three month periods of sprint testing of different elements of the programme.

Critically each of these two to three months sprints will include a number of experiments where we will be testing bits of the system, and as the year goes on increasingly moving to whole system tests. These will be designed to ensure that we, and all partners and participants, can learn from the process and iterate the design to make it work better. Our learning objectives will, of course, be in the open, as will what we think we have learnt at the end.

We can’t do this alone, no-one can; not NHS England, not some big consultancy firm and not four agile organisations with a wide-range of complementary skills. We are going to need to work with many more individuals and organisations to answer the multiple questions and tension that arise from designing a democratic structure with real power from scratch.

So, over the next three months we will also be developing a Challenge Fund to be used to engage others with ideas and interest to work with us and NHS England to develop and test solutions to some of the key challenges and questions raised during the design phases of the programme. NHS Citizen will also have a Participation Fund to facilitate the engagement, throughout the whole journey, of key individuals who have day jobs and lives outside the world of democracy wonkery.

What makes this different?

I’ve described two ways above that I think the way we intend to design NHS Citizen is different, that we’ll be:

  • Operating in the open at all times; and
  • Our agile method of project management ensuring regular points of open and participative reflection on the lessons learnt.

I’d like to highlight one more way that NHS Citizen is different; the extent of senior involvement in, and buy-in into, the need for an Assembly to hold NHS England to account and into the process described above.

Three Board members, Tim Kelsey, Victor Adebowale and Ciaran Devane, have been tasked with leading on the work. They have attended workshops and are engaging actively with both the process and the ideas behind the design of NHS Citizen.

They have their own views and have brought these to the workshops last year. Indeed, it’s fair to say that they are not presenting a united front, but are debating, in public, their different but complementary visions for NHS Citizen.

I also think it is significant that they have made it very clear, in public, that this is not a done deal. Our work on NHS Citizen is not an unstoppable steamroller that means that the Assembly system gets developed come what may. If the broad consensus of opinion is that there is no role for it then NHS Citizen will cease to exist.

For me this is critical because it hands some power over to participants, if they feel that there really is no role, or that the emerging system won’t work, then they have the potential to pull the plug (video).

A second critical element of the three Board members’ support is around the experiments we plan. Tim, Victor and Ciaran are committed to this approach as a programme of active inquiry and design; that it may not always work. In essence we have been given the space to fail as long as we have clear learning objectives for each experiment and actively bring this learning back into the process of design.

Find out more and get involved:

If you want to find out more, get involved, or follow progress then there are a number of ways you can do so, by:

EDIT 12 May 2014 to update the NHS Citizen blog link.

9 Responses to “NHS Citizen: Designing democracy in the light”

  1. January 31, 2014 at 10:17 am

    It’s fascinating to read the approach that Involve are taking, and from an audit body’s perspective really interesting to see how the testing changes the nature of the project.

    I hate to link to work we’ve been doing, but we recently took part in the NHS Hack Day in Cardiff, and it was great to see that patient involvement was central to many of the projects developed, including this one ( and this one (

    Really looking forward to hearing more about your work as you take it forward, and good luck!

    – Dyfrig

    • Simon Burall
      January 31, 2014 at 11:14 am

      Thanks Dyfrig, that’s kind of you. I’ll take a look at the links you’ve posted. I will also make sure that you get updates about the project as it progresses unless you let me know you’d prefer not.


  2. Cassandra
    December 13, 2015 at 11:32 pm

    NHS Citizen: Designing democracy in the light
    Published on January 28, 2014

    3 Responses to “NHS Citizen: Designing democracy in the light”
    ”Three ”responses” in TWO years?” [As before the posting of this comment.]

    One from a member of the ‘public’
    One from the author
    One …Err, which has gone missing, or been deleted?

    Is this Value for Money?


  3. Simon Burall
    Simon Burall
    December 14, 2015 at 8:35 am

    Dear Cassandra

    Thank you for your comment. The programme that this post refers to, NHS Citizen, is being delivered by a partnership of organisations, of which Involve is one. The post is a way for us to communicate to people interested in the work of Involve what we are up to and not for engagement around NHS Citizen. The main NHS Citizen website is here: . There are a much larger number of blog posts on this site which is kept up-to-date in a way that this more descriptive page isn’t.

    The programme also has a twitterfeed if you are interested:

    This online activity is only a small part of the overall activity of NHS Citizen, much of which happens face-to-face. If you wanted to have a look at the evaluation of the design phase, which finished in March last year, to get an idea of the number of people engaging and some of the impact, then you’ll find the evaluation here:

    I have had a look in the backend of our blog and can only see one other (external) comment having been made (and one ping back from another Involve blog post that doesn’t appear to be showing; I’m not sure why and will try to chase it down). If you think another comment is missing please do let me know a little more detail and I’ll look into it.


  4. Cassandra
    December 14, 2015 at 9:04 am

    ”If you think another comment is missing please do let me know a little more detail and I’ll look into it.”
    ” Reports that say that something hasn’t happened are always interesting to me, because :
    as we know,
    there are known knowns;
    there are things we know we know.
    We also know there are known unknowns;
    that is to say we know there are some things we do not know.
    But there are also unknown unknowns – the ones we don’t know we don’t know. … ”

  5. Simon Burall
    Simon Burall
    December 14, 2015 at 9:59 am

    Not quite sure how to respond to having Donald Rumsfeld quoted at me.

    As you can imagine I don’t keep an encyclopaedic bank of every comment on our site in my memory. I was reporting to you what I could see at the back end of our system. Given that you seemed very certain that a comment was missing (in the realm of known knowns from your perspective and a new known unknown from mine) I thought I’d admit my fallibility and ask you for a bit more information so I could track it down. Going all Rumsfeldian on me doesn’t help, but does leave it looking like you think I’m hiding something from you, which I’m not. I’m just being honest about what I can see. (I have also asked the wonderful people who host our site if they can help).

    Did you find the other links I sent you useful?


  6. Cassandra
    December 14, 2015 at 10:57 am

    In the words of our beloved Leader
    ”Calm down, dear boy, calm down.”
    The banner proclaimed, before I contributed my piece, that there were THREE ”Responses”
    I could only see evidence of TWO
    One from Dyfrig
    A reply from you.

    That’s TWO

    I know nothing of the ”Mystery of the Missing Response”, since I only stumbled upon this Ghost site minutes before I posted my comment which seems to have touched a nerve and caused you so much hurt.
    Still – the consolation is that you’re getting paid for posting, I’m doing it for ”nowt”, and at least you’ve got some outside input into your previously comatoze ‘duck’.

  7. Simon Burall
    Simon Burall
    December 14, 2015 at 2:47 pm

    If that’s the case then the missing comment is almost certainly the ping back from the other Involve blog post Hopefully that clears up that mystery.

    It’s always useful to get constructive comment and criticism.

    best wishes

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