Published on May 9, 2014

Reflecting on two NHS Citizen days in Leeds

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.

Leeds Town Hall, Urban OutlawThe NHS Citizen Team has just finished two intense days at a workshop in Leeds. This workshop was the end of our three-month sprint, to test, refine and redesign the vision for NHS Citizen. The purpose of the workshop was to work with existing collaborators and people new to NHS Citizen to learn lessons from the sprint and to agree what the key questions are for the next sprint.

Each member of the NHS Citizen team committed to writing a quick reflection on some of the lessons they will be taking away from Leeds. Here are mine. All of the reflections will be collected onto the NHS Citizen blog.

It’s all too complex

1. The detail in the NHS Citizen vision document is important, but it is far too much. Even people who have been to a number of our events have not fully understood how the system will work.

2. We now have the basic NHS Citizen system structure in place. We have to move from abstract designing to practical testing. Our Assembly Meeting test (see below) showed just how valuable this can be.

3. The views and opinions of citizens are central to the whole vision of NHS Citizen – for me they infuse the whole system. But apart from the name of the system, citizens and their role are hidden our text for many of the people who read it.

Working openly is the only way to design complex systems

4. Yet again our methodology of working in the open and testing elements of the system with collaborators has proved its worth. The way we were proposing to run the Assembly Meeting demonstrated that it would fail in its intent. The relatively spectacular failure, and in the subsequent discussions about why it failed afterwards, have given us a clear steer about how to redesign it.

We want NHS Citizen to contribute to collaboration not confrontation

5. The failure of the Assembly Meeting brought into starker relief the tension between the different types of accountability. Mixing hard accountability, with the Board being formally held to account by citizens in an Assembly Meeting, is totally at odds with our desire to develop a system for genuine co-production and collaboration.

6. To put it another way, hard accountability, with Board members sitting in front of citizens in the Assembly Meeting, will reinforce a ‘parent-child relationship’ (as someone in Leeds put it). It risks reinforcing not only the alienation of citizens and patients from the Board, but also the Board from patients and citizens.

Time is a precious resource and a tight constraint

7. However, it demands far less time from the Board. Turning up for a couple of hours to sit in front of the Assembly Meeting is a very different prospect to spending two intensive days working collaboratively with a group of citizens and patients to develop shared solutions to shared problems.

8. We are moving at breakneck speed because of the timetable required by the Board for designing a fully working NHS Citizen system. This means that we are only able to finish preparing materials for workshops, for example, just before the event itself. This stops us providing materials (such as hand-outs and slides, for example) in accessible formats. We have absolutely must find a way to carve out more time to do this.

9. The workshops themselves are also very packed. Rewriting the vision document late into the evening of the first day of the design workshop is important because it means we have a sense of progress. But we have to acknowledge that it is impossible for some people to contribute to this. We have to communicate better that the rewrite is not the definitive end, but just another stage in an open process.

Webcasting is essential to openness, but….

10. The webcasting of all of our workshops is a vital element of working in the open and bringing in voices of people who can’t be physically present at the workshops. However, it does present some hard constraints about what can be done in the room. The Assembly Meeting test should have included participants stepping into different roles, and us totally changing the set-up. But the camera positions, and the difficulty of webcasting table discussions made the impossible. This reduced the usefulness of the test, both for us, but I suspect for a good number of participants as well.

Hearing from everyone

11. We still didn’t manage to create an environment where everyone felt able to contribute. Too many of our plenary discussions included contributions from the same voices (ours included). The contributions were valuable and important, but there was more richness there that we need to pull out.

But it really isn’t all negative

12. I am by nature keen to learn from mistakes, this can lead to reflections like this sounding very negative. Notwithstanding what I’ve written above, I thought this was a fantastic workshop.

13. Despite point 11 above (it is always possible to do better), we had a wide diversity of voices and views that have contributed significantly to our thinking. The lessons I am taking away will affect not just the practicalities of how NHS Citizen ultimately works, but the look and feel, and even the philosophy lying behind it.

14. Everyone who was present (both physically in Leeds, and online) worked so hard and so thoughtfully. The NHS Citizen system was not given an easy time, but it was done in such a constructive and thoughtful way it was truly inspiring.

15. For the Assembly Meeting test three NHS England managers volunteered to role play being board members sitting in front of the assembled citizens. They had a hard time of it, both in role and a bit out of it, and all live streamed. They did it with great humour and dedication. I’m constantly amazed by the risks that the organisation and individuals within it are taking to make it work.

Finally, thank you to everyone who took part in the workshop. Your good humour and dedication was also evident and has really moved NHS Citizen on considerably.

Picture credit: Urban Outlaw

4 Responses to “Reflecting on two NHS Citizen days in Leeds”

  1. SamWoe
    May 12, 2014 at 5:25 pm

    Oh Dear!
    Whilst I was not there,I do appreciate the obvious feelings that flew
    around, yet one senses, there was no direction! Not unusual, however if this NHS concept, is going to help anyone, be they patients, families or staff, even managers – Then we have got to focus, concentrate on our goals. Naturally everyone has their own ideas, also a large percentage of the gathering, having gone to the trouble to attend plus incur expenses – must at least inwardly want to ultimately go home, feeling they have achieved something worthwhile. So if the gathering is 50, 100 or 200 delegates, whilst
    all will have their own pet subjects – this is a non goer!
    The chairman needs to gather in the total ideas bank, then with colleagues choose FIVE to progress with.
    To then avoid dismay from the ‘non chosen’ ideas folk in the audience, he/she should explain the reasoning –
    ‘We need to concentrate on a small group of issues, focus all our energies. That way we will ensure more progress, we’ll ALL be part of the projects success. The alternative is for us to all, to be trashing about everywhere, probably with overlapping. That will usually result is failures, general despair – only by concentrated focus will we progress to our goal. As it becomes obvious a particular chosen sector is galloping along then a further area can be focused on – Success breeds Success.
    Matters directly effecting patients will be popular, but the staff sector must be included. Management too. All effect patients directly plus covering these other important operations, would bring
    the whole concept nearer together – none can be successful without
    a combination of effort in these three principle sectors.
    No! This 80 year old, ex general manager,one time MD and definitely
    retired journalist: will observe, putting in my two pennies worth – But that is all. Far too often I’ve seen causes bloom , then fade, one has to focus on the possible, build on the successes, not easy to keep the concentration long term. However from experience start big, collapse fast. Concentrate on success – The doable.

    • Simon Burall
      May 12, 2014 at 5:34 pm

      Thank you for your comment. You highlight a key tension for NHS Citizen. How do we develop something that can deliver what it promises, while meeting the expectations that some are already placing on it? We are already being criticised – see here for example – for not moving fast enough.

      Are we getting the balance right. I’m not sure I know how we’ll know until we have succeeded or failed. My sense is that we are managing to deliver a sense of urgency and forward motion in terms of what we are developing, without moving so fast I’m lying awake at night wondering if we can deliver. But your supportive challenge is very much taken on board.

  2. steve sharples
    May 14, 2014 at 10:27 pm

    I think that overall the design meeting met my objectives and looked forward to the next stage in the development of a working system.

    My one gripe, if thats the right word, was the last afternoon assembly session. we all know that it was a try out but it was the most pathetic and pretentious trial that I have seen.

    If you are going to trial something please make certain that the main participants are fully briefed and understand what they are supposed to do

    • Simon Burall
      May 15, 2014 at 3:59 pm


      Thank you for your comment, and more importantly your time and energy during the workshop. It was much appreciated. I’m glad that overall it met your objectives. We found it very useful, though we do have to do more to ensure that those voices that are not normally heard feel confident to speak in the room; I do think we could have done better with this.

      I’m sorry that you had a gripe with the Assembly test, though if you thought it was both pathetic and pretentious it sounds like more than a gripe.

      I’m not quite sure who you mean by the ‘main participants’. Do you mean the people who played the Board members? If you do I’d love to know a bit more about what they got wrong so that I can understand better what you mean. This is even more important because this wasn’t my perception. I felt the most useful part of the exercise was that what I felt was a relatively authentic reaction to the process really helped expose how badly what we were planning would work in practice.

      If you mean that the participants themselves, ie the Assembly Members, weren’t briefed properly then I would agree. We had hoped that the earlier parts of the workshop would throw up an issue that we could use and would give us enough material to brief participants. We should have planned ahead much better and prepared material that would be more useable (though the NHS England team did a fantastic job in getting us even that at very short notice).

      If you mean that the participants needed a better briefing about what the exercise was about – rather than the content of the test discussion – then I’d also like to know, because that wasn’t my impression so it would be very helpful to hear a bit more so we can do better next time.

      We can always get what we do better, there is much to learn, even for experienced facilitators, so I’m very grateful to you for taking the time to comment on my post.


Leave a Reply