Published on May 29, 2014

The NHS Citizen Assembly and the Board: envisaging a collaborative relationship

NHS Citizen

By Sonia Bussu

Dr Sonia Bussu is a researcher at Involve. She is passionate about increasing citizen voice in public policy (so much so that she did a PhD on the topic) and over the past few years she has been involved in several research projects on citizen participation in policy-making.

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Anna Geyer

The more we delve into the details of NHS Citizen and the Assembly Meeting, the more we find ourselves rethinking overarching questions and the very purpose of the Assembly.

Testing the Assembly plenary with the Board at the Leeds’ design workshop was a sobering reality check, as it showed us how we risk falling into the “public meeting format” trap if we fail to address clearly what type of relationship we expect and want between the Assembly members and the Board. The participants in the workshop agreed they want to encourage a more collaborative and less hierarchical relationship, but what does that mean in practice and how does it change the role of the Assembly Meeting?

To me there is one key issue to consider before we move forward: what is the role of the Assembly Meeting within the NHS Citizen framework? That is: do we envisage the Assembly Meeting as an instrument to enhance the legitimacy of the whole NHS Citizen architecture before the Board? Is it where (national level/ systemic) problems (and solutions) identified in Discover and discussed and clearly framed in Gather are debated by citizens in a face-to-face deliberative environment with the aim to develop advisory recommendations for the Board?

Or is it a space where citizens co-design with the Board actual solutions to problems? In this latter understanding it might be more appropriate to have stakeholders already engaging with NHS England.

The way we understand the role of the Assembly completely alters the dynamics between the Assembly and the Board. I have tried to capture the difference in this simple table (obviously this is quite stark categorisation and we can think of a few hybrid solutions in between).

Table 2

In the first case the Assembly Meeting would function mainly as instrument of gaining public insights on systemic issues and ensuring accountability from the Board. This would be a role similar to other cases of Citizens’ Assemblies, which are often randomly selected. Here people, broadly representing the country’s socio-demographics, deliberate and develop recommendations (after a thorough learning phase) on 1 to 3 issues/ questions, clearly and concisely framed in Gather (offline and online). The Board participates in the Assembly but cannot deliberate; it takes the final decision and should be expected to justify publicly any rejections and be accountable on implementations of agreed recommendations.

In the latter case, the relationship between the Board and the Assembly is more collaborative and solutions are co-planned with stakeholders with direct experience and/ or knowledge of the issue at stake.  In this case we should reflect upon a few important questions:

  1. Which solutions to which issues can be co-designed at this level?
  2. Is a two-day event twice a year a feasible context to offer Assembly members and the Board the space and time to co-plan tangible solutions?

There are also some practical considerations:

  1. The time commitment required from the Board members, who would be expected to participate at the very least in the whole event (and possibly be involved beforehand in Gather)
  2. Co-planned solutions entail greater responsibilities for citizens as well as the Board and NHS staff. A consensus would need to be reached within the Assembly Meeting, rather than the Board having to justify its decisions. Would that create risks of pressure on stakeholders to conform to the Boards’ priorities?
  3. The process of co-creating innovative solutions requires a facilitative leadership that is able and willing to take on certain political risks in order to shield staff against a culture of risk aversion that pre-empts meaningful change. Is the Board in a position, from an administrative and political perspective, to do so?

Irrespective of the role we envisage for the Assembly meeting, a clear understanding of the issues for discussion is crucial to choosing the right format of collaboration.

  1. What are the issues that should be discussed at this level, how to ensure they do not fall outside the Board’s competencies and remit and that proposals can be effectively implemented?
  2. How can we guarantee that issues within the remit of the Assembly will emerge from Gather? What other channels will we have in place if few/ no national-level issues emerge from Gather (which is likely to have a more local perspective)?

We’d really welcome your feedback and comments; this is not something that a small team can design alone. Do you have examples of where this kind of collaboration at a high-level has worked well before? Which kind of collaboration will add most value within the NHS England system? What will we need to do to make it work well?


One Response to “The NHS Citizen Assembly and the Board: envisaging a collaborative relationship”

  1. Oliver Escobar
    June 8, 2014 at 7:34 pm

    On balance, I think I’d go for the 1st option -a citizens’ assembly model. Reasons:

    -it seems more doable and realistic given the time constraints; I mean, co-producing/co-planning usually works best on an ongoing basis rather than through episodic encounters. I think that involving stakeholders in that limited time may be counterproductive and frustrating for them and yourselves as organisers. In the citizens’ assembly model stakeholders can be part of the process in the learning phase, and perhaps have a more meaningful impact on the Board through the assembly members –rather than through a short encounter with the Board in which it may be hard to develop the dialogic quality of communication necessary for co-creation

    -in my view, one of the most promising features of NHS Citizen is that it may break entrenched patterns of interaction. My fear is that if the assembly is stakeholder-led (rather than citizen-led) those patterns of interaction and communication may make it difficult to generate meaningful work. To change that, perhaps a citizens assembly stands a better chance by undertaking something like an arbitration role to help all of those already involved in this policy world to consider alternatives and question entrenched habits and rituals.

    I also believe that there hasn’t been a lack of stakeholder forums when it comes to the NHS. What we haven’t had before is a citizen-led process with the claim to legitimacy that a randomly selected and fairly facilitated citizens’ assembly may offer

    Having said that, I do appreciate that many of the ‘key stakeholders’ may think that this would give them a secondary role. And I realise that this may present the team of democratic innovators behind this initiative with considerable dilemmas -e.g. does this have any chance of success if those stakeholders are not 100% on board? I hope though that all those stakeholders appreciate that this may be an opportunity to do things differently. If they agree that the stakeholder-led model that has prevailed so far in so many NHS forums has perhaps not met all their aspirations, then perhaps they will be willing to support an initiative that brings in new voices, ways of knowing, and interacting. Otherwise, paraphrasing the cliche, we cannot expect that doing things in the same way is going to produce different results.


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