Published on August 1, 2014

Designing simple to understand, robust process for setting the NHS Citizen Agenda? Couldn’t be easier!

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.

Agenda Setting sticky wall, Bristol July 2014The NHS Citizen team is just back from the latest Design Workshop in Bristol.

Involve’s main focus at the workshop was on building the conversation about the Assembly Meeting. Specifically we worked with participants to better understand how the agenda for the Assembly Meeting will be developed. On one level agendas are tedious and boring things, but they are also one of the ways that those with power exert their power. Deciding what is on and off the agenda, and exactly how it will be discussed is a powerful way to control the debate.

The picture below is part of a graphic representation of the NHS Citizen System. It shows the Gather space of the system. Our tests so far suggest that we will receive far more issues into Gather than the Assembly Meeting could possible cope with. We currently think that five issues is all that the participants at the Assembly Meeting could possibly deal with in a way that has a chance to lead to change within NHS England.

Gather from May 2014 Leeds Graphic Facilitation


Many of the issues which go into Gather won’t be issues that the Board of NHS England can deal with, but we can expect a number more than five to come out of the other end requiring some kind of response from the Board.

We ran a series of small discussion groups over the two days exploring different aspects of how to make this process as effective as possible. Effectiveness being defined as a process that is robust, open, transparent and not subject to those with power in the system making the choice of issues for the Board to discuss collaboratively with 250 citizens. The picture at the top of this post shows how we captured notes and connected the different conversations.

What criteria will be used to select the issues discussed at the Assembly Meeting?

Our discussions identified a small number of principles that workshop participants felt needed to be used design the criteria by which issues for the Assembly Meeting agenda should be selected:

  • the level and significance (e.g. the reach to different groups of people, including generally marginalised voices);
  • whether the issue is open and/or contested rather than being a simple yes/no answer;
  • the issue is systemic, ie is likely to have national-level repercussions.

The discussion about criteria raised a significant question about whether issues should be also be chosen based on the extent to which have the most chance of impacting on Board policy. Overall participants seemed clear that this shouldn’t be a criterion, and if the will of the NHS Citizen system is to discuss an issue that the Board is unwilling to move on it is still important that they hear the debate and are forced to acknowledge it.

On a related question, people generally felt happy that the Board could propose an issue for discussion at the Assembly Meeting, but that this should not get a free pass; every issue, from wherever it comes should have to go through the Gather process.

How will the criteria be applied?

It’s fine to have some objective criteria to decide which issues should form the basis of the discussions between citizens and Board Members, but who should apply them and how?

We discussed various options, from those active in Gather choosing, to the participants of the Assembly Meeting itself. However, in the end everyone we spoke to agreed that a small group of citizens acting in the form of a jury would be the most transparent and objective way of doing it. The consensus was that the jury should consist of around 25 people, it must involve experts to explain the issues and it should not be live streamed or jurors identified (there were significant fears about trolling of jurors).

We will have to find a way to make the process as transparent as possible without compromising the privacy of the individual citizens invited to take part.

The question then focused around how citizens should be selected to sit on the jury. People split into two very clear camps.

  1. There were those who thought that selecting citizens at random, in the way that juries in the court system are selected, would be the most open, objective and transparent method.
  2. There was also a smaller group of people who were worried that citizens picked in this way would not understand the issues in enough depth. This group felt that jury members should be elected from the regional senate structures which are currently being formed.

How do we make the choice between these two very different views? It really depends on what on what we want. We all agreed the process has to be transparent, fair, reasonable, thorough, objectives and evidence based. So what format would allow us to achieve this? Citizen juries promise more transparency and impartiality, while elective juries would guarantee greater expertise of members on issues and networking capacity to feedback to local communities. But they might also run the risk of ending up representing particular groups and agendas.

Overall, the academic and practice based evidence tells us that randomly selected citizens are more than capable of making complex and nuanced decisions. This is our preferred solution; sometime towards the end of this calendar year or into 2015 we will run a test of a randomly selected jury to demonstrate whether this is true or not and identify what sort of support such a group would need to do an effective job at selecting the issues.

One group had an interesting discussion about whether to have two stages to the issue selection, either by some initial ranking by those participation in Gather, or by asking the Assembly Meeting to endorse the selection of the jury. Both throw-up their own challenges, and while I am personally attracted by the “Gather ranking idea”, I now think, on reflection after Bristol, that we need to keep this as simple as possible and so should stick to a robust one stage process.

In summary, the shape of the experiments we need to run over the next few months have become clear. But how to resolve the tension between an open, robust and objective process on the one hand and the need for simplicity on the other seems further away than ever!

Thanks to all the participants who gave so much time and thought into these discussions. Thanks also to Sonia Bussu and Houda Davis who took excellent notes that have formed the basis of this post.



2 Responses to “Designing simple to understand, robust process for setting the NHS Citizen Agenda? Couldn’t be easier!”

  1. Alan Mercer
    August 4, 2014 at 12:11 pm

    An interesting blog on the intricacies of agreeing an agenda. Having a jury based approach will certainly provide openness and transparency, but my concern would be whether it is providing the flexibility that may be demanded by the Board. How does the approach deal with an urgent issue which may arise?
    It strikes me that there may be an analogy with the BIS 2013 Public Attitudes to Science study which showed that the public were keen that their views were considered in decision making, but that they were prepared to trust others to input on their behalf. Is it an option, or a statement of where we are with the NHS, that there is not an organisation sufficiently trusted to make the decisions on the agenda. Maybe that could also be a question to the jury?

    • Simon Burall
      August 4, 2014 at 5:56 pm

      Thanks Alan, an interesting and helpful observation. It isn’t just the Board who will want flexibility, the members of the Assembly Meeting themselves may want to discuss an urgent item that comes up between the agenda being decided and the meeting itself. There is a significant tension here between ensuring that all Assembly Members have enough information, evidence and data to have a productive conversation, and being timely.

      At the moment our thought is that the Assembly Meeting itself can decide to add an urgent agenda item as the Assembly Meeting starts, but that this will require an infrastructure of some kind to provide an adequate evidence base that is understandable to people from very different backgrounds. It’s been one of our questions during the design workshops, people are keen to make sure that this is possible.

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