Published on October 9, 2014

The democratic experiment continues: Reflections on the first NHS Citizen Assembly test

NHS Citizen

By Houda Davis

Houda Davis is a Research Assistant at Involve interested in participation in health, the environment and science and technology.

Image credit: Tom Blackwell

Image credit: Tom Blackwell

It’s an exciting time for democracy. Two weeks ago while the Scots were voting in their referendum Involve ran the first ever NHS Citizen Assembly Test. For those that don’t know, NHS Citizen is a democratic innovation[i] which will eventually be an infrastructure where participants become citizens of the NHS, not just consumers. The idea is that people can hold the Board of NHS England to account, set the agenda for discussions, and find others with shared interests– all in an open, transparent and public environment.

The Assembly was an enormous achievement bringing together civil society groups, expert citizens, NHS England managers and Board members to talk about 5 big health issues selected through Gather: Mental Health, Access to Services, Gender Identity Services, Young Peoples’ Health, and Self Care. However, in the NHS Citizen spirit of improvement and learning, here are some of my reflections about the event:

  • Participant diversity – NHS Citizen needs clarity on whether the Assembly meeting is for ‘ordinary citizens’ or ‘expert citizens’. The latter have deep knowledge and expertise on health issues and are accustomed to acting as patient representatives, which significantly affects the type of deliberation that takes place. Other deliberative forums typically recruit a representative sample of the population to increase legitimacy and ensure more marginal voices can be heard.
  • The breadth of issues – The Gather part of the system was not fully up and running so it was an unfair test of the issue selection process, however the issues chosen (apart from Gender Identity Services) were incredibly broad. This meant that much of the first part of the day felt like a repeat of the Gather ‘refine’ process and discussions were sometimes unfocussed. We need to make sure that the Assembly builds on work that takes place in Discover and Gather.
  • The relevance of issues –The Assembly is intended to provide a space for NHS England Board members and citizens to discuss problems and develop solutions. However NHS England only has remit over certain parts of the health system, so we need to figure out how to select and frame issues so they fall under the remit of NHS England so that action on these issues can realistically be taken. Can NHS Citizen signpost other issues to the relevant part of the health system where they can be addressed (this is part of a bigger question about how NHS Citizen interacts with local level structures, which is the focus of the most recent public workshop in Birmingham)?
  • Board commitments and accountability – Board members demonstrated their ability to listen in the final part of the Assembly as they reflected on what they had heard in the sessions they had joined. BUT they did not make commitments. We need to think about what we mean by accountability and work closely with Board members to ensure that NHS Citizen is useful and meaningful to their work whilst maintaining the bottom-up citizen-focussed momentum and support that it has already gained.
  • Deliberation vs. Public Meeting – The contrast between the deliberative dialogue format of the Assembly and public meeting format of the AGM was stark and uncomfortable. While the deliberative dialogue clearly encouraged a less antagonistic interaction, the pressing questions on thorny issues around commissioning and the role of private sector, did not really emerge in the deliberative engagement, but exploded into the public meeting. But people did not receive answers and it was clear NHS England felt its control over these issues was limited. There is clearly a great deal of energy around these debates – how can we make the most of this innovative spirit and the disordered creativity of critical democracy to strengthen deliberative dialogue, rather than using participatory democracy to tame this bottom-up energy?

And just a few things on process:

  • Time – An event like this would typically be held over at least two days and there just was not enough time to develop new ideas or move beyond problems towards solutions.
  • Layout – The set-up of each room was intended to give maximum flexibility but the lack of tables was a problem for older participants and those using wheelchairs. This also meant many materials languished on the floor and conversations were not captured.
  • Facilitation – The facilitators demonstrated a huge amount of flexibility and innovation in their sessions but it might have been beneficial if they had been involved in the planning at an earlier stage to give a better sense of existing work in Gather. Also a lack of table facilitators meant small group discussions sometimes lost focus or became dominated by the loudest voices.

All that said, the Assembly test demonstrated an incredible effort on access, translation, transcribing, webcasting, graphic recording and facilitation. There was a huge amount of care taken to ensure people felt included. The team worked incredibly well and it was inspiring to see so much expertise, from participants, volunteers and staff. It remains a privilege to be part of such an exciting and ambitious project and I look forward to the next phase of development.

NHS Citizen is being designed in the open and depends on the energy and input from anyone who is interested, so do get in touch or join us at one of our events.

[i] See Graham Smith (2009) Democratic Innovations: Designing Institutions for Citizen Participation

4 Responses to “The democratic experiment continues: Reflections on the first NHS Citizen Assembly test”

  1. Huw Evans
    October 16, 2014 at 12:45 pm

    I have an interest in public engagement – approaches to and processes for and I developed an evaluative framework for such a few years ago. It draws upon a range of theoretical domains and references to the Human Rights Act. It is potentially a tool to help plan engagement and support the design of such interventions – depending on the outcome(s) you are aiming for.

    Don’t aim for too much structure – as that smacks of seeking more control over the inputs and/or outputs.

    For what it’s worth I’d seek to get the whole system in the room to create dialogue and understanding between service users and service deliverers (I’d refrain from making too hard a distinction about who might be expert at what. Service users / citizens are the people who need to be heard / listened to and those providing the service need to understand how services should be designed to meet user needs (not necessarily ‘wants’) and apply whatever their expertise might be to design the most effective value for money arrangement in response.

    If this is truly a more open, transparent and inclusive approach – then it cannot be a one-off and you cannot expect ‘perfect’ results immediately even with micro-managed facilitation (facipulation?). This ought to be a long-term arrangement that develops with each iteration. It could take decades to effect a cultural change that people trust ….

    May I suggest that overarching guiding concepts can be found in systems theory and complexity theory if you’re serious about this.

    • Houda Davis
      Houda Davis
      October 22, 2014 at 2:33 pm

      Hello Huw
      Thanks very much for your thoughtful comments. Perhaps you could send a link to your evaluation framework if it is available online and I will certainly delve into some systems theory and complexity theory for some inspiration.
      I appreciate your comment about not making the distinction between experts and citizens. However I do think NHScitizen should aspire to reach out to people who do not usually engage, in particular marginalised groups. ‘Expert citizens’ can certainly play an important role in connecting to these groups.
      I agree that NHScitizen needs to develop over each iteration and we are planning more tests of different parts of the system over next few months so do keep an eye on the NHScitizen events pages.

  2. Huw Evans
    October 22, 2014 at 3:15 pm

    Hi Houda,

    Thanks for responding.

    A problem for ‘hard to hear’ groups is that continual treatment as a marginalised entity reinforces that marginalisation and might develop more perverse effects such as handing power to unelected/unrepresentative individuals as a token to be able to say a certain group has been involved. Sometimes the ‘representation’ is flawed. You can see it with consultation for the 3rd Sector via NCVOs et al. The public sector and Govt can often seek to simplify the complexity of engagement by reducing representation to single bodies or people – because it makes the ‘job’ of engagement simpler to do.

    I think you’re right to reach out to all – users and non-users – ‘get the whole system in the room’.

    See below for a synopsis – a few years old now:
    Evans, H. D. (2009). “‘Can we all join in?’: Developing an Evaluative Framework for group processes to aid decisions about their use in approaches to participative engagement.” The Police Journal 82(1): 50-78.

    See what you think


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