Putting The Puzzle Together

One idea of how NHS Citizen could be the missing link between isolated deliberative forums with little impact and a revolutionary deliberative system.

I’ve been working on NHS Citizen for Involve for just over a month. As I become more and more immersed in the design of the Assembly Meeting (a truly exciting challenge for a participatory geek like me), I find myself facing some big dilemmas: as a citizen, as an academic and now as a practitioner as well.

For years I’ve studied the failures of participatory and deliberative democracy in its many forms (local, national, international…) and this certainly makes me more alert to the things that are likely to go wrong. And there are many insidious pitfalls: from underfunding and member selection decisions before the process to power dynamics and exclusionary practices during the process, to weak political commitment to participatory decisions after the process.  As I talk about NHS Citizen to scholars, practitioners, NHS staff and ordinary citizens, I sense some degree of justifiable cynicism, because, after all, we’ve done this before many times and with very shaky results at best.

Particularly within NHS England there is so much going on at the moment in terms governance mechanisms at the local and national level, from Healthwatch, Citizens’ Senates and Patient Voice groups to NICE councils. Every level wants its governance mechanisms and participatory processes, to increase legitimacy or just to tick the ‘governance’ box. Participation participation participation is the mantra, even if at the end of the day it seems that once again most people don’t even know about the existence of all these new initiatives. How can we make sense of all this and give some coherence to the whole governance framework so that we can make it meaningful for ordinary citizens? How can we help citizens use these different spaces to voice their concerns and problems within the NHS but also to develop their own creative solutions?

It sounds like a Quixotian effort against resistance to meaningful change from within political and managerial quarters and much public disaffection. And yet NHS Citizen could be a one in a million opportunity to change these dynamics. This will be challenging and we have no naive illusions, but the NHS Citizen team are determined to do their very best to contribute to setting up a process that can actually learn from past experiences and from itself, through self-reflective practice. NHS Citizen could become a dynamic instrument of genuine citizen voice, at a time of commissioning and growing democratic deficit within the NHS.

So here’s one idea of how NHS Citizen could be the missing link between isolated deliberative forums with little impact and a revolutionary deliberative system: instead of seeing each of these new forums – NHS Citizen, NICE Councils, Healthwatch, Citizens’ Senates, and everything else that goes on locally – as separate and even competing with each other, couldn’t we instead maximise their influence by thinking about this plurality of deliberative forums as a system of multi-level governance? A system that would guarantee a variety of overlapping and mutually checking procedures that would help increase the legitimacy and the effectiveness of the NHS deliberative system as a whole.

How? Well, NHS Citizen, through its multi-level architecture (Discover, Gather and the Assembly Meeting) could offer the answer, if we think of Discover and Gather as a sorting office where different conversations involving different people are picked up and encouraged (Discover) and issues are framed and discussed (Gather). Many of the issues might be outside the remit of the Assembly Meeting. So it is important to clarify the scope and remit of the Assembly Meeting, while continuing to use Discover and Gather as a space to explore and discuss any issues relevant to the NHS. Gather might in fact represent a national-level arena to discuss and frame issues. We could imagine mechanisms to direct issues from Gather to the most appropriate level and facilitate and support the opening of public dialogues at that level, through continuous coordination between Healthwatch, Citizens’ Senates, CCGs and NHS Citizen.  Each public dialogue would produce policy recommendations submitted to the attention of the appropriate level, whether Healthwatch or the NHS England Board, depending on the scope of the issue.

Issues discussed within the Assembly Meeting should be systemic, but the deliberation, and ensuing recommendations, might encourage and strengthen local dialogues on related issues. One practical example would be the restructuring of the NHS. The Assembly won’t be able to deliberate on the closure of a particular hospital, yet its considerations, and the dialogue opened with the Board on overall accountability to citizens on hospital closures, will inform local deliberation on a specific hospital. The opposite process is also likely, as local issues and personal stories might inform a higher-level dialogue at the Assembly, where local experiences could be presented as evidence and case studies.

Groups active in other forums and people framing issues on Gather could be involved as experts and witnesses to give evidence at Assembly Meetings, where ordinary citizens would deliberate and offer a fresh perspective. So instead of replicating or bypassing conversations at other levels, NHS Citizen could in fact work as the link between all these public dialogues, which would reinforce each other. The involvement of key policymakers at all levels through Gather could give greater visibility to the whole process. It would offer an incentive for participation, as the opportunities to translate innovative and collaborative ideas into tangible policies would increase with clear and visible political endorsement.

It is challenging indeed, but worth trying, if our goal is to move beyond the trap of isolated and/ or one-off deliberative events that continue to dent the legitimacy of deliberative democracy in the eyes of its detractors and increasingly of its champions as well.

Photo Credit: Ken Teegardin https://www.flickr.com/photos/teegardin/