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Designing the NHS Citizens Assembly

This post is a response to Sonia Bussu’s recent blog outlining two potential models for the NHS Citizens’ Assembly; the first a deliberative polling approach to informing the overall strategic direction of the NHS; the second, a collaborative problem-solving approach between the Board and citizens.

The overall thrust of Sonia’s blog is an important one – that different objectives are best met by different institutional designs. Therefore, it is important to have a clear vision for what the objectives are for the Citizens’ Assembly in order to ensure it is designed in a way that can realistically meet those objectives. One of the things I wrote about (see this blog) after the London meeting last year was that many people at the meeting advocated that NHS Citizen should be facilitating the expression of people’s and patients’ voices and evidence, but there seemed to be many alternatives for what voice and evidence could be. Unpicking what people mean by voice and evidence will be key to ensuring that the process is a success.

From observing the NHS Citizen process to date, there seem to me to be five broad aims that are regularly alluded to with regard to whole NHS Citizen process (not just the Assembly, which is only one component). These are: to enable public expression of values (1), priorities (2), needs (3); to incorporate public expertise (4); to hold the NHS Board to account (5). The question is then, which of these are appropriate aims for an assembly-type process – namely, a process that is time limited, relatively infrequent, and where participation is restricted to a certain number of people?

My opinion is that objectives (1) and (2) – to express public values on, and public priorities for, the NHS – are a good fit for an Assembly-type event, as well as, perhaps, (5) to hold the Board to account. The expression of public needs (objective 3) and the incorporation of public expertise (objective 4), I think, could be better dealt with on an ongoing basis and would probably be more usefully facilitated and have more traction at a local level, working with the organisations that provide services. There doesn’t seem to be a good reason to restrict these objectives to a relatively infrequent, time-limited process, with limited participation, since this could inhibit the effective co-design of solutions. Effective co-design of solutions may require months of work with a variety of participants taking part in various different ways. There may however be some issues that arise from these processes that could be filtered up through the gather process for consideration by a Citizens’ Assembly.

A space for members of the public to formulate and express their values on and priorities for the NHS in order to influence it’s strategic direction seem like much more appropriate aims for an Assembly-type event. If the Assembly is to have an influence on the strategic direction of the NHS, this is likely to at least partly be through influencing public opinion and being taken up by the media, which then influences politicians and policy-makers. Large national events are more likely to get the type of publicity necessary to achieve that (it may be useful to think of the Assembly as part of a deliberative system). Therefore, I’m more in favour of this model, however, I would not necessarily think of it as a deliberative poll, but perhaps more like one of America Speaks’ “21st Century Town Hall Meetings” that have been used to to set the agenda for local governors in Washington.

The second question posed by Sonia’s blog is, what is the role of the Board and how should any collaboration work? I think this question should be answered with a question, if the Assembly is a forum for the public to articulate and express it’s values and priorities, should the Board and Assembly actually collaborate at all? It might be good for the legitimacy of the both the Board and the Assembly if they are independent, so what is the collaboration meant to achieve? If the Board is to collaborate with the Assembly, then perhaps the most suitable role would be to perform the sort of function that is undertaken by Finland’s ‘Open Ministry’ and provide the skills and expertise that members of the public may lack in turning their ideas into workable policy recommendations and proposals. I don’t see a clear reason, however, why the recommendations of the Assembly should respect the competencies and remit of the Board. This may be appropriate if the aim of the Assembly is simply to feed information to the Board to enable the Board to carry out its business. However, if the aim is to express public values on the NHS, then there is no reason to assume that the public will think the current institutional arrangements are the best ones. A further way that the Assembly and Board could collaborate is when the public calls for changes that are outside the Board’s remit, the Board could still use it’s broader influence to advocate and agitate for these changes.   

Finally, to return to the objective (5), holding the Board to the account. If the aim of the Assembly is to hold the Board to account, then this would suggest to me that it needs a significant degree of independence, otherwise it will just be viewed as a patsy. However, the extent to which the Assembly will be able to hold the Board to account is quite limited as I don’t think anyone is proposing that it has formal powers (for instance to appoint members of the Board), and anyway it is not clear why the Assembly would have the legitimacy to wield such power. This would just kick the accountability can down the road – if the Assembly is to have formal powers, then who is it accountable to? Therefore, the Board’s reaction to the Assembly is most likely to be held to account in the court of public opinion. It is thus important to focus on the soft power that the Assembly can wield through publicity and transparency. One function of the Assembly might therefore be to play a citizen auditor role and produce a public report on how the Board has furthered the recommendations set out in the previous Assembly. However, this would probably involve some people being involved on a more ongoing basis to produce this report, so perhaps the Citizens’ Assembly could appoint the citizen auditors.

These are intended to be some tentative suggestions to continue the debate about the design of the Citizens’ Assembly, but of course comments and alternative suggestions are most welcome.

Originally posted @ (now defunct) NHS Citizen Blog
June 9th, 2014

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