NHS Citizen is seeking to deliver engagement processes that meet the needs of policy-makers as well as ensuring the public’s views are heard

Designing public engagement processes and institutions from the perspective of citizens alone makes them easy for policy makers to ignore, argues Simon Burall. He suggests we need to pay more attention to the needs of those making policy in order to design public engagement processes which make a difference, and outlines the development of the NHS Citizen programme, which is being designed to achieve this objective.


Policy makers are from Mars, and citizens from Venus? Credit: Sunghwan Yoon, CC BY-SA 2.0

I’ve just finished two fascinating Democratic Audit posts exploring whether the internet has the potential to transform politics. The first, by Adam Lent, is relatively positive, suggesting that the internet will allow the ‘disintermediation’ of politics. That is facilitating the aggregation of citizens views and perspectives without the need for political parties. The second, by Jonathan Hopkin on the limitations of the internet for replacing politics is much less positive.

Both posts highlight our project, NHS Citizen, as an attempt to use the internet to play this disintermediation role, to aggregate citizen and patient views in order to hold the board of NHS England to account. Both posts are worth reading in their own right, but they also miss an important point that has become much clearer to me over the past six months as we have dived deeply into the design of a new democratic space for the NHS.

Hopkin notes that NHS Citizen,

“involves an Assembly, meeting twice a year, which will ‘gather’ citizen views and concerns to hold the NHS Board to account.”

He goes on to ask,

“[are we] so accustomed to the medium of a Westminster-style representative assembly that we cannot think beyond it, or because these much maligned institutions are the only feasible way to provide citizens with a fair say in policy decisions?”

I’m tending more to the view that it’s not a failure of imagination that leads us back, like Athenian democracy groupies, to citizen assemblies. It is something much more fundamental about the way we organise our societies that demands such structures.

As public engagement practitioners we spend a lot of time designing processes that will work for the public, ensure that citizens are able to participate by making the space right, and doing it at times and in ways that make citizens feel welcome, for example. This is absolutely right and must always be the case. It’s no good designing a space where citizens don’t feel comfortable, or able, to express their views, otherwise there’s nothing meaningful to aggregate.

But I’ve come round to the view that focusing solely on the needs of citizens all too often leads to citizens being ignored because those with power just can’t engage with what they hear, even when they want to (and there are far too many times when they don’t even want to do this, where ‘listening’ to the public is nothing more than a cynical manipulation of public opinion).

For better or worse, policy makers move at an incredibly fast pace; in the NHS they think in terms of policies involving millions of pounds, and are literally worrying about life and death in an incredibly pressured media environment. Public engagement processes which don’t report at exactly the right time, in ways that give the policy makers confidence that they know who they are hearing from and in ways that make sense within their own (sometimes very limited) frame of reference don’t stand a chance of being heard.

We are deliberately designing NHS Citizen to try to meet the needs of both the public and the policy makers who need to listen to them, take account of what they say, and be held accountable by them. I’ve included a bit more about the different spaces in NHS Citizen below to explain how I’m understanding what we are doing.

Designing NHS Citizen

The outer space of the NHS Citizen System, Discover is active and ‘persistent’. Discover aggregates information and opinions through social media, public comment, online and offline tools. This gives a picture of the “state of the conversation” on health, allowing issues of public concern to bubble up. In short it will try to operate with citizens, in the way they are living their lives and expressing their opinions.

The periodic Assembly Meeting on the other hand is the expression of the system that the NHS England Board will interact most with. It will express formal opinions and raise questions for the Board to respond to. It will have rules and procedures which give the Board confidence that it hasn’t been captured by special interests, for example. In short, it plays a vital role in meeting the needs of the policy maker as much as the citizen.

However, for many citizens it will almost certainly remain invisible and arcane, however hard we try to make it accessible. Meeting twice a year, for two days at a time, just doesn’t work with the warp and weave of citizens’ lives.

This is where the Gather space comes in. This is the part of NHS Citizen that is genuinely new and is our attempt to connect the space that is designed to work for citizens, with the space that policy makers will recognise. It is where the aggregation of view, and crucially evidence, will happen. Much of the time this aggregation, or building of a case for an issue to make it into the Assembly Meeting, will happen online, but it doesn’t need to.

In their two posts, both Lent and Hopkin focus too much on the citizen perspective for me. Worrying about disintermediation and aggregation of views, without thinking about the plumbing that will connect these views to our institutions and decision-makers misses the point.

We are almost certainly in transition mode, NHS Citizen of 2024 won’t look anything like the design blueprint of 2014 (PDF). However, I also suspect that there is a basic truth about the way we need to organise complex societies; we need to delegate power and authority to smaller groups of people, and we need to hold them to account. For that to happen effectively we are going to have to design institutions that are much better at working for and with citizens. However, at the same time they must also work for those we delegate power to, otherwise they will be ignored.

We are trying to design an institution that works for those in power who genuinely want to listen to citizens, but find it hard to do so. We are also trying to pull off another trick: to make it impossible to ignore by those who continue to show a cynical distrust of citizens and refuse to listen.

This post was originally published on the Involve blog. For more information about how you can get involved in NHS Citizen visit the website here.

Note: This post represents the views of the author and does not give the position of LSE or Democratic Audit. Please read our comments policy before responding. Shortlink for this post: buff.ly/1m5L4d0

imageSimon Burall is the Director of Involve, and Chair of Democratic Audit’s Board of Trustees. He has extensive experience in the fields of democratic reform, governance, public participation, stakeholder engagement, and accountability and transparency.


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