Public involvement in health service governance and development: questions of potential for influence

Two papers in this issue of Health Expectations consider efforts to strengthen public involvement in health service governance and development. Both highlight the inappropriateness of a narrow focus on public involvement as a source of demonstrable impacts on health service decision-making. This is consistent with recent calls to recognize a variety of rationales for involvement and to value the processes as well as the outcomes of participation.1 But it does not render questions about the influence people can have on health services obsolete. In this editorial, I suggest that attention to the conceptualization and assessment of potential for influence, as well as to the dynamic social attitudes and interactions within which this develops, might be useful for future debates. Mark Learmonth et al.2 focused on the representative bodies that have been established in England to help ensure that health services are responsive to service users’ needs and accountable to local communities. They identified a ‘catch 22’ in expectations about the people who serve as members of these: they are supposed to be both ‘ordinary’ (somehow typical and representative of local people, and perhaps explicitly not experts on health issues) and ‘professional’ or not ordinary (because they are required to be interested in and knowledgeable about health care, to be willing and able to dedicate significant time to the work of the representative bodies, and to be able to influence health service officials and professionals). Learmonth et al. suggest the ‘catch 22’ has arisen at least in part because of efforts to assess and manage the performance of local representative bodies according to (inappropriately) narrow criteria of effectiveness. They recommend that these bodies should ‘be given space and time to pursue their own agendas’ so they have a chance to ‘bring new sources of creativity to public services, and encourage more open debates that represent wider constituencies and interests’. Questions about the balance of emphasis between representation and contribution to health service management have a long history and are unlikely to be resolved quickly.3 Any shift in the direction that Learmonth et al. propose, however, would still require careful attention to the scope that public representatives have to influence services. The notion of participation makes little sense if potential for influence is entirely lacking.3 Andrea Litva et al.4 highlight a type of involvement that illustrates a number of issues relating to potential for influence. They asked people with varied health care needs and relationships to health services to consider public involvement in three aspects of clinical governance: assessing and improving service quality; educating and training health professionals; and dealing with poorly performing health professionals. They found, to some extent as anticipated, that people with different health-related experiences were inclined to adopt different perspectives as they thought about their potential to be involved (e.g. as citizens, consumers or advocates). They also found that people expressed preferences for different types of involvement or ways of being involved. One type of involvement that was preferred by all but one group of participants in relation to at least one aspect of clinical governance was labelled ‘overseeing’. This was understood mainly as a matter of observing clinical governance proceedings to check that officials or experts adhered to key goals and followed due process, and particularly to ensure that they paid adequate attention to service user and community views in their deliberations and decisions. This type of involvement has been relatively neglected in classifications of involvement to date. Overseeing would possibly make fewer demands on public representatives than some other types of involvement. Overseers would not, for example, need the kinds of knowledge, skill and confidence that are required to generate and present substantive proposals or to muster well-evidenced and well-reasoned arguments for or against particular courses of action. And they need not be the primary or main sources of information about service user and community views for decision-making committees. In Litva et al.’s study, it was notable that in relation to assessing and improving service quality, overseeing was the type of involvement preferred by the two groups with least experience of health care need and health service use, and that in relation to dealing with poorly performing health professionals, it was preferred by all but one group (of people who had previously worked together as activists on a health service issue). But the demands of overseeing are not trivial. Overseers need to be able to follow the discussions of officials and experts, request and obtain clarification or explanation where necessary, assess collective actions, and recognize and intervene to correct any deviations from due process. And if they are to do more than uncritically endorse dominant managerial and professional viewpoints, they must be able to influence those whose actions they oversee: it is crucial that their efforts to intervene when they see shortcomings are appropriately heeded and not dismissed or deflected. This leads us to an important general point. The potential for public representatives to exert influence is not just a function of their formal positions (e.g. as designated overseers) or of their (individual or collective) knowledge, skills and self-assessments of their potential to contribute. It also depends crucially on the views that others hold about them. If they are not taken seriously by those with whom they interact, their potential for influence will be constrained. Our social identities in particular spheres of action as well as in broader social domains can have significant implications for our agency.5 Further attention to the notion of potential for influence might be fruitful for efforts to develop the theory and practice of public involvement. Conceptual work that helps us to characterize potential for influence might usefully suggest criteria for assessing the scope that different approaches to involvement give service users and community members to contribute to health service governance and development. And methodological work could enhance attempts to assess public representatives’ potential for influence in different involvement contexts. (Such assessment is likely to be challenging, as potential for influence will often be latent, as for example in the case of overseers working with committees whose members conscientiously seek and attend to service user and community views in their work). And empirical work could usefully improve our understanding of the ways in which the potential that individuals and groups have to influence health service agendas can be developed. Such work will need to attend to the ways in which potential for influence is shaped by the dynamic interplay between social identities and action in the context of different structural and attitudinal relationships. For overseeing roles, for example, the complex relationships between trust and the behaviours associated with the checking and possibly challenging of others’ behaviour are likely to be important.6 Questions will also need to be asked about what makes particular levels of potential for influence more and less appropriate. Public representatives, like health service staff, have various limitations in terms of their expertise and competence, and these should, of course, be recognized. But many people think that some (potential) public representatives are inappropriately prevented from participating effectively, that they are unfairly excluded, or that their contributions are dismissed or harnessed to serve dominant interests rather than their own. The bases of these normative judgements need to be critically analysed. Health Expectations will welcome submissions relating to any of these issues.