Community participation and citizenship in British health care planning: narratives of power and involvement in the changing welfare state

Abstract

This article considers changing conceptions of local citizenship with particular reference to the idea of 'community participation' in the planning of state health care within Britain. The aim is to gauge the extent to which a political rhetoric of community participation in the 1990s constituted an attempt to redefine the relationship between health authorities (responsible for planning and prioritising services) and local communities. Data from an investigation encompassing 75 interviews is used to chart the manner in which health authority managers have re-articulated and given substance to the rhetoric of participation. The analysis appears to confirm a 'democratic deficit' with regard to decisionmaking in health care planning but there is a significant qualification. A process of 'professionalisation' and the growth of 'active management' (rather than 'active citizenship') may in part be off-setting the democratic deficit. This process is however highly contingent upon developments in health service policy and organisation.

Representativeness, legitimacy and power in public involvement in health-service management

“…However, public participation is limited by various constraints, including a widely observed reluctance on the part of health professionals and managers to engage with the public and put into practice the outputs of public-involvement processes (Milewa, 1997;Rowe & Shepherd, 2002;Crawford, Rutter & Thelwall, 2003). By seeking to undermine the legitimacy of those involved (Beresford & Campbell, 1994), controlling the course of meetings (Williams, 2004), or selectively implementing the suggestions of publicparticipation processes (Milewa, Valentine & Calnan, 1999), professionals and managers are seen to retain control over decision-making processes, or manipulate public participation to ensure that it advances their own interests (Harrison & Mort, 1998;Milewa et al, 1999;Tritter, Barley, Daykin, Evans, McNeill, Rimmer et al, 2003). In order to further their own influence, involved members of the public too are forced to defend their own legitimacy, and so are drawn into a complex discursive game with staff, as each group seeks to assert or undermine the legitimacy of participants (Contandriopoulos, 2004).…”

Historicising involvement: the visibility of user groups in the modernisation of the Chilean Mental Health System

“…Second, the consumerist turn shaping the health sector in England and other countries through the 1980s and 1990s (Milewa, Valentine, & Calnan, 1999) forced services to hear what users had to say (Campbell, 1996). This turn afforded opportunities for users to be regarded as a group with consistent and challenging views, although it was not a deep democratisation of the mental health field (Tovey, Atkin, & Milewa, 2001).…”

Governance and public involvement in the British National Health Service: Understanding difficulties and developments

“…The board"s focus was on the practical difficulties of accessing "public opinion", conceptualised as being "informed" versus being "representative". The approach was to identify local opinion as merely one source of advice for the board to consider in its decision making process, much in the way that Milewa et al (1999) relate in their research following "Local Voices" (1992). While this enables information to be gathered about the local community and its views, there is no reciprocity involved in the relationship established.…”

“…As relationships of accountability change, the potential for meaningful participation remains open to question. In their review of the role of participation in health care in the 1990s, for instance, Milewa et al (1999) argued that involvement was best conceived as based on "active management" and professionalisation rather than active citizenship, because the citizen lacks the knowledge required to participate fully in the complex responsibilities of health care planning. Our own empirical research (authors 2002) identified both the limited effect of exhortations to involve the public and the distinctive impact of the different ways in which PCTs engaged with them.…”