Editorials

Consulting the public about the NHS

We need a culture of involvement not policymaking by 12 million leaflets

Patients and members of the public in England have just been consulted by the government on how they would spend the extra funding promised to the NHS over the next five years. The consultation is meant to inform the government, which in July is publishing its plan for the NHS, defining how the increased funding will be spent (Department of Health, press release, 23 March 2000). Twelve million leaflets with prepaid response forms have been distributed through supermarkets, pharmacies, opticians, hospitals, and general practices, asking, "What are the top three things you think would make the NHS better for you and your family?" "Census day" was 31 May, when service providers were asked to actively encourage their users to fill in the leaflet. The public consultation process also includes a website, two public forums, patient representation on the six action teams for modernisation, and meetings between patients' organisations and ministers.

Public involvement has an increasingly high profile in health services policy. Justifications for this trend include the need to ensure the democratic basis of publicly owned health services and the view that user involvement leads to services with better outcomes. There is already substantial research on how to achieve public involvement of a high quality. In a recent policy statement from the Department of Health on public consultation, both integration and inclusion were defined as essential to initiatives on patient and public involvement.¹ Yet these qualities are not evident in the current consultation process.

To achieve an integrated approach to public involvement, NHS organisations should "strategically and systematically build patient and public involvement into the way they operate." ¹ As the Department of Health's guidance makes clear, this aim is not served by treating patient and public involvement as an "add-on" task. Yet this is exactly what has happened in this instance. When the prime minister, Tony Blair, launched the consultation process in March, he identified leaders of the professions and health organisations as the key stakeholdersno mention was made of the involvement of patients and the public. The announcement of the broader public consultation strategy came in May, some time after six working groups on modernisation had been established and almost two months into an already intensive four month process.

The leaflets were issued on 22 May, to be returned by 5 June. The analysis and incorporation of potentially millions of people's views before the plan is published on 15 June will be challenging indeed. Failure to take meaningful account of the opinions of the people you canvass is a sure way to engender cynicism.

To achieve an inclusive approach to public involvement, NHS organisations were told "to make special efforts to involve under-represented individuals, groups and communities." ¹ Other widescale consultation exercises have shown just how difficult it is to engage with the public in general, let alone with more marginalised groups. ^{2 3} Little evidence exists of such efforts being made in this exercise. The leaflet is wordy and only available in English and was disseminated through NHS service providers and supermarkets without any support from the local community. In the absence of specific interventions geared to engaging people and communities across the whole population, many groups will remain on the margins of healthcare decision making.

The involvement of patients and the public in the NHS is a long term goal. A transparent, responsive health service in which patients, carers, and the public are genuine partners is still some way off. Partnership requires engagement with people on their own terms, with a genuine sharing of interests. Considerable commitment to this process exists at local level, despite the overwhelming pace of change in the NHS.⁴ National high speed exercises, which return to the secrecy of the government as rapidly as they emerge from it, leave people squarely outside the system. This may actually undermine local involvement processes and cause "consultation fatigue."⁵

How much these problems will matter depends to some extent on the way the results are used. The lack of clarity of the aims and scope of the consultation, however, will make it difficult to assess its impact. International examples have shown that meaningful consultation, especially at a national level, is complex, lengthy, and expensive.⁶ With its overly simplistic approach, the exercise may produce some useful ideas, but, at worst, it will undermine the long term partnerships which the NHS should be seeking to build with its own staff, its users, and the public.

Will Anderson, project officer, primary care programme. 
Dominique Florin, fellow, primary care programme. 

King's Fund, London W1M 0AN

1.	Department of Health. Patient and public involvement in the new NHS. London: DoH, 1999.
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4.	Anderson W, Florin D. Involving the publicone of many priorities. London: King's Fund, 2000.
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