Governance, participation and avoidance: everyday public involvement in the Scottish NHS

Abstract

Public involvement in health services is an area of policy where ostensibly good intentions appear to repeatedly fail in implementation. Since the late 1990s public involvement in the UK NHS has been subject to frequent reforms, and this has continued in Scotland since devolution. Reformers have criticised mechanisms for being subject to manipulation by managers, parochial in their outlook, and crucially, ‘unrepresentative’ of the wider public. Academic literature has responded primarily by seeking to ‘fix’ the problems of public involvement, offering typologies and models of participation intended to apply across a wide range of settings and to the entire ‘public’. Taking a different route focused on the complexity of a single case, this thesis explores the multiple meanings and goals contained within the public involvement agenda in Scotland, and argues that these are far-removed from the way that many individual patients seek to influence their health-care in the everyday. In particular this project illuminates the creative and political potential of citizens’ interactions with public services. Research comprises an interpretive case study of the implementation of public involvement policy within one Community Health Partnership in Scotland, and a nested case study of interviews with ‘ordinary’ young adults in the area. Fieldwork across twelve months included semi-structured interviews with staff, participants, and young adults; observation of public and private meetings of the Community Health Partnership and the Public Partnership Forum; and analysis of local reports and plans for public involvement. Given a low level of awareness or interest in public involvement, interviews with young adults concentrated instead on accounts of using health services. Rather than simply illuminating ‘non-participation’, the resulting data act as a lens through which public involvement policy can be seen anew. Public involvement is depicted as an unevenly embedded assemblage of actors and materials pursuing a range of goals, including the strengthening of public influence and the diversification of the public voice. I argue that many current participants in the Public Partnership Forum seek not to change the NHS, but to serve or assist it, and accordingly that their actions can best be understood as work or volunteering, not as activism. Finally, drawing on the reported experiences of my young adult interviewees, I argue that the transition from individual patient to participant is an unlikely one, revealing a range of alternative (oppositional) tactics available to individuals who feel unhappy with some aspect of their care. I conclude by arguing that NHS staff confront the inherently chimerical nature of participatory projects within public services. By operating without a sense of what amount or degree of participation is ‘good enough’, public involvement re-interprets my young adult interviewees as apathetic nonparticipants, and NHS managers and staff as failed engagers. The thesis uncovers the neglected, often-mundane everyday realities of public involvement as both governmental practice and citizen participation. In doing so it troubles the growing literature on contemporary forms of citizen participation and engagement, demonstrating the need for a critical approach to an ostensibly compelling policy agenda.