New Labour's PPI Reforms: Patient and Public Involvement in Healthcare Governance?
| Date | 01 March 2009 |
| Published date | 01 March 2009 |
| DOI | http://doi.org/10.1111/j.1468-2230.2009.00742.x |
LEGISLATION
New Labour’s PPI Reforms: Patient and Public
Involvement in Healthcare Governance?
Peter Vincent-Jones,
n
David Hughes
nn
and Caroline Mullen
nnn
Following a ¢rst waveof reform at the beginning of the decade, the system of patient and public
involvement in he althcaregovernance is being further overhauled under the Local Government
and Public Involvement in Health Act 2007 and the Health and Social Care Act 2008.The current
reforms re£ect a signi¢cant shift in dominant political discourse from an earlier concern with
patientand public i nvolvement towards a more exclusivefocus on consumer choice and economic
regulation,with collectivevoice and citi zen participationat best playing a subordinate part in the
government’s NHS modernisation agenda.While there is some potential for increased respon-
siveness in the new arrangements,the overall e¡ect is likely to be a weakeningof the foundations
of democratic decision making in the governance of healthcare in England.
INTRODUCTION
This article presents a critical analysis of the current reform of patient and public
involvement (PPI) in healthcare governance in England,
1
under Part 14 of the
Local Government and Public Involvement in Health Act 2007 and Part 1 of
the Health andSocial Care Act2008.
2
Public participationinitiatives in healthcare
are part of a trend in democratic societies towards an increased role for citizens
and service-users in public services governance.
3
UK initiatives in this ¢eld go
back at least as far as the formation of Community Health Councils (CHCs) in
1974 and the Patient’s Charter of the Major Government,
4
but have gained
n
Professor of Law,University of Leeds
nn
Professor of Health Policy, SwanseaUniversity
nnn
Research O⁄cer,University of Le eds
The research undertaken for this article is supported by an EU grant for the FP6 project, Re£exive
Governance in the PublicInterest(REFGOV ^ CIT3 -CT-2005- 513420),and byan NHS ServiceDel ivery
and Organisation Research& Development Programmegrant for the project, Contractual Governancein
a System of Mixed Modes of Regulation (SDO/127/2006).The views expressed are those of the authors
alone.
1 Since devolution there has been signi¢cant policy divergence across the UK on PPI.On the con-
trasting trajectories of English andWelsh NHS reforms generally, see D.Hughes and P.Vincent-
Jones,‘Schisms in the Church: NHS Systems and Institutional Divergence in England andWales’
(2008) 49 Journalof Health and SocialBehaviour 400.
2 Hereafter respectivelythe 2007 Act and the 2008 Act. Partsof the 2007 Act concerning local gov-
ernment will not be considered, nor will parts of the 2008 Act dealing with regulation of health
professions and public health protection.
3 ‘The right of citizens and patients to participate in the decision-making process a¡ecting health-
care. . . must beviewed as a fundamental and integral part of anydemocratic society’ ^ Council of
Europe, Recommendation No.R (200 0)5,The Developmentof Structuresfor Citizen and PatientPar-
ticipationin the Decision-makingProcessA¡ecting Healthcare (adopted by the Committee of Ministers
24 February 200 0),Appendix: Guideline 1.
r2009 The Authors. Journal Compilation r2009 The Modern LawReview Limited.
Published by BlackwellPublishing, 9600 Garsington Road,Oxford OX4 2DQ,UK and 350 Main Street, Malden, MA 02148, USA
(2009) 7 2(2) 247 ^271
momentum since 1997 as a central component of New Labour’s NHS moderni-
sation agenda.
5
Recent PPI policies have been criticized for their rhetorical content, patchy
implementation, and lack of clarity about underlying objectives. Many commen-
tators believe that the ‘patient’ and ‘public’ dimensions of PPI pull in di¡erent
directions.
6
While the ¢rst aspect focuses on micro-level decisions a¡ecting
patients’ treatments and self-care, the second concerns the role of the public in
in£uencing service development and the allocation of resources. It is evident that
the issues th at matter most to patients may not be of paramount importance for
citizens conceived as tax payers or representatives of local communities.
7
The ten-
sion between these aspects of policy is further re£ected in contrasting rationales.
While patient involvement is seen as contributingto the more responsive adapta-
tion of services and facilities to service-users’ needs, public involvement is com-
monly justi¢ed as a means of improving accountability for public services and
reversing declining public con¢dence in traditional forms of political representa-
tion.
8
In the New Labour era, the di¡erent strands of PPI have become associated
with competing conceptions of involvement.The traditional emphasis on collec-
tive representation and ‘voice’ is being displaced by a new preoccupation with
consumer ‘choice’ and the ability to exit unsatisfactory market relationships.
9
Despite the attempt made by some policy makers to reconcile these elements, for
example th rough the not ion of the ‘citizen co nsumer,’
10
the tension remains. Most
recently, government pronouncements have suggested that user choice should
properly be seen as an alternative to citizen voice, implying that increased choice is
needed precisely because voice has failed as a mechanismof involvement.
11
4 R. Klein and B.New,Two Cheers for Democracy (London: Kings Fund, 1998).
5 I. Greener,‘The Three Moments of New Labour’s Health Policy Discourse’ (2004) 32 Policy &
Politics 303; R. Forster and J. Gabe,‘Voice or Choice? Patient and Public Involvement in the
National Health Service in England under New Labour’ (2008) 38 InternationalJournal of Health
Services 333.
6 D. Florin and J. Dixon, ‘Public Involvement in Health Care’ (2006) 328 BMJ 159; A. Coulter,
‘Patient Engagement: Why is it Important?’, in E. Andersson, J. Tritter and R. Wilson (eds.),
Healthy Democracy: The Future of Involvement in Health and Social Care (Warwick: Involve and the
NHS National Centre forInvolvement, 2006).
7 Memorandumto the House of Commons Select Committee on Health, Inquiry i ntoPublic and
PatientInvolvement in the NHS,10 January(London: Picker Institute, 2007).
8 House of Commons Health Committee, Patientand PublicInvolvement in the NHS,ThirdReport of
Session 2006^07, HC 278^1; see also M. Barnes, J. Newman, and H. Sullivan, Power,Participation
and Political Renewal: Case Studiesin Public Participation (Bristol: Policy Press,2007), 23^25.
9 A.Thompson, ‘The Meaning of PatientInvolvement and Participationi n Healthcare Consulta-
tion: A Taxonomy’ (2007) 64 Social Scienceand Medicine 1297. On the question of the extent to
which‘choice’i svalued by patients and the public, see J. Barnett J. Ogden and E. Daniells,‘The
Value of Choice: AQualitative Study’ (2008) 58 BritishJournal ofGeneral Practice 609; M. Calnan
and R. Rowe,‘Trust, Accountability and Choice’(2008) 10 Health,Risk and Society 201..Although
surveys haveshown that the idea of patient choice of hospital is popular with the public at large,
when patients are askedwhat is most important to them as individuals, choice of treatmentloca-
tion ranks relativelylowon the scale of priorities ^ N. Richards and A. Coulter,Is t he NHS Becom-
ing More Patient-Centred? Trends from the National Surveys of NHS Patients in England 2002^07
(London: Picker Institute,20 07).
10 J. Clarke, J. Newman, N.Smith, E. Vidler and L.Westmarland, Creating Citizen-Consumers: Chan-
ging Politics and ChangingPublic Services(London: Paul Chapman Publishing, 2007);C. Needham,
Citizen-Consumers: NewLabour’sMarketplaceDemocracy. (London: CatalystForum, 2003).
New Labour’s PPI Reforms
248 r2009 The Authors. Journal Compilation r2009 The Modern Law ReviewLimited.
(2009) 72(2) 247^2 71
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