PUBLICS, PATIENTS, CITIZENS, CONSUMERS? POWER AND DECISION MAKING IN PRIMARY HEALTH CARE
| DOI | http://doi.org/10.1111/j.1467-9299.2006.00603.x |
| Date | 01 August 2006 |
| Author | GERALD WISTOW,GILLIAN. D. CALLAGHAN |
| Published date | 01 August 2006 |
Public Administration Vol. 84, No. 3, 2006 (583–601)
© Blackwell Publishing Ltd. 2006, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.
PUBLICS, PATIENTS, CITIZENS, CONSUMERS?
POWER AND DECISION MAKING IN PRIMARY
HEALTH CARE
GILLIAN . D . CALLAGHAN AND GERALD WISTOW
This article uses theoretical approaches to the discussion of power in order to con-
sider the role of public and patient participation in primary health care organizations
in the UK. There is considerable evidence to suggest that, despite major national
initiatives to extend participation in health services, the role of participation in deci-
sion making remains underdeveloped. The primary purpose of this article is to
understand how and why this should be the case. Using fi ndings from qualitative
research that explored approaches taken by the dominant professional groups on
primary care groups (PCGs) to involving patients and the public, we consider how
these approaches refl ect the exercise of different forms and levels of power. The
explanation combines Lukes ’ categorization of three forms of power with Bourdieu ’ s
dynamic conceptualization of the relations of habitus and fi eld. It is argued that the
models observed represent different opportunities for the operation of power with
implications for the role that participation can play.
INTRODUCTION
Successive governments in the UK have expressed their intention to involve
patients and the public in decision making about health services, although
the nature and extent of intended involvement varies (National Health Ser-
vice Management Executive (NHSME) 1992; Department of Health (DoH
2001, 2003). Despite guidance from central government, there is considerable
room for local discretion in terms of the content and methods used, resulting
in substantial local variation ( Milewa et al. 2002 ). A recent review, however,
concluded that there had been little real progress in extending involvement
( Farrell 2004 ). While one explanation could be that its true purpose lies in
its symbolic meaning rather than any real intended impact on relations
( Hood 1998 ), the research reported here suggests that this explanation is
insuffi cient.
In particular we explore why, given the general agreement about its
importance at a rhetorical level, the impact of participation is so limited. Our
argument is that to understand participation in the UK National Health
Service (NHS) we need to explore, theoretically, the relationship between the
roles of stakeholders and the differing claims to knowledge and legitimacy
Gillian D. Callaghan is Lecturer in Sociology in the School of Applied Social Sciences, University
of Durham. Gerald Wistow is Visiting Professor, University of Durham and Department of Social
Policy, LSE.
584 GILLIAN D. CALLAGHAN AND GERALD WISTOW
© Blackwell Publishing Ltd. 2006 Public Administration Vol. 84, No. 3, 2006 (583–601)
within which struggles for power are conducted. Lukes ’ formulation of
power and its operation in the dynamic relations between habitus and fi eld
( Bourdieu 1977 ) are employed to analyse how participation is understood
and how far it shapes decision making in health services.
In 2000, primary care organizations were established. These were set up
partly to address inequities created through General Practitioner (GP) fund-
holding. Primary care groups (PCGs) and, subsequently, primary care trusts
(PCTs) brought together professionals and lay people to improve health as
well as to develop services. This signalled some reorientation from medical
to social models of health. Although dominated by GP members, PCG boards
included representatives from social services and the lay public to broaden
the social perspective. PCTs in fact have a lay majority. They therefore pro-
vide a useful context for the study of participation, combining novelty of
organizational form with existing histories of involvement ( Barnes 1997;
Klein and New 1998 ). The focus of the fi eldwork discussed here is on the
early experience of primary care organizations, though it should be stated
that the contribution this article seeks to make is not primarily empirical.
While more recent changes in primary care board membership may not be
insignifi cant, it is argued that understanding rival claims to legitimacy is
more important than counting the balance of interests represented. Struggles
for power within boards refl ect wider struggles between professional and
managerial claims to legitimacy, something that is documented across the
UK Health Service. Indeed, research has shown that these groups have been
competitive in seeking to colonize the voices of both publics and patients
( Mort and Harrison 1999 ). This article focuses on activity at the level of the
board and the relationship it establishes with the public as something that
emerges from a combination of these confl icts, policy expectations and more
straightforward participatory objectives. Despite these continuing internal
struggles, boards are required to involve the population at large in decision
making about service planning and delivery precisely because the legitimacy
of interests from outside NHS organizations has been recognized.
The requirement that boards extend patient and public involvement raises
the question of how they conceive of those they involve. On what basis
should participants have a voice in decision making and what role should
those voices play? To explore these issues it is important to recognize that
each individual may occupy different roles in health services: the public,
patient, consumer and citizen are but four of these. Each implies different
bases of legitimacy and has consequences for participation structures and
their impact on decision-making processes.
BASES OF LEGITIMACY: CONSUMER OR CITIZEN,
PATIENTS AND PUBLIC
The notion of ‘ the consumer ’ identifi es a relationship between individuals
and their services, primarily with rights of exit supported by limited rights
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