The Democratic Potential of Public Participation: Healthcare Governance in England
| DOI | 10.1177/0964663910391349 |
| Published date | 01 March 2011 |
| Date | 01 March 2011 |
| Subject Matter | Articles |
Article
Social & Legal Studies
20(1) 21–38
The Democratic
ª The Author(s) 2011
Reprints and permission:
Potential of Public
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DOI: 10.1177/0964663910391349
Participation: Healthcare
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Governance in England
Caroline Mullen
University of Leeds, UK
David Hughes
Swansea University, UK
Peter Vincent-Jones
University of Leeds, UK
Abstract
Public participation is commonly advocated as part of the solution to the problem of
democratic deficit in the development and implementation of policy. This article
considers the democratic function of different arrangements for public participation,
with reference to alternative rationales for democratic engagement in the health
services context. We review the limitations of aggregative and representative notions,
before exploring the senses in which a deliberative approach based on justification to
the public can increase confidence in the democratic legitimacy of decisions. This
theoretical understanding is used to evaluate the democratic potential of the legal
framework for Patient and Public Involvement (PPI) in healthcare governance in England.
Keywords
democratic theory, healthcare governance, Patient and Public Involvement, public
participation, public services regulation
Corresponding author:
Peter Vincent-Jones, School of Law, University of Leeds, Leeds, LS29JT, UK.
Email: lawpvj@leeds.ac.uk
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Social & Legal Studies 20(1)
Introduction
Public participation is increasingly regarded as playing an important, and perhaps even a
necessary, role in the democratic development and implementation of policy in Western
societies. The Council of Europe has stated that ‘[t]he right of citizens and patients to
participate in the decision making process . . . must be viewed as a fundamental and inte-
gral part of any democratic society’ (Council of Europe, 2000). A democratic function is
also recognized in trans-national governance instruments, for example, the UNECE
Aarhus Convention on Access to Information, Public Participation in Decision-
making and Access to Justice in Environmental Matters (UNECE, 2008). Public partici-
pation is frequently advocated in contemporary debate as a remedy for weaknesses in
traditional representative structures, which suffer from ‘low electoral turnout, a focus
on service provision rather than local voice [and] poor representation’ (Harrison and
Mort, 1998: 61). Again, while most people can exercise some control over policy
through elections, voting usually amounts to deciding between limited sets of choices,
with little depth of involvement (Mullen, 2008: 398–402). A related argument is that
public participation is necessary in order to enhance democracy by redressing power
imbalances and increasing the influence of citizens and the public relative to that of
bureaucrats and professionals (Arnstein, 1969).
If we accept in principle the democratic case for public participation, the question
becomes whether or how this role may legitimately be fulfilled. We address this
question by distinguishing alternative democratic rationales for public participation,
showing how this account can be used to evaluate regulatory arrangements for partici-
pation with reference to the example of recent developments in the system of Patient and
Public Involvement (PPI) in healthcare governance in England. Rather than simply
applying theoretical ideas in the evaluation of practical arrangements for participation,
we suggest that consideration of such arrangements can allow insight into, and clarifica-
tion of, theoretical aspects of democracy (in this we follow an approach used by Bohman,
1998: 400). Healthcare governance provides an illuminating focus for discussion and a
promising subject matter for testing ideas and systems of democratic decision-making,
not only because it affects people’s fundamental interests, but also because decisions
on access to, and provision of, healthcare services are contentious and open to debate and
disagreement. Yet despite general acknowledgement of the importance of public partici-
pation, there has been remarkably little scrutiny in policy and even in academic discourse
of the democratic purpose of regimes such as PPI, and of how the success or limitations of
associated regulatory frameworks might be judged. The suitability of this case study of the
democratic potential of public participation is enhanced by the history of government
initiatives on citizen and service user involvement in this field over the past 40 years.
In the first part of the article, we assess approaches to participation that might claim
democratic legitimacy through aggregative and representative procedures which give
people a say in decisions which will affect them. While acknowledging that these
approaches might supply an element of democratic legitimacy, we emphasize fundamen-
tal limitations of lack of depth of public involvement associated with each approach. We
then show how such limitations may be avoided through the development of a concep-
tion of public participation based on deliberative democracy. However, we contend that
Mullen et al.
23
while the deliberative conception might contribute to increased confidence in democratic
legitimacy of decisions, this approach also suffers from inherent limitations. In the later
sections of the article, we show how this theoretical analysis may be applied in the pro-
visional evaluation of key aspects of the system of PPI in the field of healthcare govern-
ance in England, focusing on reforms introduced under the Local Government and
Public Involvement in Health Act 2007. We suggest that the clarification of reasons why
public participation is important in these theoretical terms is a crucial preliminary step
towards empirical research investigating the effectiveness of policies encouraging
increased citizen involvement in fields such as healthcare (cf. Barnes et al., 2007).
Before continuing, we should note that since our discussion is specifically concerned
with the democratic aspect of decision-making processes, we ignore for present purposes
other possible rationales for public participation, for example, its role as a means of
increasing public trust in official decision-making affecting public services (cf. Milewa,
2004: 243), and its function in monitoring the provision of healthcare services (see
HCHC, 2007; Vincent-Jones et al., 2009a). While we do not consider explicitly the prob-
lem of power, the proposed deliberative model is dependent both on citizen empower-
ment in the sense of the endowment of patients and the public with the capacities to
contribute to decision-making processes, and on the responsiveness of bureaucrats and
professionals to their inputs. The analysis presented here is part of a broader research
project focusing on the communicative, democratic and cognitive conditions that argu-
ably need to be satisfied in order for reflexive governance effectively to operate through
social learning on the part of key actors and stakeholders in public service networks
(Vincent-Jones and Mullen, 2010).
Democratic Legitimacy based on Participation for All
Public participation might perform a democratic function by providing members of the
public with a voice, or the ability to express an opinion, which then carries weight in
determining policy and implementation. If public participation is to claim democratic
legitimacy on this basis, then we need to decide who is entitled to have a voice – that
is, who is the relevant public or constituency. People have interests in public services
as users, taxpayers and citizens, and while memberships of these groups overlap, they
are not identical (Callaghan and Wistow, 2006: 584; Tritter and McCallum, 2006:
160). Once the relevant constituency has been identified, we need also to consider the
capacity in which individuals should be involved (Mullen, 2008: 399). Democratic
legitimacy in this sense is arguably dependent on every person within the constituency
(or at least every member satisfying certain criteria, for example, adulthood) having the
opportunity to express an opinion (see Harris, 1989: 87).
A further problem then concerns processes or mechanisms of participation. One solu-
tion could lie in the adoption of an aggregative approach (see Chambers, 2003: 308), for
example, using large-scale surveys, thus giving each member of the constituency the
opportunity to have a direct say on particular issues. Unsurprisingly the appeal of this
method is likely to be limited to relatively simple issues where straightforward choices
may be made between limited numbers of fixed options, and even then this model would
require an explanation of how responses should be aggregated in order to reach a
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Social & Legal Studies 20(1)
decision. In more complex cases there may be concerns about the limited opportunity for
participants to give voice to nuanced ideas, choices, or arguments (cf. Mullen, 2008:
401–402). Moreover, unless participants have a say in deciding what choices should
be offered, or who should set these choices, then we might question the extent to which
the results of surveys could be considered to have been derived from the opinions of the
constituency.
Elections might appear to avoid the limitations of surveys, while retaining democratic
legitimacy by providing each member of the relevant constituency with the opportunity
to express an opinion. Members of the constituency could each have a vote for (and could
stand as) representatives to form a group which would engage in the definition and dis-
...
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