Citizens at the centre

Citizens at the centre: Deliberative participation in healthcare decisions

Celia Davies
Margaret Wetherell
Elizabeth Barnett
Copyright Date: 2006
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  • Book Info
    Citizens at the centre
    Book Description:

    Involving citizens in policy decision-making processes - deliberative democracy - has been a central goal of the Labour government since it came to power in 1997. But what happens when members of the public are drawn into unfamiliar debate, with unfamiliar others, in the unfamiliar world of policy making at national level? This book sets out to understand the contribution that citizens can realistically be expected to make. Drawing on the lessons from an ethnographic study of a public involvement initiative in the health service - the Citizens Council of NICE (National Institute for Clinical Excellence) - the book explores the practical realities behind the much-quoted faith in 'deliberation' that underpins so many models of public involvement and presents the analysis of sixty four hours of video and audiotape capturing a warts-and-all picture of deliberation in action. It sets deliberative participatory initiatives within a broad inter-disciplinary context and challenges politicians, policy-makers and academics to develop more realistic approaches to democratic innovation. Citizens at the centre will be of interest to academics and students in social policy, sociology, politics, health, social care, economics, and public administration and management. It will also be valuable to anyone involved in the policy making process, not only in the UK, but also in Europe, the USA and other countries where deliberative democracy is being implemented or discussed.

    eISBN: 978-1-84742-167-8
    Subjects: Health Sciences, Political Science

Table of Contents

  1. Front Matter
    (pp. i-ii)
  2. Table of Contents
    (pp. iii-iii)
  3. List of figures and boxes
    (pp. iv-iv)
  4. Acknowledgements
    (pp. v-vi)
  5. A note on terminology
    (pp. vii-viii)
  6. Introduction
    (pp. 1-12)

    Governments today are asking citizens to come forward to participate in political decision making, not just locally but on a national stage, to debate some of the most complex, and the hardest decisions of our time – about science policy, for example, health, environmental issues, world poverty and global resource use. But how feasible is such a demand? We are often told that citizens are more sophisticated and reflective than ever before. They are better informed, they weigh options and make myriad personal and family choices. Yet they have become less loyal to leaders and more critical of governments. Their lives...

  7. Part I: Context

    • ONE The rise and rise of participation
      (pp. 15-36)

      The idea of direct participation of the public in the business of collectively governing their lives has been a vision and an aspiration that has fascinated politicians, political theorists and political commentators down the centuries. In contemporary times it can be seen, for example, in the intense interest across western democracies associated with Robert Putnam’s work on the collapse of civic engagement in the US and its potential for revival (Putnam, 2000), and in talk of a need for greater social solidarity and cohesion. It can be seen too in the flurry of work in political science on ‘deliberative democracy’...

    • TWO Deliberation: towards an understanding of practice
      (pp. 37-62)

      Consider a sentence that opens as follows: ‘As a result of the committee’s deliberations, we have concluded…’. Such a sentence is more likely to be written than spoken. The phrase is less likely to come from the lips of a politician than from those of a public figure, respected and deemed independent. It is still likely – although perhaps a little less so than in the past – that the speaker will be white and will be male. Invoking the word deliberation in this context conjures not only a ‘who?’ but also a ‘how?’ question. We are invited to picture the committee’s...

  8. Part II: A Citizens Council in action

    • THREE Setting up a Citizens Council
      (pp. 65-84)

      New social practices are never entirely new. The ‘vestiges of order’ that we insert into apparently novel situations and the constraints that are thereby put in place serve to bring at least some familiar routines into play. Furthermore, the process that Karl Weick (1995) was later to call ‘sense making’ in organisations will be visible in the dialogues and debates through which new practices start to crystallise and become embedded. Exploring the unfolding of this in the meetings of the Citizens Council of NICE is a major theme of the chapters that follow. But sense making and creating constraints also...

    • FOUR Doing deliberation: the first Citizens Council meeting
      (pp. 85-108)

      It was inevitable that the Institute’s operating model would construct ‘the citizen’ and ‘deliberation’ in particular ways and would rely on a mix of explicit, implicit and sometimes contradictory assumptions and premises that would only come into sharper focus once the Council had met. This chapter thus explores what occurred as the Citizens Council migrated from an in–house organisational plan to an actual embodied event, in other words, as the meso–level gave way to the micro–level. What consequences flowed from the attempt to implement the model? Would the hopes and ambitions of the advocates of the ideal...

    • FIVE Better by design? Subsequent Citizens Councils
      (pp. 109-136)

      Despite the impression sometimes given of the ‘naturalness’ and spontaneous ease of democratic deliberation, artful performances are demanded from citizens, organisers and facilitators alike, if deliberation is to occur, and if its results are to be documented and put to use. Aspects of the design of the Citizens Council meetings changed following the first event, and there were further changes as experience began to accumulate. With different kinds of sessions, a different balance between them and different styles of facilitation in place, the focus of the analysis in this chapter is on the impact of changing design. Using the findings...

    • SIX Power, discursive styles and identities
      (pp. 137-168)

      The last two chapters tracked through the Citizens Council meetings chronologically, generating a blow–by–blow account of how one community of practice grappled with the challenge of democratic deliberation. It turned out to be a much more contingent process than anyone might have suspected (including perhaps a deliberation theorist). Deliberation emerges as fragile, as proceeding in fits and starts, as requiring a large amount of thoughtful nurturing and as permeated through and through with dilemmas of inclusion, control and engagement. This chapter, the last one using ethnographic data from the Council meetings, returns to some of the broader issues...

    • SEVEN Reactions, reflections and reworkings
      (pp. 169-190)

      It is clear that over the first two and a half years of the Citizens Council initiative, the Institute put a great deal of time into shaping just how the Council should work and into modifying its decisions in the light of experience. We have argued that the changes served to create more of an expertise space for citizens and that there was a perceptible rise in the amount of deliberation; we have also shown that important challenges remained. This chapter, the final one in the series presenting empirical data, will explore the thinking that accompanied change within the host...

  9. Part III: Implications

    • EIGHT Reframing citizen deliberation
      (pp. 193-214)

      NICE’s Citizens Council aimed to bring the voices of ordinary citizens into the centre of a key governmental decision–making process in healthcare. Politicians, civil servants, officials and many of the experts associated with the Institute already accepted that in giving advice to ministers about which drugs and treatments should be made available to the NHS, science alone could never be entirely decisive. In each case, there was a value judgement to be made. The Institute’s process of stakeholder dialogue already acknowledged this to an important extent; patient groups, clinicians, managers and the pharmaceutical industry had a say. Creating an...

    • NINE New directions for policy and practice
      (pp. 215-232)

      How feasible is it, we asked at the outset of this book, to call on ordinary people to come forward and take part in decision making, not just locally but in relation to the institutions of central government? Is there a viable space for participating citizens at the centre of the institutions of a democratic state? Visions of politics with places for citizens – both locally and at the centre – have loomed ever larger in recent years. Chapter One charted the rise and rise of citizen participation initiatives in Britain, the growing quest, through citizens’ juries, people’s panels and more, to...

  10. References
    (pp. 233-246)
  11. APPENDIX 1: Study design and methods
    (pp. 247-254)
  12. APPENDIX 2: Members of the Citizens Council, 2002-05
    (pp. 255-260)
  13. APPENDIX 3: Detailed agenda for the four Citizens Council meetings
    (pp. 261-268)
  14. APPENDIX 4: National Institute for Clinical Excellence: background and developments
    (pp. 269-272)
  15. APPENDIX 5: Key data sources
    (pp. 273-280)
  16. Index
    (pp. 281-292)