Whose interests do lay people represent? Towards an understanding of the role of lay people as members of committees

Consumers' and health providers' views and perceptions of partnering to improve health services design, delivery and evaluation: a co-produced qualitative evidence synthesis

BACKGROUND

Partnering with consumers in the planning, delivery and evaluation of health services is an essential component of person-centred care. There are many ways to partner with consumers to improve health services, including formal group partnerships (such as committees, boards or steering groups). However, consumers' and health providers' views and experiences of formal group partnerships remain unclear. In this qualitative evidence synthesis (QES), we focus specifically on formal group partnerships where health providers and consumers share decision-making about planning, delivering and/or evaluating health services. Formal group partnerships were selected because they are widely used throughout the world to improve person-centred care. For the purposes of this QES, the term 'consumer' refers to a person who is a patient, carer or community member who brings their perspective to health service partnerships. 'Health provider' refers to a person with a health policy, management, administrative or clinical role who participates in formal partnerships in an advisory or representative capacity. This QES was co-produced with a Stakeholder Panel of consumers and health providers. The QES was undertaken concurrently with a Cochrane intervention review entitled Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation.

OBJECTIVES

1. To synthesise the views and experiences of consumers and health providers of formal partnership approaches that aimed to improve planning, delivery or evaluation of health services. 2. To identify best practice principles for formal partnership approaches in health services by understanding consumers' and health providers' views and experiences.

SEARCH METHODS

We searched MEDLINE, Embase, PsycINFO and CINAHL for studies published between January 2000 and October 2018. We also searched grey literature sources including websites of relevant research and policy organisations involved in promoting person-centred care.

SELECTION CRITERIA

We included qualitative studies that explored consumers' and health providers' perceptions and experiences of partnering in formal group formats to improve the planning, delivery or evaluation of health services.

DATA COLLECTION AND ANALYSIS

Following completion of abstract and full-text screening, we used purposive sampling to select a sample of eligible studies that covered a range of pre-defined criteria, including rich data, range of countries and country income level, settings, participants, and types of partnership activities. A Framework Synthesis approach was used to synthesise the findings of the sample. We appraised the quality of each study using the CASP (Critical Appraisal Skill Program) tool. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. The Stakeholder Panel was involved in each stage of the review from development of the protocol to development of the best practice principles.

MAIN RESULTS

We found 182 studies that were eligible for inclusion. From this group, we selected 33 studies to include in the final synthesis. These studies came from a wide range of countries including 28 from high-income countries and five from low- or middle-income countries (LMICs). Each of the studies included the experiences and views of consumers and/or health providers of partnering in formal group formats. The results were divided into the following categories. Contextual factors influencing partnerships: government policy, policy implementation processes and funding, as well as the organisational context of the health service, could facilitate or impede partnering (moderate level of confidence). Consumer recruitment: consumer recruitment occurred in different ways and consumers managed the recruitment process in a minority of studies only (high level of confidence). Recruiting a range of consumers who were reflective of the clinic's demographic population was considered desirable, particularly by health providers (high level of confidence). Some health providers perceived that individual consumers' experiences were not generalisable to the broader population whereas consumers perceived it could be problematic to aim to represent a broad range of community views (high level of confidence). Partnership dynamics and processes: positive interpersonal dynamics between health providers and consumers facilitated partnerships (high level of confidence). However, formal meeting formats and lack of clarity about the consumer role could constrain consumers' involvement (high level of confidence). Health providers' professional status, technical knowledge and use of jargon were intimidating for some consumers (high level of confidence) and consumers could feel their experiential knowledge was not valued (moderate level of confidence). Consumers could also become frustrated when health providers dominated the meeting agenda (moderate level of confidence) and when they experienced token involvement, such as a lack of decision-making power (high level of confidence) Perceived impacts on partnership participants: partnering could affect health provider and consumer participants in both positive and negative ways (high level of confidence). Perceived impacts on health service planning, delivery and evaluation: partnering was perceived to improve the person-centredness of health service culture (high level of confidence), improve the built environment of the health service (high level of confidence), improve health service design and delivery e.g. facilitate 'out of hours' services or treatment closer to home (high level of confidence), enhance community ownership of health services, particularly in LMICs (moderate level of confidence), and improve consumer involvement in strategic decision-making, under certain conditions (moderate level of confidence). There was limited evidence suggesting partnering may improve health service evaluation (very low level of confidence). Best practice principles for formal partnering to promote person-centred care were developed from these findings. The principles were developed collaboratively with the Stakeholder Panel and included leadership and health service culture; diversity; equity; mutual respect; shared vision and regular communication; shared agendas and decision-making; influence and sustainability.

AUTHORS' CONCLUSIONS

Successful formal group partnerships with consumers require health providers to continually reflect and address power imbalances that may constrain consumers' participation. Such imbalances may be particularly acute in recruitment procedures, meeting structure and content and decision-making processes. Formal group partnerships were perceived to improve the physical environment of health services, the person-centredness of health service culture and health service design and delivery. Implementing the best practice principles may help to address power imbalances, strengthen formal partnering, improve the experiences of consumers and health providers and positively affect partnership outcomes.

Optimizing Community Participation in Healthcare Planning, Decision Making and Delivery through Rural Health Councils

Background

The aim of this scoping study was to understand the opatimal structure and function of rural health councils (RHCs).

Methods

The study used the scoping review methodology, informed by both Arksey and O'Malley's (2005) framework and the Joanna Briggs Institute Reviewers' Manual (The Joanna Briggs Institute 2015).

Findings

Evidence demonstrates that the functions of RHCs range from identifying healthcare issues and priorities to local resource management. Enabling structures included the use of skills-based merit matrices to determine membership.

Conclusion

We found evidence on how to build effective models to support patient involvement in healthcare planning and service delivery to lead to care that reflects the needs of rural communities.

Defining Polyamory: A Thematic Analysis of Lay People's Definitions

This study aimed to analyze laypeople's definitions of polyamory and compare definitions presented by people who are not willing to engage in consensual non-monogamy (CNM) and those who are or are willing to be in a CNM relationship. This exploratory qualitative study used data collected from a convenience sample through a web survey, where people answered the question "What does polyamory mean?" We conducted thematic analysis to examine patterns in meaning and used demographic data to compare themes among groups. The final sample comprised 463 participants aged 18-66 years (M = 32.19, SD = 10.02), mostly heterosexual (60%). Of the total sample, 54% were in a monogamous relationship, followed by 21% not in a relationship, and 13% in a non-monogamous relationship. Analysis showed that people define polyamory mostly as a set of behaviors in a relationship, followed by the potential of multiple relationships or feelings for multiple people. Definitions also include emotional, sexual, and ethical aspects. People in CNM relationships are more likely to define polyamory as constituting a potential form of relating, focus more on interpersonal feelings and ethics, and include consent in their definitions than those unwilling to engage in CNM. People in CNM relationships also focus particularly on the non-central role of sex within these relationships, which might challenge assumptions about sexuality in these relationships in clinical and research settings.

Defining Polyamory: A Thematic Analysis of Lay People's Definitions

This study aimed to analyze laypeople's definitions of polyamory and compare definitions presented by people who are not willing to engage in consensual non-monogamy (CNM) and those who are or are willing to be in a CNM relationship. This exploratory qualitative study used data collected from a convenience sample through a web survey, where people answered the question "What does polyamory mean?" We conducted thematic analysis to examine patterns in meaning and used demographic data to compare themes among groups. The final sample comprised 463 participants aged 18-66 years (M = 32.19, SD = 10.02), mostly heterosexual (60%). Of the total sample, 54% were in a monogamous relationship, followed by 21% not in a relationship, and 13% in a non-monogamous relationship. Analysis showed that people define polyamory mostly as a set of behaviors in a relationship, followed by the potential of multiple relationships or feelings for multiple people. Definitions also include emotional, sexual, and ethical aspects. People in CNM relationships are more likely to define polyamory as constituting a potential form of relating, focus more on interpersonal feelings and ethics, and include consent in their definitions than those unwilling to engage in CNM. People in CNM relationships also focus particularly on the non-central role of sex within these relationships, which might challenge assumptions about sexuality in these relationships in clinical and research settings.

Defining Polyamory: A Thematic Analysis of Lay People's Definitions

This study aimed to analyze laypeople's definitions of polyamory and compare definitions presented by people who are not willing to engage in consensual non-monogamy (CNM) and those who are or are willing to be in a CNM relationship. This exploratory qualitative study used data collected from a convenience sample through a web survey, where people answered the question "What does polyamory mean?" We conducted thematic analysis to examine patterns in meaning and used demographic data to compare themes among groups. The final sample comprised 463 participants aged 18-66 years (M = 32.19, SD = 10.02), mostly heterosexual (60%). Of the total sample, 54% were in a monogamous relationship, followed by 21% not in a relationship, and 13% in a non-monogamous relationship. Analysis showed that people define polyamory mostly as a set of behaviors in a relationship, followed by the potential of multiple relationships or feelings for multiple people. Definitions also include emotional, sexual, and ethical aspects. People in CNM relationships are more likely to define polyamory as constituting a potential form of relating, focus more on interpersonal feelings and ethics, and include consent in their definitions than those unwilling to engage in CNM. People in CNM relationships also focus particularly on the non-central role of sex within these relationships, which might challenge assumptions about sexuality in these relationships in clinical and research settings.

Expertise, experience, and excellence. Twenty years of patient involvement in health technology assessment at NICE: an evolving story

From its inception in 1999, the National Institute for Health and Care Excellence (NICE) committed to including the expertise, experiences, and perspectives of lay people, patients and carers, and patient organizations in its health technology assessments (HTAs). This is our story of patient involvement in HTA: from early methods designed for use when assessing medicines, widening to address the different requirements of HTAs for interventional procedures, medical technologies, and diagnostic technologies. We also chart the evolution and development of all our patient involvement methods over the past 20 years through regular evaluation and by responding to external challenge. However, we know that processes and methods alone are not enough. Through case studies we demonstrate the value of patient involvement in HTA and highlight the unique perspectives and experiences that patients bring to HTA committees. Finally, we discuss the underpinning principles and commitments that have made NICE a world leader in delivering meaningful and legitimate patient involvement.

Patients' perspectives on interprofessional collaboration between health care professionals during hospitalization: a qualitative systematic review

OBJECTIVE

The objective of this review was to gain a better understanding of the interprofessional collaboration between health care professionals from the patients' point of view during hospitalisation; the influence of interprofessional collaboration on patient care, safety, and well-being; and patients' perspectives of their role in the interprofessional collaboration process.

INTRODUCTION

Interprofessional collaboration is a key factor in improving patient health care outcomes and safety through better communication between health care professionals, better teamwork, and better care coordination. However, implementing interprofessional collaboration in the clinical setting can prove complex. Patients are increasingly interested in becoming partners within the health care system. They have the potential to contribute to their own safety and to observe professionals during the care process, thus gaining a better understanding of the interprofessional collaboration process and facilitating changes in the behavior of health care professionals.

INCLUSION CRITERIA

This review considered qualitative research and mixed-method studies. Participants were hospitalized patients. Studies were included when they explored i) patients' perceptions of interprofessional collaboration, ii) the influence of interprofessional collaboration on patients' care, safety, or well-being, or iii) patients' perceptions of their own role in interprofessional collaboration. Qualitative studies focusing only on the care process or families' points of view were excluded.

METHODS

Searches of six databases including MEDLINE, CINAHL, Embase, Web of Science, PsycINFO, and Sociological Abstract, limited to English, French, and German were conducted from March 2017 to June 2018. Assessment of methodological quality of studies was performed using the JBI Qualitative Assessment and Review Instrument. Data were extracted using the standardized data extraction tool from JBI. Data synthesis following the JBI approach of meta-aggregation was performed. The level of confidence for each synthesized finding was established based on ConQual.

RESULTS

A total of 22 studies were included, which resulted in 89 findings and 24 categories. Eight synthesized findings were generated: patients' perceptions of interprofessional collaboration based on personal experiences and observations; patients' experiences with effective or ineffective interprofessional communication; patients' experience with power imbalance and paternalistic attitudes; patients' perceptions of key factors for a confident relationship with the interprofessional health care team; patients' need for comprehension of discussions between health care professionals; patients' perceptions of their role in an interprofessional health care team; patients' perceptions of opportunities for empowerment in interprofessional health care teams; and patients' need for humanizing care from interprofessional health care teams. The level of confidence of synthesized findings varied from low to moderate according to ConQual.

CONCLUSIONS

This systematic review synthesized the perspectives of hospitalized patients regarding interprofessional collaboration and their perceived role in collaborative practices. Hospitalized patients observe interprofessional collaboration, either directly or indirectly, and the way interprofessional collaboration is performed may impact both their care and their well-being. However, little evidence has been found regarding the impact of interprofessional collaboration on patient safety. Patients' perspectives on their perceived role is not unanimous; some patients want to play an active role in the collaborative process, whereas others prefer to trust the health care professionals' expertise. Health care professionals should consider patients' preferences and act accordingly regarding both the collaborative process and the inclusion of the patients in collaborative practices.

Laypeople roles at road traffic crash scenes: a systematic review

This study aimed to identify the roles of laypeople at road traffic injuries (RTIs). A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The key words of 'laypeople', 'layman', 'layperson', 'bystander', 'first responder', 'lay first responder', 'road traffic', 'road traffic injury', 'crash injury', 'crash scene', 'emergency', 'trauma care', and 'prehospital trauma care' were used in combination with the Boolean operators OR and AND. We did electronic search on Google Scholar, PubMed, ISI Web of Science, CINAHL, Science Direct, Scopus, ProQuest. Based on the reviewed studies, some factors such as cultural conditions, knowledge, relief agencies, and demographic factors affect the interventions of laypeople at the crash scene in functional areas. Regarding the permanent presence of people at the crash scene, the present study can provide an opportunity to reduce different side effects of RTIs imposed on the society.

Implementing community participation via interdisciplinary teams in primary care: An Irish case study in practice

Background

Community participation in primary care is enshrined in international and Irish health policy. However, there is a lack of evidence about how stakeholders work collectively to implement community participation within interdisciplinary teams; community perspectives are rarely captured, and a theoretical underpinning for implementation of community participation in primary care is absent.

Objective

To conduct a theoretically informed, multiperspectival empirical analysis of the implementation of community participation via primary care teams (PCTs) in Ireland.

Methods/Design/Participants

Participatory learning and action (PLA) focus groups and interviews were held with 39 participants across four case study sites within a nationally funded programme designed to enable disadvantaged communities to participate in primary care. Normalization process theory (NPT) informed data generation and analysis of how diverse stakeholder groups worked together to implement community participation via PCTs.

Results

The various stakeholders had a shared understanding of the value of community participation on PCTs. Motivations to get involved in this work varied, but were strong overall. Challenges to enacting community participation on PCTs included problems with the functioning of PCTs and a lack of clarity and confidence in the role of community representatives at PCT meetings. Informal appraisals were positive, but formal appraisal was limited.

Discussion and Conclusion

The implementation and sustainability of community participation on PCTs in Ireland will be limited unless (i) the functioning of PCTs is strong, (ii) there is increased confidence and clarity on community representatives’ roles among all health‐care professionals, and (iii) more sophisticated methods for formal appraisal are used.

Developing a service-user framework to shape priorities for nursing and midwifery research

Many people believe, and government policy recommends, that service users should be involved more in research agenda setting. This paper helps to provide a way of undertaking this, drawing on the approach used in a national research priority setting exercise for nursing and midwifery service delivery and organisation. A framework of service-user expectations for nursing and midwifery services was developed through a process of focus group discussions. Thirty-two participants were recruited from Community Health Councils (CHCs) because of their formal role in linking to health providers and as advocates of local communities. Discussions focused on the main gaps in nursing and midwifery services, priority areas for improvement and ways of involving service users in these developments. Nine broad expectations for nursing and midwifery services were identified and were used as a framework for the alignment of professional stakeholder data and literature and policy analysis. This enabled five priority areas for research to be identified that were important to all of these groups. Targeted sampling, information giving prior to the focus groups, careful explanation of confidentiality and the purpose of the exercise and facilitation skills were important for developing a framework that covered the wide breadth of the topic area. The process also raised important questions for nursing and midwifery research. Conceptual difficulties about balancing service-user control and researcher influence, and the authenticity of the data in representing diversity, were limitations of the approach. A final report is available at www.sdo.lshtm.ac.uk/nursingandmidwifery.

Group affiliation in self-management: support or threat to identity?

BACKGROUND

Self-management is considered important in chronic illness, and contemporary health policy recommends participation in support groups for individuals with chronic conditions. Although withdrawal from or non-participation in support groups is an important problem, there is limited knowledge about individuals' own motivation for participation in or withdrawal from self-management support groups.

OBJECTIVES

To investigate how individuals with type 2 diabetes perceive participation in group-based self-management support.

DESIGN

This is a qualitative focus group study using a semi-structured interview guide.

SETTING AND PARTICIPANTS

Sixteen participants diagnosed with type 2 diabetes were included in the study. Individuals with and without group affiliations were mixed in three focus groups to trigger discussions. In the analysis, reoccurring themes of engagement and discussions between participants were focused within a theoretical frame of institutional logic. The focus groups are seen as social spaces where participants construct identity.

RESULTS

Both participation and non-participation in group-based self-management support are associated with dealing with the stigma of having type 2 diabetes. Negotiations contribute to constructing an illness dignity as a response to the logic of moral responsibility for the disease.

DISCUSSION AND CONCLUSION

Contemporary policy contributes to societal understandings of individuals with type 2 diabetes as morally inadequate. Our study shows that group-based self-management support may counteract blame and contribute in negotiations of identity for individuals with type 2 diabetes. This mechanism makes participation in groups beneficial for some but stigma inducing for others.

Sustaining universal health coverage: the interaction of social, political, and economic sustainability

The sustainability of health care systems, particularly those supporting universal health care, is a matter of current discussion among policymakers and scholars. In this article, we summarize the controversies around the economic sustainability of health care. We attempt to extend the debate by including a more comprehensive conceptualization of sustainability in relation to health care systems and by examining the dimensions of social and political sustainability. In conclusion, we argue that policymakers when taking decisions around universal health care should carefully consider issues of social, political, and economic sustainability, their interaction, and often their inherent trade-offs.

Patient involvement in a scientific advisory process: setting the research agenda for medical products

Patient involvement in scientific advisory processes could lead to more societally relevant advice. This article describes a case study wherein the Health Council of the Netherlands involved patient groups in an advisory process with a predefined focus: setting a research agenda for medical products development. A four-phase approach was developed to stimulate needs-articulation concerning future medical products for a broad range of patient groups covering 15 disease domains. 119 (expert) patients and 92 non-patient representatives were consulted using interviews and focus groups. In a facilitated way, patients appeared capable and willing to provide input useful for an advisory process. A broad range of medical products was defined serving different purposes. This study showed two dilemmas: first, finding a balance between a predefined focus and being sufficiently broad to enable patients and patient representatives to contribute, and second, finding a balance between relevance for many patients groups and saturation of data for a lower number of patient groups. By taking the context of patients' daily life as starting point patient groups provided new insights. The predefined focus was sometimes perceived as constraining. The GR considered the articulated needs constructive and incorporated patients' input in their advice to the Minister of Health.

User involvement in hospital wards: professionals negotiating user knowledge. A qualitative study

OBJECTIVE

To investigate how health professionals in hospital wards that have voluntarily initiated user involvement negotiate user knowledge into their professional knowledge.

METHODS

Qualitative interviews were conducted with 18 health professionals from 12 hospital wards in Central Norway.

RESULTS

The main value to health professionals of initiating user involvement was gaining access to user knowledge. Two functions of user knowledge were identified--user knowledge as an alternative to professional knowledge and user knowledge as support for professional knowledge. The need for good professional practice was used as an argument for closing professional fields to user involvement. Professionals were also under scrutiny from other discourses, such as scientific-bureaucratic medicine, which had a strong impact on how user involvement was carried out.

CONCLUSION

Health professionals saw knowledge transfer as valuable, but ultimately valued professional knowledge above user knowledge.

PRACTICE IMPLICATIONS

Even health personnel who embrace user involvement limit the influence of user knowledge on their own professional work. It seems necessary that user involvement be included in health policy and practice guidelines at hospital wards, if it is desirable that user knowledge influence professional knowledge and everyday work.

The role of community representatives on health service committees: staff expectations vs. reality

OBJECTIVE This paper examines staff views about legitimacy of different roles for community representatives sitting on health service committees as part of a formal Community Participation Program (CPP) in an Area Health Service (AHS) in Australia. DESIGN A cross-sectional survey using a self-completed questionnaire by staff on committees with community representation in the AHS in 2008. SETTING The study site has a population of approximately 1.4 million and covers 6000 km(2) . The population is ethnically and socio-economically diverse. RESULTS There are generally positive staff attitudes at this AHS for community participation as part of the CPP with positive impacts identified, including on service delivery and the conduct of health service meetings. Most saw community representatives having legitimate roles in representing the community, improving communication between the health service and the community and providing constructive feedback. However, staff expectations about the community's role on committees do not match the reality they say they observe and less than half the staff thought the community and health service agree on the role of community representatives. CONCLUSIONS As well as reviewing and enhancing training and support for representatives and staff as part of the CPP, there is a need to question staff expectations about community members who sit on health service committees and whether these expectations are shared by other key stakeholders, most notably the community representatives themselves. These expectations have implications for the CPP and for similar programs designed to engage community members on committees and working groups with health professionals.

Patient organizations in Finland: increasing numbers and great variation

OBJECTIVE

There is very little research on patient organizations (POs), even though their numbers and influence seem to be increasing. The purpose of this study was to describe the establishment, membership, size, organization, decision making and basic funding of national POs in Finland.

SETTING AND PARTICIPANTS

National POs (n = 130) were identified from their umbrella organizations and by Internet searches. Data were collected from POs' web pages (87% of POs had one), Finland's Slot Machine Association (RAY, an important public financier of POs), a relevant survey done by a local TV-company, and interviews and written materials of POs.

RESULTS AND CONCLUSIONS

Some current national POs were established around the turn of the 19(th) century. The rate of establishment of new POs increased from the 1970s and particularly in the 1990s when POs were characterized by increasing specialization. POs focused on different patient groups and diseases and were founded by philanthropists, physicians, patients, parents and the drug industry. Members could be patients, patient relatives, health-care professionals and organizations. POs widely varied in memberships (20-145 000, in 2002) and in number of paid personnel (0-1395, in 2002), organizational structure and decision making. Interest groups and financiers were often represented in decision-making organs. Activities included mutual support and service production, and, increasingly, informing and lobbying. POs had wide domestic and international co-operation and networking. Drug industry marketing was visible on PO web pages. Budget sizes varied (4000-15 million euros, in 2001). The main public financier was RAY. The old national POs were large and part of national social and health care, but newer ones were often established for mutual support and lobbying. National POs are not uniform but characterized by great variation. The number of national POs is increasing suggesting tighter competition for financing and visibility in the future.

On the Ethics Committee: The Expert Member, the Lay Member and the Absentee Ethicist

This paper considers the roles and definitions of expert and lay members of ethics committees, focussing on those given by the National Research Ethics Service which is mandated to review all research conducted in National Health Service settings in the United Kingdom. It questions the absence of a specified position for the ‘professional ethicist’ and suggests that such individuals will often be lay members of ethics committees, their participation being a reflection of their academic interest and expertise.

The absence of a specified position for professional ethicists and the concomitant but implicit denial of ethical expertise appear to be an anomalous state of affairs if one considers that the training offered to members of ethics committees is often delivered by academic ethicists. It is suggested that this is based on a misunderstanding of the concept ‘ethical expertise’ and that properly understood the ethicist can assist the work of ethics committees by drawing on their expert knowledge.

Engaging the public in priority-setting for health technology assessment: findings from a citizens' jury

OBJECTIVES

To assess the feasibility of using a citizens' jury to elicit public values on health technologies and to develop criteria for setting priorities for health technology assessment (HTA).

METHODS

Sixteen individuals were selected from 1600 randomly sampled residents of the Capital Health Region in Alberta, Canada. They participated in a 2 (1/2) day jury which comprised presentations by 'expert witnesses', who represented innovators, patients, health-care policy-makers and clinicians, as well as a series of small and large group priority-setting exercises based on actual examples of technologies that had recently been considered for assessment by local and national HTA bodies. The session was audio-taped, and transcripts were independently reviewed by two researchers using content analytical techniques in order to ensure that no important concepts expressed by individual jurors were missed during group development of the final list of priority-setting criteria. Jurors evaluated the process by completing self-administered, semi-structured questionnaires at the end of the session. Responses were analysed using qualitative methods.

RESULTS

The jury identified 13 criteria, which they subsequently ranked in order of importance. The top two criteria included 'potential to benefit a number of people' and 'extends life with quality'. Based on feedback from questionnaires, jurors valued the opportunity to become engaged in such a process, and expressed interest in participating in future juries.

CONCLUSIONS

Citizens' juries offer a feasible approach to involving the public in priority-setting for HTA. Furthermore, technologies that may benefit a number of people and improve quality of life appear to be of greatest importance to the public.

Addressing men's health policy concerns in Australia: what can be done?

There is a lack of consensus about what men's health constitutes in Australia. The absence of a widely accepted definition has been problematic for establishing state and national men's health policies. I consider that one impediment to the implementation of state and federal men's health policies has been a lack of willingness to approach men's health from a broad public health perspective. In particular, scant attention has been paid to exploring lay perspectives of how men define and understand health, and in turn, how these relate to significant policy problems such as men's health service use. I conclude by suggesting that a focus on men's lay perspectives of their health emerging from the United Kingdom and the Republic of Ireland provides a useful framework to guide men's health policy discussion in Australia.

Bringing ‘the public’ into health technology assessment and coverage policy decisions: From principles to practice

Those making health care coverage decisions rely on health technology assessment (HTA) for crucial technical information. But coverage decision-making, and the HTA that informs it, are also inherently political. They involve the values and judgments of a range of stakeholders as well as the public. Moreover, governments are politically accountable for their resource allocation decisions. Canadian policy makers are at an early stage in the design of legitimate mechanisms for the public to contribute to, and to be apprised of, HTA and coverage decisions. As they consider the options, questions arise about whom to involve (e.g., which publics), how to engage them (e.g., through what public involvement or accountability mechanisms), and for what purpose (e.g., to inform the public of decisions and their rationales, or to have the public directly affect those decisions). Often key concepts, such as the difference between public accountability and public participation, are not well articulated or distinguished in these debates. Guidance is needed regarding both rationales and methods for involving the public in HTA and technology coverage decisions. We offer a framework that clearly distinguishes specific roles for the public, and relates them to several layers of policy analysis and policy making where 'the public' may engage in different tasks. The framework offers a menu of choices for policy makers contemplating changes to public involvement, as well as a model that can be used to characterize and analyze different approaches across jurisdictions.

Health service staff attitudes to community representatives on committees

PURPOSE

This paper sets out to report attitudes of staff on key health service committees towards community participation before and after appointment of community representatives.

DESIGN/METHODOLOGY/APPROACH

The paper shows a self-completed questionnaire administered to staff on committees as a baseline measure and 12 months after community representatives had been appointed.

FINDINGS

The paper finds that significantly more staff at the follow-up survey reported that they and other staff were clear about the role of community representatives and how to work with them on committees. Significantly more staff at follow-up felt that the health service was ready for this type of initiative. There was no significant increase in the percentage of staff who felt that financial and other supports for community representatives were sufficient and no significant changes in staff views about the potential for community representatives to influence decision making, although there were strong trends in a positive direction.

RESEARCH LIMITATIONS/IMPLICATIONS

The study in this paper was conducted in one health service and did not follow changes in attitudes of particular staff over time. Larger samples would be necessary to assess generalisability of findings and future studies should examine in more depth staff beliefs about the role and influence of community members on committees.

PRACTICAL IMPLICATIONS

The paper implies that the development of ongoing and constructive relationships between health services and communities clearly takes time and, at least in part, results from direct experience working alongside community members.

ORIGINALITY/VALUE

The paper shows that this is the first study examining how the attitudes of health service staff to community participation change over time and as a direct result of interaction with community members on committees. A better understanding of health service staff attitudes to community participation is important for health care managers to effectively address structural and attitudinal barriers to community participation.

From rhetoric to reality: including patient voices in supportive cancer care planning

OBJECTIVE

To explore the extent and manner of patient participation in the planning of regional supportive care networks throughout the province of Ontario. We consider the disconnect between the rhetoric and reality of patient involvement in network planning and co-ordination.

CONTEXT

In 1997, the Province of Ontario, Canada, established a new, regionalized cancer care system. By transferring responsibility to the regional level and to networks, the architects of the new provincial system hoped to broaden participation in decision making and to enhance the responsiveness of decisions to communities.

RESEARCH APPROACH

Through a qualitative, multiple case study approach we evaluated the processes of involving patients in network development. In-depth, semi-structured interviews and document analysis were complemented by observations of provincial meetings, regional council and network meetings.

RESULTS

The network development processes in the three case study regions reveal a significant gap between intentions to involve patients in health planning and their actual involvement. This gap can be explained by: (i) a lack of clear direction regarding networks and patient participation in these networks; (ii) the dominance of regional cancer centres in network planning activities; and, (iii) the emergence of competing provincial priorities.

DISCUSSION

These three trends expose the complexity of the notion of public participation and how it is embedded in social and political contexts. The failed attempt at involving patients in health planning efforts is the result of benign neglect of public participation intents and the social and political contexts in which public and patient participation is meant to occur.

Regulating the health care workforce: next steps for research

This article explores the recent ferment surrounding professional self-regulation in medicine and other health professions. It reviews the academic literature and sets out an agenda for research. The first section considers definitions, acknowledging the particularly complex regulatory maze in UK health care at present, in which professional self-regulation is only one part. The second section reviews academic writing, currently dispersed among the disciplines. 'The logic of light touch regulation', a feature of the 19th century establishment of the General Medical Council, can perhaps shed light on present debates. Alongside the intense political spotlight on regulation in the wake of the Bristol case, consumer-led research and consumer pressure to rethink the principles of regulation has emerged. This is examined in the third section. Finally, themes for research are advanced. First, there is a need to explore the changing relationship between the state and professions and implications, not only for the professions but for health care more broadly. Second, calls for a new professionalism need to be given clearer content. Third, the moves towards more lay involvement in regulatory bodies need study. Fourth, questions of human rights and professional registers must be explored. Fundamental questions of what professional self-regulation can hope to achieve and where it fits in relation to government ambitions as a whole, remain unresolved. Alongside the work programme of the new overarching regulator, there may well be scope for a new style of public enquiry covering the whole territory of regulation.

User involvement in clinical governance

OBJECTIVES

To investigate the involvement of users in clinical governance activities within Primary Care Groups (PCGs) and Trusts (PCTs). Drawing on policy and guidance published since 1997, the paper sets out a framework for how users are involved in this agenda, evaluates practice against this standard and suggests why current practice for user involvement in clinical governance is flawed and why this reflects a flaw in the policy design as much as its implementation.

DESIGN

Qualitative data comprising semi-structured interviews, reviews of documentary evidence and relevant literature.

SETTING

Twelve PCGs/PCTs in England purposively selected to provide variation in size, rurality and group or trust status.

PARTICIPANTS

Key stakeholders including Lay Board members (n = 12), Chief Executives (CEs) (n = 12), Clinical Governance Leads (CG leads) (n = 14), Mental Health Leads (MH leads) (n = 9), Board Chairs (n = 2) and one Executive Committee Lead.

RESULTS

Despite an acknowledgement of an organizational commitment to lay involvement, in practice very little has occurred. The role of lay Board members in setting priorities and implementing and monitoring clinical governance remains low. Beyond Board level, involvement of users, patients of GP practices and the general public is patchy and superficial. The PCGs/PCTs continue to rely heavily on Community Health Councils (CHCs) as a conduit or substitute for user involvement; although their abolition is planned, their role to be fulfilled by new organizations called Voices, which will have an expanded remit in addition to replacing CHCs.

CONCLUSIONS

Clarity is required about the role of lay members in the committees and subcommittees of PCGs and PCTs. Involvement of the wider public should spring naturally from the questions under consideration, rather than be regarded as an end in itself.

Consumer involvement in health research: a review and research agenda

The involvement of consumers in health research is now Department of Health policy within the UK. Despite the existence of policy directives, there is a dearth of knowledge on the effects of such involvement. This paper critically reviews the state of our knowledge on this issue, and maps out a research agenda with the aim of stimulating systematic, empirical inquiry into consumer involvement in health research. The paper discusses definitions of 'the consumer'; considers why consumer involvement is believed to be important to health research; traces the development of the policy; analyses the epistemological and methodological implications of the policy; discusses the various levels of consumer involvement in research; and outlines the objections to the policy that have been put forward by clinicians and researchers. Four questions were identified during the review as being in need of theoretical and empirical attention: (1) how can consumer involvement in health research be further conceptualised? (2) how and why does consumer involvement influence health research? (3) how can the influence of consumers in health research be measured and evaluated? and (4) what factors are associated with 'successful' consumer involvement in health research?