Engaging matters: making sure the public have a voice in the future of Welsh health and social care

This blog draws on a recent Wales Centre for Public Policy (WCPP) report Public engagement and ‘A Healthier Wales’, co-authored by Paul Worthington, Sarah Quarmby and Dan Bristow from WCPP. The report considers how the commitments to public engagement in A Healthier Wales might be translated into an evidence-informed programme of activity.

A Healthier Wales sets out Welsh Government’s vision of transformed health and social care services, which focuses on a shift towards community-based care models, and a more preventative approach.

Woven through this is the idea that ‘public engagement’ should be central both to the future system and to the process of getting there.

This is unsurprising. There is widespread support for increased engagement, not just in discussions about the future of health and social care, but across a range of policy areas.

Involving the public, it is argued, is good in and of itself – surely those affected by decisions should have a say in them?

More than this, though, it is hoped that engagement will lead to improved policy and service design and improved outcomes: those who would experience the consequences of decisions are well placed to help assess their potential impact.


What is engagement?

Part of the challenge in trying to realise these benefits is that the term ‘engagement’ is used to describe very different things; ranging from providing information, through to people having the power to make a particular decision.

Common across these is an effort to bring the public into the decision making process in some way.

But the lack of clarity over what ‘engagement’ is, and what it should be, leads to a focus on the process at the expense of a discussion of the purpose.


‘Good’ versus ‘bad’ engagement

Too often the starting point for efforts at public engagement is to try to define the process itself: should it be an online consultation, a citizens’ assembly, a twitter conversation, or all of the above?

The problem with this is that it skips the all-important step of articulating why the public are being asked to get involved. What are they being asked to do? And what impact will their engagement have on the decision-making process?

This clarity over the purpose of engagement is one of the main distinguishing factors between more and less successful efforts.

If the starting point is ‘how will we engage the public?’, the risk is that the choice is influenced by a sense that more or deeper engagement is ‘better’; and that processes that give a lesser role to the public are somehow ‘worse’.

In fact, evidence shows that any offer of involvement is likely to be unsuccessful unless the offer is genuine – the public do not respond well to tokenistic engagement.

Which is why it is important to be clear and transparent about the role of the public, and to be open about how their views will influence what happens. If a decision has already been made, don’t pretend otherwise.


Engagement and A Healthier Wales

What does all this mean for the health and social care transformation programme?

A Healthier Wales links public engagement to a range of different issues and outcomes, including – patient-centred care, healthy behaviours, service design, service reconfiguration, and changing the relationship between the public and the health and care system.

In our report, we look at the evidence on the role and nature of engagement in achieving each of these. We also summarise what we gleaned from our conversations with stakeholders about this evidence base.

What emerges quite strongly from all of this is the need for a greater shared understanding and clarity about the purpose of any programme of engagement, beyond the commitments in A Healthier Wales.

At the moment, public engagement is not central to the delivery of the transformation programme in the way envisaged in A Healthier Wales, and responsibility for it is shared between local, regional and national bodies in a way that makes it unclear who should be doing what.

Greater focus should be given to how the public can inform both the development of new models of care, and how services will be configured in the future. But this would require an active decision to put in place the oversight, coordination and resourcing needed to make it happen.

There is also space for a national engagement exercise, like a citizen assembly, on a key issue facing the health and care system. Indeed, A Healthier Wales suggests involving the public in figuring out what to do about social care funding. This would serve to show leadership on public engagement, and to signal the shift in the relationship between the public and the sector.

The aspiration for greater public engagement has a sound basis in the evidence, and broad support from the sector. The challenge is marshalling both to define, and deliver on, a coherent and meaningful role for the public.