Public involvement in primary care : an analysis of policy implementation

Abstract

Public involvement in primary care has gained increasing acceptance through a sustained position in government policy since New Labour began in 1997. When Primary Care Groups (PCGs) were introduced (Department of Health 1997), they were seen as vehicles for public involvement, reflecting devolution of power and local decision-making. During the process of this study (1999 - 2006) policy directives have highlighted a number of paradoxes, with the potential to impact on public involvement. Detailed development was left to local discretion, set against a national agenda that emphasised citizenship and consumerism. The purpose of this study was to explore, interpret and understand how public involvement policy was interpreted and implemented within the new organisational structures. The study was designed to address the research question `How is public involvement defined and operationalised within PCGs'. Due to the pace of organisational change, the research expanded to track lay experiences within Primary Care Trusts (PCTs). The research methods included case study, national survey, telephone interviews and the development of a conceptual framework for public involvement in primary care. From the analysis of the national survey and two in-depth case studies, the study provided a detailed profile of lay members across England. Issues regarding representativeness and the identification of a potentially discriminatory appointment system were raised. Despite inadequate training lay members were strongly represented in public involvement and health-related issues but less so in financial and operational areas. There were widespread difficulties with individual capacity and a minority of members identified themes relating to isolation, exploitation and lack of skills recognition. There was little evidence of strategic and organisational development in implementing and responding to involvement initiatives. The majority of approaches to public involvement within this study focused on information exchange and therefore, were tokenistic in relation to power sharing. The impact of the national agenda was evident and the lack of specific central directives relating to involvement led it to remain a low priority. As the move to PCT status became central, public involvement was reclaimed as a management prerogative. The analysis showed that the concept of citizenship, so central to Third Way politics was poignantly missing. The study reflected a focus on service users and the different roles of citizen and user were not clearly demarcated. The use of Foucault's concepts of governmentality and discipline provided an explanatory framework for elucidating the study's findings. The effects of governmentality embedded in policy directives and disciplinary mechanisms within NHS organisations were identified as crucial factors for the lack of significant progress of public involvement over the period of the research study.