Like many of our readers, I spend a lot of my time trying to encourage public organisations and service providers to reach out and involve more people in their decision-making, to go beyond the people they normally hear from. People want to be involved and so you have to involve them, I tell them. How useful to have this view supported by Hands Up and Hands On, a recent report from Consumer Focus and Involve looking at localism and community empowerment. An impressive 82% of those surveyed agree that “people need to have more say in what is happening in their local area beyond local elections”. Oh, but hang on a minute! What’s this?
“However, the support for a greater say does not necessarily reflect a personal appetite to do more, with just 28 per cent of people saying they’d like to have an input in influencing local decisions (rising to 38 percent for parents of children under 18) whereas 71% say they are not interested“.
Not interested? How can this be? But perhaps it is true. Perhaps loads of people really are not that interested. It is certainly my experience as a school governor that whilst some parents will jump on you as you try to sneak out at 9.05am, many more when you talk to them, will be pretty happy with the way things are going and not that bothered about what the governors are getting up to in their name.
Where is everybody?
My daughters’ school is currently carrying out a consultation on whether to federate with another local school. So there I was a couple of weeks ago sitting on a little plastic chair in a circle in the school hall with my head on one side using my best listening techniques when it struck me as it always does on these occasions that whatever these vocal and articulate people were telling us about what they thought, we really were not getting a full cross-section of the views of the wider parent body. The total number who had attended our various consultation meetings represented about 5% . Of course, they are a great bunch – thoughtful, challenging, committed to the school, capable of being a bit stroppy from time to time but that’s all to the good – critical friends, the grit in the oyster, the Usual Suspects. But they are a very small subset of our parents and we have no idea of how representative of the views of the other 95%. Where was everybody else?
Frankly, they don’t give a damn
There is nothing unique about this scenario. The same could be said of pretty much every public consultation or user meeting that I have ever been to. Often at meetings like this people will tell you that there is great discontent out there somewhere. They are here to speak for the unhappy silent majority. But when you ask why these people don’t come and talk to you, either at the meetings or anywhere else, they tell you it is because they don’t see the point – and they don’t think it will make any difference. So which is it? Is it just that they are happy with the decisions that are being made on their behalf and frankly have loads of other things they’d rather be doing with their time or are they sitting in their kitchens nursing their wrath to keep it warm but too disillusioned to email, or talk to us, or come to a meeting or fill in the consultation response form? We would really like to know, but how do we find out?
Perhaps we need to accept that there will always be a pretty substantial group of people who really are not that interested in getting involved. And what is wrong with that? We are all entitled to say there are things we don’t give a damn about and let the state get on with its job.
How to catch the low hanging fruit
Nevertheless there is still the group that sits between the 5%-10% we hear from so regularly in and the reported 28% to 36% who do want to be involved but are not.
The report helps to highlight what is putting them off. So here’s our take on how to get to grips with their top five “barriers” to involvement.
- Lack of information – engagement mechanisms appear to be invisible. I’d say we need to find out what really works - and what doesn’t – and decide how we measure success or otherwise. Posters and PowerPoint presentations in draughty halls may tick the boxes but won’t really do much communicating. Word of mouth and personal social contact must be a big part of the answer and we need to find ways of measuring our efforts and our successes in this area.
- Lack of time (and fear of being sucked into the time and good-will eating machine that is the world of volunteering and involvement – my words not theirs). We need to be really clear about what we are asking of people; make good use of their time by sticking to timetables, running meetings properly, conducting and enabling conversations so everyone gets a say, ending things on time and not asking favours of people who are already doing too much.
- Lack of faith in local authorities – (which could presumably be extended to any local provider). Trust is the holy grail. But it takes a long time to develop it, especially if you are starting from a low point as many are, and it can be destroyed in seconds. The development and nurturing of trust should lie at the heart of every single contact. Don’t insult people’s intelligence, and don’t patronise them and don’t ask for their views if you have already made up your mind.
- Fear of the usual suspects. Are the people who come to meetings thinking they are standing up for the down-trodden, “silent” people actually the very ones who are putting them off in the first place? Should we politely ask them to leave? Probably not, though it is sometimes tempting, but we might have to ask them to be quiet and listen for a minute. We need these people working for us: they are key networkers and influencers in communities, whether we like it or not, so how do we make the most of what they have to offer? And we also need to create some “safe” spaces in which we can talk to the people who are less happy about standing up in meetings or manning the barricades.
- Lack of return on investment – working hard for a desired result and not getting it puts people off . To some extent this may be inevitable. People engage when it matters to them. When the battle is over they are likely to move on, especially if they have not got what they wanted. But is it possible to get people to appreciate the process itself and see it is fair and worth being part of even if they don’t get exactly what they expected out of it?
I can’t exactly remember why Billy Connolly took to wearing these splendid Big Banana Boots in the nineteen seventies. I do remember my parents going to see him and telling me how unsuitable he was for nice young girls (which is what I was then, more or less). All I know is that I can’t see a banana now without thinking of them. What a delight that they now have pride of place in Glasgow’s splendid celebration of people power, the People’s Palace.
Now the humble banana has taken on a new role in the venacular of citizen empowerment. BANANA has apparently replaced NIMBY (Not In My Back Yard) as the acronym of choice when describing public resistance to building projects: Build Absolutely Nothing Anywhere Near Anything. Another acronym which manages to encompass all the weaseliness you would expect from public officials trying to put a positive spin on recalcitrant members of the community is LULU: Locally Undesirable Land Use. But my special favourite is CAVE: Citizens Against Virtually Everything – sometimes it feels like there are a lot of them about.
What we need now is a nice acronym for the sort of people who make a positive contribution to public life: Sensible Undervalued Citizens, Keen, Empowered and Rational. Got any suggestions?
I’m thinking about starting a list of unhelpful phrases about the NHS and top of the list is going to be “post code lottery”.
“London NHS care is postcode lottery” screamed the Evening Standard recently in response to a study from the Kings Fund showing variations in what London PCTs spend on cancer, heart disease and other things. Cue tabloid shroud waving and health-campaigner handwringing: funding differences = dreadful unfairness to people in areas where spending does not match the highest levels = heartless NHS bureaucrats putting people’s health at risk (shame!).
Simplistic league tables comparing health spending in uncritical ways don’t help public understanding, whether it is between London boroughs or between so called “developed” economies. The US spends more than anyone to achieve often mediocre outcomes and high wastage in their health transactions.
Is there really any significance for the health of their respective populations that Ealing comes “bottom” in England for cancer spending per patient and Redbridge is the highest spender? If that level of spending reflects an analysis of health needs and an allocation of resources according to population characteristics and desired outcomes, then the local spend is probably right for each place. It is the job of PCTs as commissioning bodies to do just this kind of localised analysis and investment to meet health needs and improve health outcomes. This point is sadly lost on most people and our politicians fear trying to explain it even when it has robust justification. No politician – Town hall or Whitehall – wants to put their neck on the media block for what the public perceives to be “unfair” even when it really is equitable.
Self-styled health campaigners and quite a few politicians wallow in emotive “death sentence” language claiming differential spending always means differential quality of care. On the contrary, it could just mean that all areas are not the same. We don’t have homogenous, equal-sized populations with identical needs. The fact is that uniformity of spending would be inequitable because it would smother action to meet local needs and reflect local views.
Local decision making - reflecting what patients and the public want and what public health intelligence says is needed and effective - is incompatible with national uniformity of spending. I don’t want Whitehall dictating how Wandsworth PCT should spend its resources on meeting the health needs of our population. I want local people to have an informed say about it and for clinicians, public health specialists and managers close to the issues who know the data and the effectiveness of the interventions to inform the PCT’s decisions for investment.
With this in mind, I was cheered this week to see well known South London GP Brian Fisher tackle this politically charged subject head on in a succinct letter in Health Services Journal on “local socialism” – certainly an attention grabbing title on a very serious topic.
“Unplanned and irrational differences in provision may be unacceptable”, but Ministers need to get over their fear of “planned differences” as Dr Fisher terms them. Rational and robust “differences” show that the NHS commissioners are doing their job, not the reverse. We need the health literacy and political maturity to understand and welcome that. And the thing that would make it much better is when local communities get involved in decisions about levels of health and social care funding. The participatory budgeting pilots reported in a recent issue of the HSJ point the way to greater local decision making, not less.
So here is my “Memo to Ministers”: stop taking your cue from the tabloid sub-editors and the self-interested campaigners. Get the facts first and then support the people taking the tough decisions at the front line.
As Brian Fisher sums it up: “We need to reassure Ministers and the Department of Health that localisation is usually the result of good practice.”