Citizens have their say on health care

BMJ 1996; 313 doi: (Published 09 November 1996) Cite this as: BMJ 1996;313:1164

Health authorities around Britain are piloting a radical new method of increasing grassroots input into decision making.

Backed by grants from the King's Fund of £12 000 ($18 000), East Sussex, Buckinghamshire, and Sunderland health authorities announced last week that they would run “citizens' juries” on key local issues early in the new year.

A model of public consultation pioneered in the United States and Germany, citizens' juries mimic a court of law and are designed to get to the heart of community opinion without being hijacked by interest groups or lack of information.

Sixteen jurors, recruited off the street according to the demographic profile of the community, hear evidence and cross examine expert witnesses representing all sides of the debate over a period of four days. To ensure unbiased coverage, the jurors can request information from any party in the debate and call extra witnesses.

Aided by independent mediators, the jurors are then asked to formulate recommendations, which under its pilot contract the health authority must agree to take into account when deciding on policy and funding.

In Germany and the United States juries are largely used to debate planning, environmental, transport, and social issues. German “planning cells” are sponsored by local or national government and have a direct influence on policy. In the United States juries are convened by the independent Jefferson Center for New Democratic Processes and have to rely on strong media coverage for their decisions to influence politicians.

In the King's Fund pilot studies jurors in East Sussex will deliberate on the siting of gynaecological cancer services, and in Buckinghamshire they will consider whether public money should be spent on osteopaths and chiropractors. In Sunderland the hope is that the jury will help find a way to overcome a crisis in general practice recruitment by assessing the acceptability of involving other health professionals such as nurses, pharmacists, and health authority doctors in doing work normally done by a general practitioner.

Sunderland's director of performance management, David Eltringham, said: “We need to create an awareness of the problem in the public mind as well as finding solutions that are acceptable to the public and within the health authority's own realities. I hope the jury will create the ground on which we can implement new models of care.”

Susan Elizabeth, director of grants at the King's Fund, says the jury model is based on the concept that, given enough time and information, ordinary people can make valid decisions on complex issues often thought to be beyond their understanding. She said: “Citizens' juries allow people to work through a process of deliberation backed by a lot of information instead of speaking from a preconceived position arrived at with very little information.”

Critics have suggested that juries are just another way of getting the public to countenance rationing of health services. But Ms Elizabeth says that they are more about accountability than rationing. “All health authorities need to make hard choices, and citizens' juries may be one way of engaging people in these choices, but the real interest is in how we fill the gap in the health authority accountability framework given their unelected status. Citizens' juries could be one option in the public consultation tool kit,” she said.

The three King's Fund juries follow four others organised by the Institute of Public Policy Research. The first was piloted together with Cambridge and Huntingdon health authority earlier this year and looked at priority setting (22 June, p1591-3). Jo Lenaghan, health policy researcher with the institute, said: “There is something about the process that encourages people to take a community perspective, to come together over issues as citizens rather than take the narrow view of individuals and neighbours.”—HILARY BOWER, medical journalist, London

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