Final Report > Chapter 28: Public Involvement Through Empowerment > The changing direction of policy > What is needed

What is needed

9 If the NHS is properly to recognise and reflect the public interest, we have to ask what is needed, both at the level of principle and of practice, in the day-to-day affairs of such a large and complex organisation. Historically, the views and wishes of the public have been articulated indirectly, through politicians and healthcare professionals. The Secretary of State, as an elected politician, answers to Parliament and the people for all aspects of policy within the NHS. Healthcare professionals on the ground have daily contact with patients and a strong sense of what patients want. Yet society is changing and involvement by proxy is no longer seen to be enough. The public are no longer prepared to be passive, trusting and grateful recipients of what is made available. They are no longer prepared to hope that their views will be fully reflected by the professionals. That is not a criticism of professionals; it is just a reflection of the way the world has changed. Increasingly, with public services as with commercial services, the public are ready to challenge, prepared to question, and have come to expect that services will be responsive to their needs.

10 Thus the starting point for a consideration of how the public's interests may effectively be reflected and safeguarded, is that the public itself, in some shape or form, must be directly involved. The public must be included. In the world of professional services, this is still a problematic proposition. The challenge is to find new ways of involving the public which will work and which are embedded in the fabric of the system. There must also be ways which take account of changes in society, whereby representative democracy appears to be less trusted than a democracy which is participatory: `leave it to others' being supplemented or even supplanted by `do it yourself'. Moreover, the public who must be engaged is not some, largely notional, `general public', conceived as a homogeneous entity with common views and needs. Such an entity may be relevant when truly national health issues arise, affecting, for example, the identification of national priorities or the introduction of a highly specialised service. But there are other, disparate publics, divided or grouped according to such criteria as where they live, their age, their gender, their ethnic background or their particular healthcare needs. These many sections and groups also need to be involved.

11 Two questions warrant consideration. First, what are the most pressing matters on which these various publics should be heard: essentially, what is the agenda for public involvement? Secondly, how, for the future, can we ensure that the involvement of the public and patients is effective: essentially what principles should underlie and inform any decisions about the mechanisms for involvement?