Advantages and Problems of Public Involvement in Health Care Planning Decisions - Essay Example

Advantages and Problems of Public Involvement in Health Care Planning Decisions and Introduction Over the past three decades there has been increased lobbying for public involvement in health care planning decisions. Public involvement flows from participative decision making, a concept that has for long being applied by organization’s management to promote cooperation and employee satisfaction (Black and Gregersen, 1997; Connor and Becker, 2003). Public involvement in this context means taking into consideration the views and opinions of the members of the public and the service users when making health care planning decisions. Essentially, this idea is based on the thinking that “no decision about me should be made without me” (DoH, 2011). Coutter and Ellins (2007), therefore, noted that public involvement is meant to share the decision making powers between the service users and the members of the public and the health care administrators. Its main objective is to improve social inclusion by ensuring completeness of decision making which has very many advantages as shall be explicated herein after (Cribb and Entwistle, 2011). This paper discusses the potential advantages and potential problems of public and other service users’ involvement in health care planning decisions. It will give a brief background of public involvement in health care planning decision making; it then explicates the different levels of involvement or participation by the public. Finally, the paper discusses the advantages and disadvantages and recommends instances where public involvement is suitable for maximum effectiveness. Background The UK government has been encouraging partnerships in the health care since early 1980s thereby helping service users take control of their health and assume responsibilities of the same (Clyne, Granby and Picton, 2007). Shared decision making has, therefore, been very prominent in the UK health care sector. Public involvement in health care decision making derived its impetus from activities of the disability rights movement (Cribb and Owens, 2010). These movements emphasized the fact that people who are going to be affected by a decision, for example a health care intervention, should be involved in the decision making and be afforded to choose from all possible choices (Cribb, Donetto and Entwistle, 2011; Burkitt et al, 2004). It is an ethical imperative. Proponents of public involvement suggest that it equips people with full knowledge of their treatment options and interventions (Edwards and Elwyn, 2006). Even though this shared decision making is popular in the health care sector in theory, it is not implemented with the same gusto in reality. It is general knowledge that if well implemented it can form part of the best practice in the health care delivery, therefore, the UK government is firmly placing patient involvement at the pivot of its health care policy (DoH, 2011). Levels of Public Involvement/ Participatory Planning Researchers have established that there are different levels of public involvement in health care planning. The time pressures, the nature of intervention that needs to be rolled out and the level of education, skills and experience of the public members may determine the level of involvement that the members of the public and other service users may be accorded (Entwistle et al, 2010; Fraenkel and McGraw, 2007). There are generally five levels of participation or involvement. These levels are: Information only, consultation only, deciding together, acting together and supporting independent community initiatives (Rabnowitz, 2013). Information-only public involvement in decision making entails informing the public members of what the decisions are (Jones et al, 2004). The public is accorded the courtesy of being informed but in real sense do not participate in the actual decision making. The second level is consultation-only. Here, the health care administrators actually design the options and present them to the public members who provide feedback. This feedback is what the administrators use to make decisions. Therefore, the public is involved in that they help make known their preferred option even though they do not make the final call (Richards and Coulter, 2007). The third level, and which is considered as the start of the real public participation, is the deciding together level. Here, all the stakeholders assume a partnership relationship. This relationship implies that all the parties involved in the decision making have the same powers and responsibilities with regards to decision making. All the parties’ opinions have the same weight (Walker, 2007). Additional ideas and suggestions are sought from health care users and public members by the health care administrators. Acting together is the fourth level and involves all parties not only deciding together but also implementing whatever has been decided together (Goodrich and Cornwell, 2008). It is at a higher level in the sense that the service users and public members not only air their ideas but also make efforts to make it a success. The last level is where the health care administrators actually support independent community initiatives. Rabnowitz (2013) asserts that it is the ultimate level of public involvement since the ideas are first generated by the public and the health care just offers supports, may be, in terms of advice or provision of other resources. The choice of the level of participation or involvement that the public members and health care users assume depends on the circumstances surrounding a particular decision making instance especially time constraints. It is imperative to note that true public participation starts at the deciding together level upwards (Green, 2010; Jones, 2010). Advantages of Public Involvement Public involvement in health care decision making has many potential benefits; some of them are discussed herein after. The first benefit is that there is democratic decision making. This implies that all the stakeholders’ views and opinions are taken into consideration during the decision making (Lum, 2009; Sager and Gastil, 1999). For instance, if it is in designing an intervention to reduce the high prevalence of people suffering from hypertension in the community, the doctors, the hypertension patients and the members of the public, for example, social workers and community-based organizations can all be involved in designing the intervention. According to Van der Helm (2007), the advantage is that there is promotion of social inclusion and the decisions made are well informed. Critically, public involvement provides an opportunity to the minority, often disenfranchised, community groups to air their views and opinions (Sagie and Aycan, 2003). This is crucial in diluting potential resistance when implementing the deliberated intervention. One of the programmes in the UK health care that foster public and service users’ involvement is cognitive behavioural therapy employed in the field of psychotherapy. Here, the patients are actually active participants in deriving solutions for their mental health problems such as depression and anxiety and other personality disorders such as obsessive compulsive disorder and posttraumatic stress disorders among others (Askham and Chisholm, 2006). Secondly, public involvement leads to designing and provision of more responsive services (DeMarco and Stewart, 2010). Participatory decision making helps design responsive services in that the members of the public can help provide insights that would have escaped the health care administrators. If the administrators make decisions on their own, there is a huge possibility that they may make decisions that do not mirror the situation at the ground (Abzug and Phelps, 1998). The administrators may have lost touch with the public. Involving the public or the potential beneficiaries of that health care decision ensures that the pitfalls associated by ignorance of the realities on the ground are avoided (Carmelli, Sheaffer and Halevi, 2009). Furthermore, if there are members of the public who had ever participated in a similar decision making process, they can help provide insight into how the other intervention was designed, how it performed, and if it failed the reasons why it failed. The previous mistakes can effectively be avoided (Coutter and Ellins, 2007). The services rolled out are, therefore, more responsive to the problems in the society. The other potential advantage is that there are improved clinical outcomes. This perception on the part of the public is brought about by the notion that the intervention is theirs since they helped design it. Research indicates that patients are more likely to recover fast if they are included in the decision making on their health care interventions (Cribb and Owens, 2010). Involving the public or the patients in the decision making lends more credibility to the decision made. The public has a sense of ownership and a strong base for rolling out the intervention is established (Edwards and Elwyn, 2006). That way improved clinical outcomes are achieved. Also, through public involvement, appropriate and relevant services can be offered. This is because there was a wider perspective of ideas and opinions during decision making through involving all the people who are likely to be affected by the decision. The chances that the services provided would be inappropriate or irrelevant are significantly reduced. Of great significance is that public involvement in health care decision making greatly increases accountability and public confidence in the health care services (Entwistle et al, 2010). The perceived, or real, power sharing helps make the public and service users feel like real valuable stakeholders. The health care user satisfaction thus increases with every successful use of a service. Furthermore, if the power sharing arrangement is real such that the public have actual powers to influence the programme or services being offered, the accountability of the service providers can greatly be increased (Burkitt et al, 2004). The confidence in public services is increased when the public experiences services that are beneficial to them without much hassle. The other advantages are that public participation equips the members of the public with skills that may prove useful even beyond the intervention implementation (Fraenkel and McGraw, 2007). For instance, some community members may benefit from the skills of running meetings, administrative planning, data analysis and strategic planning knowledge and skills. Public involvement also implies respect for the members of the public. Other organization outside the health care setting may follow suit in engaging the public in their decision making. The overall effect is that the public becomes empowered (Scully, Kirkpatrick and Locke, 1995). Potential disadvantages and problems Public involvement or participatory planning also has its own share of disadvantages. One of the potential problems is staff’s negative perception of the public involvement in decision making. Staffs are professionals and view themselves as better placed in making decisions concerning the public and patient’s health care because they have the expertise (Walker, 2007). They view the public as a collection of lay people who cannot make or provide technical advice or opinions. The public, according to the medical staff, can only water down proposed technical views but cannot add value in the decision making process. This conflict is also a very big disadvantage in that it creates rifts between the members of the public and the experts in that they may not agree on some issues (Jones et al, 2004). The members of the public and patients feel that they have the right to be heard because the interventions are about them. The medical experts feel that they should have the exclusive decision making rights because they have the technical know-how and are better placed to make decisions on behalf of the public. Another potential problem is that health care administrators, the service users and the members of the public do not have sufficient understanding of the ideal nature of public involvement (Richards and Coulter, 2007). This lack of understanding has caused problems because every institution interprets public involvement differently. Conflicts of interests are, therefore, bound to arise. To avoid this, all the stake holders have to be educated on the nature of user and public involvement. Through this, the level of public involvement in decision making can be ascertained and made clear, conflicts are, therefore, avoided. Closely related to the aforementioned problem is that there may be skills and knowledge deficit among the service users and the members of the public (Rabnowitz, 2013). Evidently, an ignorant public cannot provide viable solutions, ideas and opinions. Even if the health care policy makers would wish for the public and users to be involved in decision making, it would be pointless to involve an audience that lacks the skills and knowledge to design intervention programmes. A good public involvement arrangement can only take place where all the stakeholders know the desired results and the means to achieving those results. The whole essence of public involvement is to expand the idea base, promote social inclusion and reduce resistance. This argument is supported by the vigilant interaction theory which asserts that the quality of a decision making team is defined by the competence of the individual members and the attentiveness of the members during the interaction and decision making (Cribb and Owens, 2010). If the skills and knowledge is not there then the quality of the decision making team would be diluted and so would the quality of the decisions made. Another major problem facing user and public involvement is resource issues. Public involvement involves many people. The more the people involved the more expensive the process becomes because of increased consultation costs (Black and Gregersen, 1997). Getting an appropriate time when all stakeholders would be available or a venue where all could meet could pose a resource availability problem. Additionally, the decision making process is bound to take longer than it would have had the service users and public not been involved. Another problem is lack of joint working. Contrary to popular belief, public involvement does not necessarily mean that all the important people would be involved in decision making (Connor and Becker, 2003). Even if they are involved, they may not be able to make decisions because they are not held in the same regard as health care professionals. A determined individual who is keen on advancing his own agendas or a know-it-all may wreck the whole process. Additionally, opening the window for public participation does not mean that all would participate. Some may opt to forego this right may be because they had earlier participated and the process did not prove successful or there is basic mistrust because they were marginalized or their contributions not taken seriously (DeMarco and Stewart, 2010). The other category that may not participate in decision making is that of hard-to-reach groups. This group, for example, the physically or mentally challenged persons, may be critical in the designing of these interventions but the mere fact that they are not bold or outspoken may mean that they may not volunteer in decision making. The other potential problem is the tendency of the same people participating in every decision making year in year out. It becomes hard to generate fresh ideas and opinions if the people are the same. Lastly, real involvement is a major problem. Arnstein (1969) noted that there is a big difference between undertaking public involvement as a ritual and public involvement as a real tool of power sharing in decision making. Arnstein noted that many organizations encourage public involvement just for public relation purposes but not for genuine interest to get ideas from service users and members of the public (Arnstein, 1969). If the public has no power to influence the final decision then that is not real participation. Power must be redistributed to each stakeholder. Unfortunately, this does not happen in many instances. The health care administrators are, thus, able to fool the public that they are involved in decision making and boast of the same yet in reality they do not (Abzug and Phelps, 1998). Recommendations It is apparent that the advantages by far outweigh the potential problems. Organizations should promote public involvement in health care decision making. In order for the process to be effective and successful in the long run, health care administrators need to be sure of the circumstances that require public involvement in decision making and the level of participation that is required. The following are the recommendations pointing out the different levels of public involvement and when it is appropriate to use each. The first level of involvement is the information-only involvement. As pointed out earlier, this involves providing the members of the public with information only. They do not participate in real decision making. This level of involvement should only be used when the decision has already been made by the health care policy formulators (Rabnowitz, 2013). Informing the public acts as a formality and as a tool for diluting resistance by giving information prior to providing the service. The other instance where this level of public involvement is apt is where the administration simply wants to report about the decision or just wants to equip the members of the public with information and nothing else (Green, 2010). The consultation-only is the second level of public involvement. As pointed earlier, it involves the health care administrators providing the service users and the members of the public with a variety of credible options from which they select the favourable option. This level of public involvement is appropriate when there are limited options or when the decisions to be made are on already existing interventions and no new ideas are required (Jones et al, 2004). It is imperative that the public’s sentiments be echoed in the decision making. Otherwise, engaging them just for the sake of it may end up infuriating the public. If the public’s views and opinions are sought then the decisions should be affected by those views and opinions. Richard and Coulter (2007) propose that if the decisions do not take into consideration those views and opinions it would be courteous to explain to the public the reasons why their contributions were not considered. The deciding together is the third level of public involvement and involves all the stakeholders actively participating in airing views and decision making. This level of participation should be used when it is imperative that all the stakeholders feel ownership of the planning decision (Charles, Gafni and Whelan, 1997). It is should also be used when fresh ideas from varied sources are required. It can also be used when there is enough time to involve all the stakeholders, when it is necessary to include all who are directly affected by the planned intervention and where there is enough support for the process. It is important to balance participation, quality of decisions and time constraints (Entwistle et al, 2010). The acting together level goes a step further to not only involve the public in planning and decision making but also in implementing the plans. The public should be involved at this level when the effectiveness of implementing the planned service is enhanced if implemented by all as opposed to a single body (Coutter and Ellins, 2007). It is also apt when it is a requirement that the community be involved or where all the parties stand to benefit from jointly implementing the plan. Lastly, this level of public involvement should be used only when there is a genuine interest by all parties to form a partnership (Clyne, Granby and Picton, 2007). Supporting community initiatives is the last level of public involvement. It is apt when there is a drive to empower the community and where the community has the potential and desire to start health care intervention programmes (DeBruin, Parker and Fischhoff, 2007). The other instance is when the organization is only capable of providing support in the long run and the community is a viable partner. Conclusion Public involvement is, therefore, a critical practice. It helps promotes service users and public’s satisfaction in using the planned intervention programs and it also helps generate credible, practicable services (Arnstein, 1969). These, and many other, advantages have made the concept popular among health care policy formulators. However, it has its own problems, which have served to make remain just that, a concept in theory not applied in reality. It is, therefore, critical for health care providers to know the level of participation that the public should be engaged (Cribb and Owens, 2010). This can only be done through a cost benefit analysis by comparing advantages and disadvantages of public involvement. If the administrators decide to involve the public, they should ensure that the involvement is genuine and real (DoH, 2011). References Abzug, R., & Phelps, S. (1998). Everything old is new again: Barnard’s legacy: lessons for participative leaders. Journal of Management Development, 17, 207–218. Arnstein, S. (1969). A Ladder Of Citizen Participation, Journal of the American Planning Association, 35, 431–444. Askham, J., & Chisholm, A. (2006). Patient-Centred Medical Professionalism: Towards an Agenda for Research and Action. Picker Institute Europe, Oxford Black, J., & Gregersen, H. (1997). Participative Decision-Making: An Integration of Multiple Dimensions. Human Relations, 50, 859–878. Burkitt-Wright, E., Holcombe, C., & Salmon, P. (2004). Doctors’ communication of trust, care, and respect in breast cancer: Qualitative study. British Medical Journal, 328(7444), 864. Carmelli, A., Sheaffer, Z., & Halevi, M. (2009). Does Participatory decision-making in top management teams enhance decision effectiveness and firm performance. Personnel Review, 38, 696–714. Charles, C., Gafni, A., and Whelan, T. (1997). Shared decision making in the medical encounter: What does it mean? Social Science Medicine, 44(5), 681-692. Clyne, W., Granby, T., & Picton, C. (2007). A competency framework for shared decision making with patients: Achieving concordance for taking medicines. Keele, UK: National Prescribing Centre Plus. Connor, P., & Becker, B. (2003). Personal value systems and decision-making styles of public managers. Public Personnel Management, 32, 155–181. Coulter, A., & Ellins, J. (2007). Effectiveness of strategies for informing, educating, and involving patients. British Medical Journal, 335(7609), 24-27. Cribb, A., & Entwistle, V. A. (2011). Shared decision-making: Tradeoffs between narrower and broader conceptions. Health Expectations, 14(2), 210-219. Cribb, A., & Owens, J. (2010). ‘Whatever suits you’: Unpicking personalization for the NHS. Journal of Evaluation in Clinical Practice, 16(2), 310-314. Cribb, A., Donetto, S., & Entwistle, V. A. (2011). Medicines and patient involvement: from guidelines to good practice. Prescriber, 22, 30-36. DeBruin, W., Parker, A., & Fischhoff, B. (2007). Individual differences in adult decision-making competence. Journal of Personality & Social Psychology, 92, 938–956. DeMarco, J., & Stewart, D. (2010). Rational noncompliance with prescribed medical treatment. Kennedy Institute of Ethics Journal, 20(3), 277-290. DoH, Department of Health (2011). Government Response to the NHS Future Forum Report. Norwich: The Stationery Office. Edwards, A. & Elwyn, G. (2006). Inside the black box of shared decision making: Distinguishing the process of involvement and who makes the decision. Health Expectations, 9 (4): 307-320. Entwistle, V., Carter, S. M., Cribb, A., & McCaffery, K. (2010). Supporting patient autonomy: The importance of clinician patient relationships. Journal of General Internal Medicine, 25(7), 741-745. Fraenkel, L., & McGraw, S. (2007). Participation in medical decision making: The patients’ perspective. Medical Decision Making, 27(5), 533-538. Goodrich, J., & Cornwell, J. (2008). Seeing the person in the patient: The point of care review paper. London: The King’s Fund. Green, J. (2010). Education, professionalism, and the quest for accountability: Hitting the target but missing the point. London: Routledge. Jones, I., Berney, L., Kelly, M., Doyal, L., Griffiths, C., Feder, G., Hillier, S., Rowlands, G. & Curtis, S. (2004). Is patient involvement possible when decisions involve scarce resources? A qualitative study of decision-making in primary care. Social Science and Medicine, 59, 93-102. Jones, F. R. (2010). Working with self-management courses: The thoughts of participants, planners and policy makers. Oxford: Oxford University Press. Lum, G. (2009). Vocational and Professional Capability. London: Continuum. Rabnowitz, P. (2013). Participatory approaches to planning community interventions. Retrieved from http://ctb.ku.edu/en/table-of-contents/analyze/where-to-start/participatory-approaches/main Richards, N., & Coulter, A. (2007). Is the NHS becoming more patient-centred? trends from the national surveys of NHS patients in England 2002–07. Oxford: Picker Institute Europe. Sager, K., & Gastil, J. (1999). Reaching consensus on consensus: A study of the relationships between individual decision-making styles and the use of the consensus decision rule. Communication Quarterly, 47, 67–79. Sagie, A., & Aycan, Z. (2003). A cross-cultural analysis of participative decision-making on organizations. Human Relations, 56, 453–473. Scully, J., Kirkpatrick, S., Locke, E. (1995). Locus of Knowledge as a Determinant of the Effects of Participation on Performance, Affect, and Perceptions. Organizational Behavior and Human Decision Processes, 61, 276–288. Van der Helm, R. (2007). Ten insolvable dilemmas of Participation and why foresight has to deal with them. Foresight, 9(3), 3–17. Walker, G. (2007). Public participation as participatory communication in environmental policy decision-making: From concepts to structured conversations. Environmental Communication, 1, 99–110. Read More