The limits of participation?

All policies which prioritise the need and value of public participation are underpinned by the idea of a democratic deficit. A democratic deficit can be defined as failings in the levels of accountability and transparency in the ongoing operation of government institutions. This idea underpins so much of the push for user involvement and participation in the public sector. From the commissioning of health and social care, through to public consultations on health and social care provision, the NHS constitution through to research funding streams.

The central idea is that there is a deficit in how much citizens can call to account, and influence, what government does. Many of the current policy structures, such as the drive to localism, are underpinned by claims that public involvement makes ongoing public decision making (around things like health and social care provision and spending), more transparent and accountable. Another central issue in this process is the idea that increased citizen participation will work to reduce the democratic deficit. Interestingly, I don’t think it is possible to ever arrive at a surplus of democracy, but we’ll leave that to one side. What I want to think through in my post is how this participation might practically work. I am not proposing answers to what are a range of complex issues, I simply want to raise a number of critical questions of what we are doing about participation, and what the implications of those actions might be.

Within all these participatory processes there are two fundamental assumptions which are directing how these processes operate. First, there is an assumption that a democratic deficit exists in how these processes are organised.  Second, that citizen involvement in activities will re-dress this deficit and make the decisions required in providing health and social care more transparent and accountable.  There is a further assumption contained within this second point that increased transparency and accountability is both possible and beneficial.  I am not arguing they are not. But there is a need for us to be clear about the assumptions that underpin the framing of the problem because they play a role in determining what are deemed to be appropriate responses or solutions.

One question that is often left to one side when considering public participation is the issue of ethics. What are the ethics of participation in these contexts? In order to begin to think through this, I draw on the work of feminist critical theorist, Nancy Fraser. In tackling the ethics of participation Nancy Fraser gives the example of mixed-sex deliberative bodies. Fraser tells us that such mixed-sex meetings operate in ways that:

“men tend to interrupt women more than women interrupt men; men also tend to speak more than women, taking more turns and longer turns; and women’s interventions are more often ignored or not responded to than men’s” (Fraser, p.64).

So there are social processes and practices (in the case above this would be patriarchy) which influence the ways in which men and women are able to participate in meetings. One response to this disparity, or participation deficit, between men and women would be to find ways to organise meetings such that these advantages and disadvantages are removed or minimised. By finding ways to ‘bracket inequalities of status’ it should be possible for the meeting to proceed with a parity of participation assured for all speakers in the room. As Fraser says, it should be possible for everyone to: ‘set aside such characteristics as differences in birth and fortune and speak to one another as if they were social and economic peers.’

This gets to the crux of my post, how best to do this? If we revisit the meeting Fraser introduced previously, the key issue was that due to the structures of a patriarchal society there was an unequal distribution of power between men and women.  If now we look at a slightly different unequal power dynamic, we could instead consider a division between health professionals and Patient and Public Involvement (PPI) representatives. Where does this get us?

“health professionals tend to interrupt PPI representatives more than PPI representatives interrupt health professionals; health professionals also tend to speak more than PPI representatives, taking more turns and longer turns; and PPI representative’s interventions are more often ignored or not responded to than health professional’s”.

Just as in the previous example, there are clear differences in the ways in which the two groups can participate in the meeting. Current participation and involvement policies in health and social care are clearly intended to prevent just such a scenario occurring. Both scenarios are underpinned by a prevailing range of social, cultural, political and economic preconditions which give one group disproportionate and inordinate power over another group.  And in both cases, the unequal social and political distribution of power operates in subtle and often hidden ways.

This raises a question around whether bracketing these prevailing inequalities of status is doing enough to address these disproportionate and inordinate differences? Formally, in terms of the structure of the meeting, there are no barriers to participation, and everyone is entitled to speak equally. However, the enduring presence of inequalities based on gender, class, sexuality or ethnicity (to name but a few) and how they might impact upon discussions within the group are insufficiently considered. This raises a broader question about whether they might ever be considered sufficiently, and in enough depth and detail for parity of participation to be possible. In a system based on hierarchy there is never going to be equal involvement, and processes which try to address this deficit, need to address the fact that hierarchies will persist outside of the meeting.

Fraser argues this ideal of participation is overly optimistic. It involves too much difficult work across a range of diverse interests and actors. Rather the best way forward is to ask what form of public life comes closest to approaching the ideal of full parity of participation? If we are to take participation seriously then, Fraser argues, we need to ask what institutional arrangements will best ‘help narrow the gap in participatory parity between dominant and subordinate groups’?

Parity of participation. On the face of it, an eminently achievable and laudable goal. The oft-repeated mantra, utilised in the context of a parity of esteem between physical and mental health, of ‘nothing about us without us’ clearly sums up the moral case for involvement. This principle is not what is at issue in this post. However, a call for a parity of esteem between physical and mental health works to background ingrained and embedded social stigmas towards many mental health issues. My contention is that parity of esteem is not a strong enough position to counter these enduring and embedded stigmas – it does not do enough to counter the wider inequalities inherent in the social distribution of health and illness. In the context of my argument, a parity of esteem position might be of more use if the link were consistently and explicitly made in terms of the clear association between material disadvantage, poverty and levels of physical illness, psychiatric morbidity and mortality.

There is a very pressing need for a participatory approach which does not ignore the role of these factors in meaningful public participation. There is a need for practices which seeks to work beyond a simple commitment to something as nebulous as ‘parity’. For example, this could be accomplished by identifying ways in which the ‘bracketing of inequalities of status’ can have negative implications and consequences for citizens. By working through these difficult issues, and by seeking to bring the enduring (and often hidden) inequalities to the fore, and to then seek to address those inequalities, it may be possible to begin to move towards a truly progressive model of involvement.