1. Local legitimacy: involving the
public
Ruth Thorlby
Senior Fellow in Health Policy, Nuffield Trust
May 2011 © Nuffield Trust

2. Local legitimacy?
• “for the first time in forty years, there will be real local democratic
accountability and legitimacy in the NHS” (Liberating the NHS: Local
Democratic Legitimacy in Health, DH 2010)
• Proposed reforms aim at increased ‘legitimacy’ via:
- Health and wellbeing boards
- Expanded role for Healthwatch
- Councillors and others on GP consortia boards?
May 2011 © Nuffield Trust

3. A framework for public
participation and decision
making
A route to legitimacy?
28 July 2011 © Nuffield Trust

4. Who will be involved?
More Expert Administrators
Exclusive
Elected Representatives
Professional Stakeholders
Lay Stakeholders
Random Selection
Open, Targeted Recruiting
Open, Self-Selection
More Diffuse Public Sphere
Inclusive
Fung, A. “Varieties of Participation in Complex Governance” Public Administration Review, vol 66 (2006):66-75
May 2011 © Nuffield Trust

5. How will people be involved?
Least Listen as Spectator
intense
Express Preferences
Develop Preferences
Aggregate and Bargain
Deliberate and Negotiate
Most
intense Deploy Expertise
Fung, A. “Varieties of Participation in Complex Governance” Public Administration Review, vol 66 (2006):66-75
May 2011 © Nuffield Trust

6. How much influence to give people?
Least Individual Education
authority
Communicative Influence
Advise and Consult
Co-Governance
Most Direct Authority
authority
Fung, A. “Varieties of Participation in Complex Governance” Public Administration Review, vol 66 (2006):66-75
May 2011 © Nuffield Trust

7. The Democracy Cube
Authority & Power
Expert Administrators
Individual education
Everyone
Direct authority
Technical expertise Participants
Listen as Spectator
Communication & Fung, A. “Varieties of Participation in Complex Governance” Public
Administration Review, vol 66 (2006):66-75
Decision Mode
May 2011 © Nuffield Trust

8. Local legitimacy in reality?
• Public attitudes towards involvement: broad support for the idea
of engagement but only a minority regularly volunteer
• Public attitudes: default setting is ‘national standards with no
local variation’
• NHS “will continue to be a national service, held to account by
Parliament”
(Liberating the NHS: Local Democratic Legitimacy in Health DH, 2010)
May 2011 © Nuffield Trust

9. www.nuffieldtrust.org.uk
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May 2011 © Nuffield Trust