Citizen control over health services is non-existent
THE NEW National Standards for Safer Better Healthcare from the Health Information and Quality Authority (Hiqa) will improve the health system.
Citizens now know what to expect from high-quality services and can voice these expectations.
Some standards are already being achieved such as “you are treated with kindness, consideration and respect” (Standard 1).
Patient surveys carried out by the Irish Society for Quality and Safety in Healthcare (ISQSH) show that 95 per cent of patients in acute hospitals agree they are always treated with dignity and respect. The vast majority are satisfied with the level of privacy received while being examined (Standard 1), and 95 per cent agree that their healthcare team protected their confidentiality (Standard 8).
Aspects of Standards 3 and 5 are clearly not being achieved: less than 1 per cent of users give feedback or make a complaint about health services. The ISQSH study found that 62 per cent of acute patients did not know the hospital had a complaints procedure and 16 per cent would have complained had they been informed about the procedure.
The Hiqa citizen participation standards will be difficult to implement. Standard 1 says that “service users are involved in the planning and design of services in their local area”. Standard 5 wants users’ views “sought and considered” when decisions are made about the way services are delivered, and Standard 7 specifies that “decisions on how services use their money are informed by service users”. Achieving meaningful levels of participation is challenging because of power imbalances between citizens and professionals in the Health Service Executive, and misunderstandings on both sides about the appropriate level of involvement in particular decisions.
More than 40 years ago, Sherry Arnstein developed a ladder of citizen participation which categorises strategies for involving the public into eight levels. The lowest rung is “manipulation”, when citizens are cynically used in public relations exercises: service users are brought in for the photocall. “Therapy” is when disadvantaged groups are invited to workshops and the hidden agenda is to adjust their values to those of society. These pseudo participation strategies are widely used in Ireland.
The third rung, “informing”, is legitimate citizen participation if health professionals listen to, and act on, what people say, are honest, and share all available information, not just the bits they think citizens need to know. Patient surveys and complaints procedures are examples of the informing level of participation.
“Consultation” is most effective when citizens’ concerns are given the same weight as professional opinions when decisions are being made.
The fifth rung, “placation”, is when a token person from a community or user group is invited to sit on a committee but HSE powerbrokers retain the right to make decisions.
These decisions are often made before or after the meetings, when citizen members are absent. Service user panels and advocacy groups are examples of placatory strategies often used by Irish health services.
The final three rungs on the ladder are “partnership” where power is shared between citizens and the HSE, “delegation” where citizens have more decision-making power than health professionals, and “citizen control” when all decisions are democratic.
Real partnership between the HSE and citizens is rare. The HSE Regional Health Forums are partnerships in theory, but are little better than bull sessions, with mistrust on both sides.
Citizen control over health services is non-existent. Some citizens don’t want to be volunteer bureaucrats. Others want to be included, particularly grass roots and user groups. A 2011 study of mental health inpatient services found that “patient participation is a top priority”.
The standards developed by Hiqa will not be achieved unless health professionals have a change of mindset. They need to stop thinking they know the answers before the questions have even been asked and accept that service users also have valuable expertise. The HSE needs to stop using pseudo and placatory strategies. A massive cultural shift is necessary otherwise citizen participation standards will become just another meaningless tick-box.
Jacky Jones is a former regional manager of health promotion with the HSE