Djellouli, Nehla; (2020) Public involvement in decisions to change health services at a large-scale. Doctoral thesis (Ph.D), UCL (University College London).

Abstract

As proposals for large-scale change (LSC) to health services are associated by the public with making cuts and downgrading services, public involvement – a dominant motif in national healthcare policy – is thought to be a way to legitimise plans for change and resolve tensions. Yet, little is known about how involvement is understood, interpreted and operationalised in practice or how it may have an impact on LSC plans and resolve controversy. Through a scoping review and two qualitative case studies, my PhD project aimed to investigate how public involvement is conducted in LSC; to explore how the public organise themselves to be involved in decision-making; and to examine how involvement can be developed to be meaningful in this context. The scoping review showed that the literature on public involvement in LSC, often adopting a technocratic perspective, focused on ‘invited’ involvement stemming from processes institutionalised within health services, experienced by the public as having no influence on decision-making. The public often actively questioned the evidence for change, opposed LSC plans and sought alternative ‘uninvited’ routes to voice their views. Using document analysis, 27 interviews (with members of the public, campaigners, politicians, clinicians, Healthwatch, practitioners of involvement and a LSC leader) and over 100 hours of observations, I explored the social and political dynamics underpinning invited and uninvited involvement, and their interplay, in two English communities facing service closures under a regional LSC programme. My thesis is set against the backdrop of a changing health system. As invited involvement is experienced as inadequate, some members of the public create uninvited routes to challenge and delay change. These uninvited activities become more visible over time than invited ones. By engaging with theories of public involvement and deliberative democracy, this thesis provides a more nuanced understanding of public involvement in LSC and seeks to contribute to debates about involvement in controversial change.

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