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NHS Citizen: Designing democracy in the light

By January 28, 2014No Comments

This post, about NHS Citizen, is by Simon Burall, Director of Involve, one of the NHS Citizen partner organisations. It is a cross-post, also published on the Demsoc NHS Citizen blog and the Involve blog.

There are times, very rare times, where a part of government decides that it needs to develop a new structure to give citizens more power to hold it to account.

When this happens, the usual way it is done is that a large consultancy or corporation, or the politically orientated flavour of the month thinktank, is sent away to work in a darkened room. They then emerge six months later with a shiny new organisational structure that they guarantee will change the balance of power. Only it doesn’t. Either it doesn’t work, or it doesn’t do so in a way that more than a few dozen people outside government have heard about and so changes nothing for most citizens.

So I’m really excited that we are involved in a radical approach to designing a new system for holding the Board of NHS England to account. In partnership with Public-i, Demsoc and the Tavistock Institute, working with the NHS England Public Voice team, we are developing an open process to answer the what, why and how questions which surround something as challenging and huge as the design of a new democratic mechanism for the NHS.

We are calling this NHS Citizen.

This post is intended to give you a high-level summary of what we plan to do, and how we plan to work. At the bottom I suggest a number of ways you can follow our progress and get involved.

How are we going to design NHS Citizen?

The mandate for this work comes from a decision of the NHS Board in early 2013 to develop citizen voice within the decision making process and to better hold the Board accountable. Following the decision, several hundred people participated in two workshops, held in July and October 2013, to begin the design process.

Both workshops were live streamed and brought twitter and other forms of online engagement into the room. At its height, over 700 people were following the live stream of the October workshop, with many of these engaging in the debates with those in the room. This something we aim to build on as we scale-up the design process.

The current model of NHS Citizen that we are exploring and testing envisages three interlinked spaces, Discover, Gather and the Assembly Meeting. It is during the Assembly meeting that the NHS Board will meet face to face with citizens. While the workshops held to date have begun the process of shaping NHS Citizen, they also identified a series of, as yet, unresolved tensions and unanswered questions arising from the way the system might work.

The programme plan that we have developed with NHS England consists of nine workstreams which have been designed to refine and test the model and start to resolve the tensions and questions. We expect this process to resolve some issues, but surface others.

Processes of institutional design like this not only normally happen in darkened rooms involving small numbers of professionals, they are also nearly always delivered against rigid project plans.

We will be working differently as we aren’t setting the next year in stone.

Instead, we will be drawing inspiration from the agile model of software development. We will be using an adaptive programme management process (described here in outline) which holds the vision and model, the research and learning questions and the programme’s critical path in public, refining and adapting them at the end of two-three month periods of sprint testing of different elements of the programme.

Critically each of these two to three months sprints will include a number of experiments where we will be testing bits of the system, and as the year goes on increasingly moving to whole system tests. These will be designed to ensure that we, and all partners and participants, can learn from the process and iterate the design to make it work better. Our learning objectives will, of course, be in the open, as will what we think we have learnt at the end.

We can’t do this alone, no-one can; not NHS England, not some big consultancy firm and not four agile organisations with a wide-range of complementary skills. We are going to need to work with many more individuals and organisations to answer the multiple questions and tension that arise from designing a democratic structure with real power from scratch.

So, over the next three months we will also be developing a Challenge Fund to be used to engage others with ideas and interest to work with us and NHS England to develop and test solutions to some of the key challenges and questions raised during the design phases of the programme. NHS Citizen will also have a Participation Fund to facilitate the engagement, throughout the whole journey, of key individuals who have day jobs and lives outside the world of democracy wonkery.

What makes this different?

I’ve described two ways above that I think the way we intend to design NHS Citizen is different, that we’ll be:

  • Operating in the open at all times; and
  • Our agile method of project management ensuring regular points of open and participative reflection on the lessons learnt.

I’d like to highlight one more way that NHS Citizen is different; the extent of senior involvement in, and buy-in into, the need for an Assembly to hold NHS England to account and into the process described above.

Three Board members, Tim Kelsey, Victor Adebowale and Ciaran Devane, have been tasked with leading on the work. They have attended workshops and are engaging actively with both the process and the ideas behind the design of NHS Citizen.

They have their own views and have brought these to the workshops last year. Indeed, it’s fair to say that they are not presenting a united front, but are debating, in public, their different but complementary visions for NHS Citizen.

I also think it is significant that they have made it very clear, in public, that this is not a done deal. Our work on NHS Citizen is not an unstoppable steamroller that means that the Assembly system gets developed come what may. If the broad consensus of opinion is that there is no role for it then NHS Citizen will cease to exist.

For me this is critical because it hands some power over to participants, if they feel that there really is no role, or that the emerging system won’t work, then they have the potential to pull the plug.

A second critical element of the three Board members’ support is around the experiments we plan. Tim, Victor and Ciaran are committed to this approach as a programme of active inquiry and design; that it may not always work. In essence we have been given the space to fail as long as we have clear learning objectives for each experiment and actively bring this learning back into the process of design.

Find out more and get involved:

If you want to find out more, get involved, or follow progress then there are a number of ways you can do so, by:

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