Towards More Meaningful, Informed, and Effective Public Consultation

by Julia Abelson | Feb 01, 2004

Key Implications for Decision Makers

  • Health policy decision makers are grappling with increasingly complex, contentious, and ethically controversial decisions. They want to be sure their decisions are in line with citizens' values and expectations.
    • Approaches to public involvement can yield productive, long-term, trusting relationships between citizens and decision makers if they satisfy the following criteria:
    • clear communication about the purpose of the consultation and its relationship to the larger decision-making process;
    • identifiable links between the consultation and the decision outcome;
    • information presented clearly, honestly, and with integrity;
    • procedural rules that promote power and information sharing among and between participants and decision makers; and
    • processes that are viewed as legitimate by citizens and decision makers.
  • Substantial organizational commitment and resources are required to successfully integrate the above criteria into public involvement processes.
  • Public involvement approaches that emphasize the principles of deliberation are more effectively applied when a range of concrete decision-making options is being considered; when there are clear links between the consultation and the decision it is designed to inform; and when the time period between the consultation and the decision it is to inform is relatively short.
  • Challenges to the process and outcomes of informed, effective, and meaningful public involvement within regional health authorities include:
    • provincial and local experiences with past public consultations;
    • organizational environment and receptivity to public involvement approaches; and
    • characteristics of the consultation issue and decision-making context.
  • Credible, neutral, third-party facilitators, in conjunction with content experts, should be used as much as possible to build trust among participants and decision makers.
  • Three key "information obstacles" must be overcome by citizens and decision makers to achieve more informed, effective, and meaningful public participation:
    • address citizen concerns about the adequacy and quality of information;
    • address decision makers' concerns about sharing information and the constraints that apply to this process; and
    • recognize public participants' experiential knowledge as an information source.

Executive Summary

Context

Health policy decision makers are grappling with increasingly complex, contentious, and ethically controversial decisions at a time when citizens are demanding more involvement in, and public accountability for, these decision processes. The aim of this research study was to assess and improve the effectiveness of public involvement methods as tools for 1) obtaining public views that will inform and improve healthcare decisions; and 2) communicating with the public about complex health and healthcare issues.

Implications

Our findings provide strong evidence of decision makers' needs for new approaches to public involvement to confirm that their decisions are in line with citizens' values and expectations. These approaches must satisfy several criteria1 for informed, effective, and meaningful public contributions:

  • clear communication about the purpose of the consultation and its relationship to the larger decision-making process;
  • identifiable links between the consultation and the decision outcome;
  • information presented clearly, honestly, and with integrity;
  • procedural rules that promote power and information sharing among and between participants and decision makers; and
  • processes that are viewed as legitimate by citizens and decision makers.

Substantial organizational commitment and resources are required up front to successfully integrate these criteria into public involvement processes. These up-front commitments, while substantial, have the potential to yield productive, long-term, trusting relationships between citizens and decision makers.

The process, outcomes, and uptake of informed, effective, and meaningful public involvement within regional health authorities is shaped by several key influences: i) provincial and local experiences with past public consultations; ii) organizational environment and receptivity to public involvement approaches; and iii) issue characteristics and decision-making context. Some of these represent considerable challenges for organizations to overcome in order to successfully implement public involvement methods.

To successfully implement public involvement approaches that emphasize informed dialogue, citizens and decision makers must also overcome three key information obstacles: addressing citizen concerns about the adequacy and quality of information; addressing decision makers' concerns about sharing information and the constraints that apply to this process; and recognizing public participants' experiential knowledge as an information source.

Approach

The study involved three phases, culminating in the design and testing of a new public involvement method, informed by the full research team (including decision-maker partners and researchers in each of five regional health authority/district health council study sites). The method tested in phase 3 was informed by i) case studies of public participation experiences in each of the five research sites involving interviews with regional health authority executives and focus groups with experienced public participants (phase 1); and ii) a survey of regional health authority decision makers to generalize province- and region-specific results to generate predictors of successful public consultation practices (phase 2). The public involvement method, pilot tested in phase 3, was a one-day, face-to-face, deliberative consultation meeting involving 20-25 participants selected from each community. The method's feasibility, acceptability, and impact on learning and decision-making were assessed for both citizen and decision-maker participants2.

Results

The 99 citizens who participated in the project's deliberative public involvement meetings rated their experience with the method very favourably, with the exception of a small group of participants who were critical of the informational aspects of the meeting. Decision makers were both aware of and concerned about the level of time required to plan for this type of public involvement process. Participant understanding of the issues improved significantly in some sites, particularly for broader-based (such as health planning) issues, to which participants had little prior exposure. The outcome of the deliberative consultation meetings had variable impacts on organizational decision-making across each of the five study sites. Concrete, clearly-defined issues situated in short-term decision-making time frames with strong organizational commitment yielded outcomes from the deliberation that had a high degree of influence on health authority decision-making. Issues that were framed more broadly within longer-term decision time frames may have been more easily swept aside once the consultation was over, and there was less certainty about future uptake among organizational decision makers.

Further research and future practice challenges

Our research study followed participants through the design and implementation of the public involvement exercise in each site and for three to four months following the consultation meeting. The longer-term effects of this type of process on individuals and organizations needs to be assessed to determine whether such interactions between researchers and decision makers have any lasting impact on organizations and their future public involvement activities and on individual and/or community capacity-building. Measures are needed to assess the effects of deliberative processes on groups and individuals, and to assess the effects of these types of processes on organizational learning. Further research is also needed to develop mechanisms for establishing more routine, institutionalized, and lower-cost public involvement processes.

Additional resources

Abelson J, Forest P-G, Eyles J, Smith P, Martin E, Gauvin F-P. Obtaining public input for health-systems decision-making: Past Experiences and Future Prospects. Canadian Public Administration, 2002, 45(1) Spring: 70-97.

Forest, P-G, et al. Participation et publics dans le système de santé du Québec, dans Lemieux, Vincent, Bergeron, Pierre, Bégin, Clermont, Bélanger, Gérard (directeurs), Le système de santé au Québec - Organisations, acteurs et enjeux, 2nd ed., Sainte-Foy, Les Presses de l'Université Laval, August 2003, p.175-200.

Abelson J, Forest P-G, Eyles J, Smith P, Martin E, Gauvin F-P. Deliberations about Deliberation: Issues in the Design and Evaluation of Public Consultation Processes. Social Science and Medicine, 2003; 57:239-251.

Forest, P-G, et al. Une expérience de consultation publique délibérative dans Charlevoix. Recherches sociographiques, 2004, no.1, p.77-104.

Abelson J and Eyles J. Public Participation and Citizen Governance in the Canadian Health System. In Changing Healthcare in Canada: The Romanow Papers, Volume 2. P-G Forest, T. McIntosh and G. Marchildon (eds.) University of Toronto Press, 2004, p. 279-311.

Abelson, J, Forest, P-G, Eyles, J, Casebeer, A and Mackean, G (for the Effective Public Consultation Project team). 'Will it make a difference if I show up and share?' A citizens' perspective on improving public involvement processes for health system decision-making [accepted, Journal of Health Services Research and Policy].

1 These criteria were generated from the first two phases of the research project which are not discussed in detail in this report. A discussion of these criteria can be found in Abelson, J et al. 'Will it make a difference if I show up and share?' A citizens' perspective on improving public involvement processes for health system decision-making [accepted, Journal of Health Services Research and Policy, 2004].

2 Two deliberative methods were implemented and evaluated in Quebec with help from the partner regional health authority. Martin, E. Dialogue sur le plan d'action régional de santé publique de Chaudière-Appalaches 2004-2007. Report to the jury. October 18, 2003, Sainte-Marie.