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

2. © Nuffield Trust 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

3. © Nuffield Trust 25 April 2015 © Nuffield Trust A framework for public participation and decision making A route to legitimacy?

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

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

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

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

8. © Nuffield Trust 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

9. © Nuffield Trust May 2011 www.nuffieldtrust.org.uk Sign-up for our newsletter www.nuffieldtrust.org.uk/newsletter Follow us on Twitter (http://twitter.com/NuffieldTrust) © Nuffield Trust