Major health service transformation and the public voice: conflict, challenge or complicity?

Objectives: Calls worldwide for major reconfigurations of health care systems have been accompanied by recommendations that wideranging stakeholders be involved. In particular, patients and the wider public are seen as critical contributors as both funders and beneficiaries of public health care. But public involvement is fraught with challenges, and little research has focused on involvement in healthcare transformation initiatives. This paper examines the design and function of public involvement in reconfiguration of health services within the English NHS. Methods: Qualitative data including interviews, observation and documents were collected in two health care ‘transformation’ programmes; interviews involved including public and professional participants. Data were analysed using parallel deductive and inductive approaches. Results: Public involvement in the programmes was extensive but its terms of reference, and the individuals involved, were restricted by policy pressures and programme objectives. The degree to which participants descriptively or substantively represented the wider public was limited; participants sought to ‘speak for’ this public but their views on what was ‘acceptable’ and likely to influence decision-making led them to constrain their contributions. Conclusions: Public involvement in two major service reconfiguration programmes in England was seen as important and functional, and could not be characterised as tokenistic. Yet involvement in these cases fell short of normative ideals, and could inadvertently reduce, rather than enlarge, public influence on system-reconfiguration decisions.