Health is once again shaping up to be a major election issue. However the major parties are not as divided on health policy as they appear. If there were no major choices to be made on the future of health and health care in Australia, such agreement would not matter. Perhaps the two main parties have simply decided to seek the centre ground because that is where the voters are. But are they? How can political parties work out what the citizens of Australia really want from their health services?

The answer lies not in opinion polling or superficial ‘consultation', but in citizens' juries. This particular form of ‘participatory democracy' involves bringing together a random sample of the relevant population; asking them to put their citizens' hats on; giving them good information on the issues for debate; encouraging them to question experts to clarify that information or seek more information; and then giving them time to reflect and to make recommendations. This approach formed the basis of the five juries which I have helped facilitate; four in WA and one in South Australia. The Canadians and the British have also embraced citizen juries in their health care reform processes.

Other forms of ‘participatory democracy' exist, but citizens' juries have several advantages over most other methods:

• The fact that participants are selected randomly reduces the over-representation of special interests and axe-grinders to which other methods are vulnerable,
• The fact that participants are given comprehensive information and time to reflect on it avoids the media-driven knee-jerk responses sometimes found by opinion polls and plebiscites,
• By asking them to put on their ‘citizens hats', citizens juries encourage participants to make recommendations that serve the widest possible number, rather than just focusing on competing sectional interests.

So, if political parties really want to find out what most Australians want from health policy, they simply need to set up say 20 citizens' juries across the country and ask them what they want from their health services. It is not difficult and in my experience people love to be involved in this way.

Importantly, these are not ‘decision-making' bodies. Their task is purely to recommend the principles that the citizens believe should underpin their health services. It remains for ministers (and others) to accept or reject the recommendations and to decide how to implement them.

For example,a citizens' jury in WA in 2005 identified the principles of greater transparency in decision making, greater equity, more prevention and increased resources for mental health as top priorities. To achieve this, they were willing to give up some small inefficient hospitals and Emergency Departments. The responsibility for decision making that followed the juries' recommendations, however, remained where it had always been; with politicians and policy makers.

In each of the citizens' juries I have facilitated, greater equity has been identified as a priority. The citizens consistently want a better deal for the disadvantaged, especially Aboriginal people. They also have some lesser concerns for other disadvantaged groups and want to shift the focus of health investment towards prevention and away from cure.

They also appear to want what might best be described as the ‘moral responsibility' for setting principles. I have witnessed jury participants puffing out their moral citizens' chests when reporting on their recommendations. They respond positively to the idea of being asked to act responsibly on behalf of their community.

Equity as a health care principle is especially interesting. There is a vacuum in equity policy in Australia. Who is currently responsible - morally responsible - for equity policy in health care? Who is responsible for its formulation, its deemed importance (relative for example to efficiency, with which it may sometimes conflict) and for putting it into practice whether nationally or at a state level or in a hospital or a general practice? Oddly, at none of these levels is the answer clear. One answer - the citizens' answer - is that it should be citizens!

The other key topics of debate by juries - on the overall objectives of the health care system (is it just improving health?), the need for transparency in decision making, etc. - can be looked at in similar terms. These issues may not carry the same weight as equity in terms of moral responsibility, but some sense of responsibility is still likely to be present in the community.

There is no impasse here; no threat to our parliamentary democracy from these citizens' juries. Having ‘citizen ownership' comes with political advantages, as the community is better informed and more aware of the problems of running a health service within a constrained budget. Citizens at the first jury with which I was involved in 2000 remarked on how, after being on the jury, they better understood the system and were more sympathetic to those who had to decide how to spend the health dollar.

In primary care, the ALP has suggested GP Super Clinics. Nicola Roxon¹ has argued that these be ‘designed to ensure more Australian families have access to doctors, nurses, specialists and allied health professionals ... all in one centre, in their local community where they need them.' The questions remain however as to what these clinics will actually do to allow this better access, what their priorities will be and where the main access gaps are from the point of view of those who might use these clinics.

The GP Super Clinics appear to be based on the GP Plus² Clinics currently being established in South Australia. I recently facilitated a citizens' jury established to consider one of these clinics.

Issues of access loomed large for participants. One of the main requirements identified for improving access to services was information. The jury recommended increased efforts to ensure that knowledge was available to the local community about the clinic and the services it provides. It also identified other access issues related to affordability; breaking down language and cultural barriers; and providing cultural safety/security, especially for Aboriginal people.

There is not much to choose between the two main parties on their current health policies. Both talk about radical change but are not committed to it. Both are concerned only with the mechanics - for example who will run the hospitals rather than according to what principles and to what end. Neither seems to have an overall strategy based on coherent principles (such as equity for example). Neither is addressing the big issue of the balance of care between hospitals and the community. Would it not be better if at least one party were prepared to go to the voters acknowledging that they are unsure how best to proceed and want some guidance on principles from the citizens? Health politicians should recognise that it is the citizens' health service. They should allow citizens to say what values they want to drive it, and then design a system that gives the people what they want.

Endnotes

1. Nicola Roxon, Speech to Catholic Health Australia's Annual Conference, Sydney, 29 August 2007.

2. South Australia's Health Care Plan https://www.library.health.sa.gov.au/Portals/0/sou...