Citizens’ juries in health. Please say Yes, Minister

The ideas in citizens’ juries are simple: a random sample of the relevant population is brought together; they are asked to put their citizens’ hats on; given good information on the issues for debate; encouraged to question experts to clarify that information or seek more information; and then given time to reflect on some appropriate issues and make recommendations. These ideas formed the basis of the four conducted so far in WA. Other forms of so-called ‘participatory democracy’ exist. Read here.

The big advantage of citizens’ juries over most other methods is that they embrace all of the key features of random selection of participants, ensuring they are informed and they are asked to act as citizens. The Canadians and the British have both engaged in such participatory democracy in health care. Read here.

In a recent ABC 7.30 Report, the Health Minister, Tony Abbott, sought to dismiss the usefulness of citizens’ juries, arguing that they are ‘ no substitute for political decision-making. In the end, politicians and policy makers can’t subcontract out the decision-making process.’ Read here.

Resolving this question of subcontracting of the decision-making process in health care is crucial. Mr Abbott argues that ‘politicians and policy makers’ are and must remain the decision makers.

That position is not challenged by citizens’ juries. They are not ‘decision-making’ bodies. Their task is purely to recommend the principles that the citizens believe should underpin their health care services. It remains for the Minister (and others) to make decisions.

For example, in the most recent jury in WA last October, the citizens identified as priorities the principles of greater transparency in decision making, greater equity, more prevention and increased resources for mental health. To achieve this, they were willing to give up some small inefficient hospitals and Emergency Departments.

I repeat. The decision making that follows juries’ recommendations remains where it is now; with politicians and policy makers.

It is of note that in all the four citizens’ juries which 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 a shift to more prevention and away from cure.

They appear also to want what might best be described as the moral responsibility for setting principles. For example I have witnessed jury participants puffing out their moral citizens’ chests when reporting on their recommendations. They like being asked to act responsibly on behalf of their community!

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

Minister Abbott may still want to argue that nationally this is his responsibility. OK but then what is his definition of ‘equity’ based upon? He could set up a committee of experts — but who is expert in the social goal of equity? Again how does he decide about its importance and who is currently treated inequitably? Which inequities are greater and by how much? And in allocating resources — and Minister Abbott is right, he has the final say — on what set of principles does he decide how much more to give, say, Aboriginal health? And within a fixed budget, at ‘whose’ expense — the rich? the acute sector?

The other key principles that juries might get into — what the objectives of the health care system might be (is it just improving health?), transparency in decision making, etc. — can be looked at in similar terms. In terms of moral responsibility in the community, they may not carry the same weight as equity but some such responsibility is still likely to be present.

There is no impasse here; no threat to our parliamentary democracy from these citizens’ juries. Having ‘citizen ownership’ has its 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.

Surely Minister Abbott would welcome the opportunity to say to a bunch of citizens directly: “As a government and health service we can’t do everything. Whatever we do has to be driven by some set of values regarding such issues as whether to spend more on aged care or more on children. Can you help us to set these values? I’ll listen and then try to incorporate your values in my decision making.”

How to proceed from here?

First, to allay Minister Abbott’s fears he needs to meet with citizens’ jury advocates and some of the citizens who have sat on the juries. Second he would need to commit to funding for the process (probably about $1 million). Thereafter a series of perhaps 20 citizens’ juries would be organised around the country. Finally the results of these would be fed into some national summit (involving citizens, experts, politicians and the Minister) with a view to providing him with a statement of the Australian community’s principles for our health care system.

Mr Abbott would then of course remain free to decide whether to adopt these principles.

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