Issue 49,

February 2009

PDF

A number of methods can be used to engage members of the public, including surveys, interviews, focus groups, requests for submissions, open houses, and public meetings. Each has its own strengths and weaknesses.i Another approach that is becoming increasingly accepted is the use of the deliberative process, which is broadly defined as “a tool for producing guidance based on heterogeneous evidence,” ii More specifically, the deliberative approach is a collective problem-solving process that involves gathering information from a wide variety of sources, with a view to making informed decisions or recommendations on a specific issue. Deliberative processes are thought to be well-suited for soliciting perspectives on a wide range of issues, including healthcare.

The Deliberative Process – A Snapshot

A typical deliberative process exercise involves engaging a relatively small group of participants (somewhere between 10 and 40). These processes have been used to bring together the scientific and decision maker communities,ii,iii but are also relied upon to bring together members of the public, patients and others. Group members, who bring diverse backgrounds, interests and values, meet face-to-face to weigh evidence on a specific issue and to debate potential options. Information pertinent to the issue is usually provided in advance, either through assigned readings before the session or through presentations by relevant experts. Participants are often given the opportunity to challenge the experts and ask further questions before beginning deliberations. In a large group or in small sub-groups, participants then debate the issues amongst themselves, with the goal of developing some formal recommendations, if not a consensus, to inform decision-making. Depending on its structure, a deliberative process exercise can range from one day to three or four days.

Early practice with deliberative processes suggests that the public finds them stimulating and informative.iv More recent research by Abelson et al. indicates that the basic framework of a deliberative process “can be implemented in a variety of contexts and with considerable success.”v They also found that deliberative processes that are more closely timed to, and directly focused on, concrete decisions are more likely to have a direct influence on healthcare decision-making.v Meanwhile, a 2008 report that examined the use of deliberative processes as a means of engaging the public on health policy issues found that participants prefer an approach that includes initial team-building sessions, pre-meeting reading material, small group sessions, and breaks in the session (particularly overnight) to allow for personal reflection.vi
   

Experiences

Using deliberative processes for public involvement remains a relatively recent phenomenon in the health sector when compared to the history of its use in other sectors.iv For example, James S. Fishkin, at the Center for Deliberative Democracy at Stanford University, continues to lead extensive work on providing public consultation for public policy and for electoral issues using Deliberative Polling®.vii Meanwhile, in healthcare in Canada, deliberative approaches have mainly been used to involve the public in values-based discussions about their healthcare systems, as well as in priority-setting processes to inform decision-making at the local health authority level.iv One well-known example of using this approach in healthcare, albeit outside of the Canadian context, is the Citizens Council, developed in 2002 by the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom.viii The primary function of this council is to gauge whether the values NICE uses in developing its evidence-base guidance “resonate broadly with the public.”viii Back on Canadian soil, Ontario has recently developed its own Citizens’ Council for Drug Policy, established to provide the provincial government with recommendations on ethical concerns related to pharmaceutical policy.ix,x

Trade-offs

Deliberative processes offer a great deal of promise for achieving informed and considered public participation. But realizing this goal hinges on clear thinking about why it’s necessary to lead a consultation, with whom, and about what.iii As with every method of public engagement, deliberative processes involve some trade-offs. The use of a small group could raise concerns about how accurately the results represent the views of the wider public. As well, these processes often are held over a couple of days, requiring time investments from participants and organizers. And because of the level of time commitment required, participants are usually paid; depending on the scope and size of the exercise, this cost could be a significant consideration.xi

Conclusion

Increasingly complex policy decisions require input from an informed citizenry. Healthcare decision makers can use deliberative processes to enable members of the general public, patients and others to weigh the available evidence related to a specific issue, consider potential options, and collectively reach an informed decision.

*Public Engagement (Part I) – Engaging the Public in Healthcare Policy: Why Do It? And What Are The Challenges? was released as part of a special double issue on public engagement.

References

i. Chafe R et al. 2008. “A Framework for Involving the Public in Healthcare Coverage and Resource Allocation Decisions.” Healthcare Management Forum; 21(4).

ii. Canadian Health Services Research Foundation. 2006. Weighing up the evidence: Making evidence-informed guidance accurate, achievable, and acceptable. (Workshop report).

iii. Canadian Health Services Research Foundation. Decision Support Synthesis Program.

iv. Abelson J et al. 2003. “Deliberations about deliberative methods: Issues in the design and evaluation of public participation processes.” Social Science and Medicine; 57(2): 239-251.

v. Abelson J et al. 2007. “Examining the role of context in the implementation of a deliberative public participation experiment: Results from a Canadian comparative study.” Social Science and Medicine; 64(10): 2115-2128.

vi. Laupacis A et al. with the University of Toronto’s Citizens’ Council 2008. PET Scanning in Ontario: Deliberations of the University of Toronto Citizen’s Council – Recommendations and Lessons Learned.

vii. Center for Deliberative Democracy. No date. Deliberative Polling®: Toward a Better-Informed Democracy.

viii. Rawlins MD and Culyer AJ. 2004. “National Institute for Clinical Excellence and its value judgments.” British Medical Journal; 329(7459): 224-227.

ix. Jeyanathan T et al. 2006. Recommendations for establishing a citizens' council to guide drug policy in Ontario. Toronto: Institute for Clinical Evaluative Sciences.

x. Silversides A. 2008. “The verdict's in: Citizens are the solution.” Canadian Medical Association Journal; 179(2).

xi. Maxwell J et al. 2003. “Giving citizens a voice in healthcare policy in Canada.” British Medical Journal; 326:1031-1033.
    

For Further Reading

Abelson J et al. 2004. Towards more meaningful, informed, and effective public consultation.

Abelson J et al. 2003. “Does deliberation make a difference? A citizens’ panel study of health goals priority setting.” Health Policy; 66(1): 95-106.

Canadian Health Services Research Foundation. 2007. Priority themes: Values-based decision-making and public engagement.

Lomas J et al. 2005. Conceptualizing and combining evidence for health system guidance.

Mark Dobrow and colleagues are synthesizing the evidence on deliberative processes to inform the Foundation’s Decision Support Synthesis Program. This work is set to be released in 2009.