Citizens’ juries are a relatively under-utilised way of setting principles and priorities around health care and resource allocation. They bring together a randomly selected group of people, who are given access to experts and information, to help them reflect on whatever questions and issues they have been asked to consider.
As previously reported at Croakey, such a group was convened in Canberra one weekend last August, under the auspices of the ACT Health Council and at the request of Katy Gallagher, the Minister for Health in the ACT.
A report on their deliberations was released just before Christmas and is worth reading if you missed it.
Among other things, the jurors strongly supported increased funding for illness prevention/health promotion, and endorsed a key principle of seeking ways to reduce the overall spend on hospitals and increase spending on health services delivered in community settings.
They also argued that ACT Health should prioritise equity over efficiency.
In identifying groups where they felt most needed to be done to reduce inequities, their top priority was Aboriginal health, followed by the health of the poor. But they also wanted priority for children over adults. Given the choice between helping many a little or a few a lot, they opted for the former.
They also wanted a more rational and consistent system for fees. They felt there seemed no rhyme or reason why one service might be free and another quite expensive.
And they identified a need for improved communication from both health services and individual health professionals. As an example, they spoke of the stress of waiting in the Emergency Department and inadequacy of information regarding waiting times and the prioritising system.
Below, some of those involved in the jury reflect on the experience.
We hear from the then chair of the ACT Health Council, Kate Moore, two of the citizens involved, Leah Card and Jack McCaffrie, and the facilitator, Gavin Mooney.
Kate Moore
Sitting in as an observer, this was a very special occasion. Striking aspects? First there was the great enthusiasm of ACT citizens to be involved. Second, the randomness of the selection process really works resulting in the very varied backgrounds of jurors but they also had a delightful capacity to come to agreement. Third they had a remarkable ability to grapple with complex information and problems and then come up with priorities. Finally quite stunning were the depth and quality of the debates within the jury. Great stuff for me but, more importantly, so clearly great stuff for the citizens.
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Leah Card
I for one think the whole process was worthwhile, in fact rather rewarding. It was a privilege to be part of a process that enabled me, as an average citizen, to have a voice. Indeed I am rather proud of the jury’s conclusions. Let’s hope the Minister is able to facilitate positive change in 2011. I am also now better educated in the complexities of making changes within the health system but I do have faith in the Minister. She came, she listened and she answered our questions. We have at the very least planted the seed.
What mattered most to me was the jury’s debate on obesity, which I found stimulating. I think we can tell the experts something on this one! In particular the health professionals must recognize that food for some is a crutch. Working as I have in the weight loss industry, I have seen this first hand. There is a need to stop victim blaming and understand that obesity is often a possible indicator of mental health issues – stress, depression, emotional overload. Helping people to manage stress might be the way to go. I think – and the jury seemed to agree – that obesity may be a physical scar for what is going on mentally.
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Jack McCaffrie
I find the whole concept of citizens’ juries really interesting. One thing the experience did for me was allow me to get a better handle on just how complex and difficult decision making in health care can be. I readily accept as did the rest of the jury that resources in health care are limited. (Given some of the examples of the uses of public funds around Canberra whether they need to as limited as they are might well be debated – but I also accept that that is for another jury’s deliberations.) Being forced to think through these issues around resource constraints and recognise that spending more on say heart disease means less for cancer treatment and trying to weigh up which is better… That is hard! Again the realisation that this involves difficult value and ethical judgments was very striking. And we cannot leave all of this to the doctors and other health care professionals. We citizens need to try to grapple with these issues.
I think ACT Health should do more by way of educating the public (as happened on the jury) in how these issues need to be addressed. They are difficult but sharing these difficulties with the public would be a good thing.
How successful are such citizens’ juries? I think we will judge their effectiveness by whether we can see any results.
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Gavin Mooney
I have now done 10 of these citizens’ juries. Each time I am struck by the skill and enthusiasm citizens bring to this process. It is frankly heartwarming and refreshing to be part of a process that allows ‘ordinary folk’ to have their say. Beyond that, as Leah and Jack say, the key is that action is taken to follow through on the recommendations emerging from citizens’ juries.
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PS from Croakey: Perhaps I should make a note in my diary – to check back in early 2012 to see if the jury’s deliberations have had any impact. Or will this end up being just another report on the shelf?
Citizens’ juries seem to be a bit political for mine. Pure cathartic focus group stuff that delivers little to public policy. And the choice of the panel of experts could have been a little more diverse. 3 representatives from the government and 2 academics from ANU? Where were the front line experts? e.g nurses, doctors, social workers, health business reps and insurers?
The true solution is to morph these juries into true stakeholder dialogues. Get doctors, insurers, economists, big pharma reps, nurses, social workers, citizens, government and public health experts in a room together to discuss health issues and you might be surprised by the innovative solutions created.
How can a randomly selected group be “political” and a round table of “stakeholders” not be? From my experience of several years with a table of 32 stakeholder representatives in a specific area of health it was time and good will which helped build consensus on broad policy issues but it was a very political process. Both, and other mechanisms, all have their place. As I understand it the jury process assists with identifying community values and gives some lead to decision makers about what the community will “buy”, “accept” “own” – whatever is the word of the moment.
I look forward to Crikey revisiting this matter in 2012 but what is the baseline to be measure from?
Scott you miss the point, well several actually. All these other groups you mention are “in there” anyway but the citizens are not. Also stick all of these “true stakeholders” (how I hate that word!) in the same room and certain groups will dominate – no prizes for guessing which. The idea of getting citizens together like this on these juries is in recognition of he fact that the health care system is not simply the province of these vested interests you mention but a social institution there to serve the citizens.
I wonder, have you ever attended a citizens’ jury? If not, try to get in on one as an observer and I’ll bet you come away thinking more positively about them – and about your fellow citizen!
Better still, chat to citizens like Jack and Leah who have first hand experience of the process.
I can’t help but notice that Gavin Mooney has ‘done 10 of these citizens’ juries’ and yet the ‘citizens’ are meant to be randomly selected. I guess I’ll have to look into how these juries work a little more thoroughly but that doesn’t sound very random to me!
I see now that Professor Mooney is the facilitator and randomisation is through the electoral roll which sounds much more valid. I’d echo Scott’s sentiments and voice concern that such juries may well be lost for context in their deliberations. Granted some stakeholders have a more dominant voice in these discussions, speaking politically, but true discussion brings everybody to the table. Citizens should be a part of the discussion, not left to have their own discussion group removed from all other relevant stakeholders.
Citizens are already in there…you don’t think doctors, nurses, insurers, big pharma reps etc are also citizens and users of the health system? That is how you get agreement in stakeholder dialogues (you might hate the term, but it is the term used in the literature). You appeal to the commonality of the various stakeholders and then tackle the areas of dispute. Besides, the citizens would also get a representative in the dialogue, along with the government (which is the ultimate representative of the populous)
As for powerful stakeholders dominating procedings, it is the role of the facilitator to stop this domination, to ensure that everyone has a voice (which I hope you did in your citizens jury…i’m sure there were a few dominant voices in that grouping as well).
A little fallacious Scott, don’t you think?
The board of directors of British American Tobacco Australia may be citizens, but I wouldn’t accept them as representative of our community’s interests when trying to gauge what would increase public health.
Stakeholders are important. So is gaining insight from as large a sample of the target population as possible.