Recent NHS Executive guidance has strongly emphasised public involvement in local decision-making, reflecting a broader government agenda to open up public services to greater local accountability and lay involvement.
But those in primary care groups, and partners in regeneration projects, are learning that engaging local interest and commitment is a long job, requiring skilled professional support.
A partnership approach has been successful in involving the public in the design of the new William Budd health centre, due to open in the Knowle West health park, south Bristol, in March 2000.
The health park is being developed as part of a healthy living centre for this area of high health need. Its values statement commits partner agencies to work in co-operation with local people. Avon health authority asked Bristol and District community health council to organise local involvement in the design of the new health centre, via its Local Voices project.
The project chose to work with a community health worker based at the existing health centre and the Knowle West Health Association, a community health project with lay people on its management committee. The project involved the public right from the start, beginning with the appointment of the architects.
With the help of local youth, health and community workers, 26 local people were recruited to attend two training sessions to explain the process involved. Six subsequently agreed to be part of the interviewing process. The HA invited six architectural practices to compete for the job in a two-stage selection process.
Stage one: each practice was interviewed by the patient interview group, facilitated by the Local Voices project co-ordinator. The practices also had to submit quality statements and their fee offers.
Stage two: three practices shortlisted from stage one were interviewed by health centre staff representatives, including GPs, nurses and the practice manager.
It was established from the outset that lay views were significant and had to be taken seriously. A unanimous decision was reached on the choice of architect because of a willingness to compromise by both the health centre staff and local people, neither of whom got their first choice.
The next step was to give residents the opportunity to influence the design of the centre. The HA funded a community arts photographer to produce a slide show of images, including pictures of the existing centre and how a new one might look. The slides were used to elicit comments at meetings with local groups, and were displayed in the existing health centre and at open days at which the public could meet the architects.
A patients' group was established from the interview panel to work with the architects as the design evolved. Additional members were recruited with community worker help and by patients in the group as they talked to friends and neighbours about it and the fact that their views were being taken seriously.
This group of around 10 people met with the architects, initially fortnightly, and then monthly as the design progressed. The meetings, which were facilitated by the project co-ordinator, were used to get feedback and agreement from the group on design options.
A health centre staff group also met with the architects as the design developed. The two groups were kept separate, with the architects mediating between the two, as it was felt the public would be reluctant to argue their case in the presence of doctors and nurses. The architects reported that this process worked well, but that it added about six months to the design period.
After agreement on the external design and internal layout, the patients felt confident to work with the staff in a joint user group, which will hopefully lay the foundations for active patient involvement in service delivery at the new health centre.
The centre now has planning permission, and the user group is working with the architects on the internal design. Patients were not paid for their involvement, but£5,000 was spent on photography, leaflets, display materials, mailings, meeting and access costs.
Gaining the support of partner agencies is crucial. In addition, local people need to see professionals value their views, with both sides accepting that compromise may be necessary.
It is vital to give people the opportunity to influence something 'real'. Consultation is not enough on its own; people expect to see results from freely given time and energy.
Finally, while public involvement takes time and money, there are considerable benefits in terms of individual empowerment and community ownership. For example, one member of the original patient interview group, who went on to be a key member of the patient design group, has already been recruited as the lay member of Bristol South primary care group.
Tony Jones is Local Voices project co-ordinator, Bristol and District community health council, and Kate Orchard is assistant development director, Avon health authority.
People power: public influence on the design
Ideas from the public
Open and friendly reception area.
Privacy at reception area.
Large, double-height reception space with children's play area and open reception counter.
Private interview room off reception area.
All patient areas on ground floor, plus automatic entrance doors.
Anti-vandalism measures incorporated into design of building.