10 ‘It’s about putting on display a show, but actually all the decisions are being made backstage’: public involvement in decisions to change health services at a large-scale

As proposals for large-scale change (LSC) to health services are associated by the public with making cuts and downgrading services, public involvement – a dominant motif in national healthcare policy – is thought as a way to legitimise plans and resolve tensions. Yet, little is known about how involvement is interpreted and operationalised or how it may impact LSC plans and resolve controversy. This grounded theory study explored the social and political dynamics underpinning public involvement in two English communities facing service closures under a regional LSC programme. Document analysis, 27 interviews (with the public, campaigners, politicians, clinicians, Healthwatch, involvement practitioners and decision-makers) and over 100 observations hours were conducted to build a comprehensive model for involvement in LSC. The resultant theory is set against the backdrop of a changing health system. Invited involvement, stemming from technocratic processes institutionalised within health services, was experienced by the public as inadequate, manipulative and having no influence on decision-making. By instrumentalising involvement to manage opposition and constrain public deliberation, health planners created an environment of distrust, omnipresent during fieldwork. Rather than address issues of trust, health planners became ‘entrenched’, further fuelling opposition and self-mobilisation of the public. Hence, the public actively questioned the evidence for change, opposed LSC plans and sought alternative uninvited routes to voice their views and challenge change. While the technocratic model aimed to depoliticise LSC, uninvited actions – initiated by members of the public turned campaigners – were a means to re-politicise it. Campaigners added another layer of scrutiny on decision-makers and contributed to the delay of service closures. Distrust in involvement is long-lasting and shapes future relationships with the public, even after controversial plans are dropped. This grounded theory study provides a more nuanced understanding of public involvement in controversial LSC and seeks to contribute to current debates.