Community participation and health care priorities: Reflections on policy, theatre and reality in Britain

In recent years, the British government has attempted to make the finite nature of publicly funded health care explicit and to involve the 'public' in discussions about which treatments (or indeed patients) should be given priority over others. This article considers the nature of the new political emphasis upon local participation through an analysis of policy and illustrative reference to a system of participatory forums in the field of mental health planning developed in an area of southern England. The tendency by the health authority in question not to respond to many of the issues raised by the forums illustrates two characteristics of the health service in Britain. Firstly, there continues to exist a political, managerial and clinical hegemony within the service such that health authorities tend not to have to account for the weight they attach to local views or the manner in which such preferences are measured against other imperatives and considerations. In a second respect, the simplistic notion of the 'purchase' of health care by health authorities on behalf of local populations is problematic. Health authorities are faced with a panoply of political, statutory and bureaucratic requirements that preclude activity in accordance with 'market forces'. This in turn renders the idea of local 'advice' to purchasers considerably more complex than the associated political rhetoric intimates.