Community values in healthcare
Herewith a summary of this article in the current MJA. It is evident that the community need to be informed . The aim of the Medical Renaissance Group is to encourage Community involvement as to the nature of the current Health Crisis and what we can do to alleviate it
Whose health service is it anyway? Community values in healthcare
Gavin H Mooney and Scott H Blackwell
MJA 2004; 180 (2): 76-78
There are various problems with seeking community preferences to guide healthcare: the time taken to achieve consensus, the difficulties in establishing informed choice, the tendency for pressure groups and interested parties to outweigh the silent majority, and so on. None, we believe, is insurmountable. There are issues of broad principle (such as equity) that do seem to be best handled by referring to community values. How best to elicit such values remains subject to debate and requires more research. Exactly which decisions, to what extent and in what way, should be influenced by community values will (we suspect) always be a contentious question and will not necessarily be answered in the same way in all health service jurisdictions. Citizens’ juries are one way forward. The best approach will vary depending on the questions being asked, the community concerned and the resources available. However, we would submit that the need for good information, choices constrained by resources, and time to reflect are requirements of any process for eliciting community v
Means of public participation
Some milestones in public participation
1954: WHO recommends involvement of the general public in health education policy making5
1977: UN report sees public participation as a central tenet of primary health care6
1984: World Federation of Public Health Associations calls for public participation in primary health care to build on local knowledge7
Early 1990s: Public
involvement in setting health service priorities in
1995: WHO reaffirms the importance of community participation in health promotion10
1990s: Citizens’ juries
Scarcity of resources is a fact of healthcare. This needs to be recognised by the potential respondents to any community survey, thereby avoiding "wish listing" in an environment where the opportunity costs of choices are not apparent. The sorts of choices they should face are those that health service planners face: whether to spend more or less on interventions in maternity care or the mentally ill; more or less on urban, rural or remote healthcare; on the young or the old; on Aboriginal or non-Aboriginal healthcare.
In the literature there is
little discussion on what approach to use in eliciting community preferences.
Is the intention to obtain community values by aggregating the preferences of
individuals concerned for themselves? Or by asking individuals to put
themselves in the position of planners acting on behalf of a community such as,
Dolan et al consider three perspectives:12
A fourth is the
"communitarian" perspective,13 where the community and not an
aggregation of individuals might be the focus. The
There are various techniques available for finding community values. In addition to citizens’ juries, these include deliberative democracy, focus groups, opinion polls, conjoint analysis and several others.14-17 There is too little evaluation of these to judge which is best. Such a judgement may not be possible: each technique may have its place.
We recommend that any process for eliciting community values should provide:
Expert views or medical specialist knowledge may be important inputs, providing information that is then filtered through a random group of citizens engaged in deliberation and reflection. Such a process allows the social context to be added to medical science.
Many decisions in healthcare are complex and technical. At the clinical level, society trains doctors to act as patients’ agents to allow the patient (or sometimes the doctor on behalf of the patient) to make decisions that are more informed than those of the patient alone. Above the level of individual clinical decisions, there are questions of resource allocation and policy that are very much social choices. They still have to be informed by technical information. In between, doctors are faced with many decisions where it is less clear which values should apply. Partly this is because it is difficult to decide where the dividing line should come between professional and social value judgments; partly because some decisions are so technical and complex that citizens cannot make truly informed choices. However, citizens may accept their limitations in some areas of decision making, while insisting on their right to decide in others. Citizens may choose the issues for which they want their preferences to be counted. They may thus have "preferences for preferences".
This last issue has
received less attention than it merits. In a study in
We would argue that the sorts of decisions for which health services should seek to discover community preferences are those:
These principles point to more community involvement at the broader level, such as in determining the principles that underlie healthcare services in general, or what has been called "a constitution" for health services.18
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