Reflections on #NHSCitizen event, by @sburall

The Citizens’ Assembly workshop last week which explored the potential for a new system of accountability and democracy for NHS England was a real privilege to be involved in. The two days were very intense, but they taught me an awful lot. Here are some very quick fire reflections in bullet form, following the lead of Catherine Howe at Public-i. As she notes in her post, this is a good way of capturing personal reflections before they get lost, but they aren’t the grand statement from the full team of people working together on the project.

What could a Citizens’ Assembly for NHS England be?

  • The NHS means many different things to many different people; there will therefore be as many different reasons for (and against) a Citizens’ Assembly. But if it tries to do everything it will fail.
  • It must identify something in the NHS system that is not already happening, but enough people think is needed – and whatever it does must make a difference to outcomes for patients and have real bite (really hold people in power to account). It must be new and useful.
  • I think the Assembly will succeed if it can help individuals move from operating in silos of knowledge, expertise and experience to working together as ‘we’.
  • Creating a system that can open up big debates, identify new questions and answers is different to creating something that can reach consensus. It’ll be important to unpick this more as the conversation develops.
  • Lots of people gave up lots of their time for free. This must be respected, celebrated and taken as a sign that something big will be possible if everyone is genuinely part of designing the Assembly.
  • An exchange on twitter with @barod_cic and @huxley06 as I was writing that last point highlights the issue and challenge this poses. One idea/solution, which is as thought through as anything on twitter is, would be to establish an #NHSCitizen timebank for all who participate. A way to build relationships, share learning and develop greater empathy? However, something like a Citizens’ Assembly for an organisation as complex as NHS England can’t be designed or run on the cheap.
  • A Citizens’ Assembly for NHS England is an audacious idea; it is bigger than any individual or organisation involved in its development. We need to weave a web together that supports us all as we explore ways to design something that will make a difference.

There are lots of challenges

  • Digital exclusion is a real issue that surfaced lots during the two days, and so are other sorts of exclusion. However, this is also true now and we mustn’t try to completely solve the problem at the expense of taking small steps in sensible directions.
  • There are other practical problems, for example most people won’t be able to give up two days to contribute to a Citizens’ Assembly. These will always be problems. This is not to discount them, but they cannot be reasons not to try something different, because it isn’t working now either.
  • There was a concern about people having different meanings for words like co-production, co-design etc etc etc and that this is getting in the way of understanding each other. Is ‘shared’ a better word?
  • Challenges are important and must be surfaced, but keeping everyone focused on helping develop the solutions is important too; it’s very easy to sit on the sidelines picking holes in it all. I’m going to take the ‘no passengers’ rule with me and deploy it more often.
  • Language is an issue. I’m a democracy, governance and accountability geek, the way I speak and write is impenetrable for some people. I cut myself out of conversations because of this – and create bubbles others find it hard to get into.


The process of designing any Citizens’ Assembly is as important as the Assembly itself

  • It is now possible to run a smallish workshop in a physical space and yet reach a much larger number of people, even bringing some of them into the room. And it is incredibly productive and energising to do so.
  • There is no right answer for NHS England to find as it thinks about designing a Citizens’ Assembly. Just lots of tensions and contradictions in any solution. Keeping the design process in the open as well as being open about the tensions and challenges (and what choices are made in the end) will be critical to its success. Anything that happens behind closed doors will kill the idea.
  • People will come to any Assembly with certain areas of expertise, prejudices and self (or organisational) interests. These are natural, but must be openly declared and acknowledged as valid in order to allow people to move beyond into a shared space.
  • Working as ‘we’ will mean developing a shared understanding of the important issues and a shared design of solutions.
  • Language is a real issue. If any Assembly is to have any bite, the language used to define it and its relationship with the Board will have to be precise, and yet this will make it difficult for people who use language differently or operate in a different frame to understand and engage with. Multiple descriptions of what it is, and what is happening within it, are going to be needed.
  • It was an intense two day workshop, probably the most intense I’ve ever facilitated. The teamwork was incredible, both those formally on the team who worked so well together and brought different strengths into the room, but also everyone present both on and offline, who identified a shared space for discussion and supported everyone through it.
  • Starting small, in the open with lots of experiments that are given permission to fail if they also bring learning back into the system must be the way forwards.
  • We need to find time for reflection more often in our own lives, within workshops, and within organisations to allow space for course corrections to be made. This is as true for any Citizens’ Assembly as it is in any other area of life, can we find a way to slow down a little to let this happen?

I’d like to echo Catherine’s thanks to everyone who took part so generously, with open minds and hearts. I believe there is an idea at the centre of the debate about whether NHS England should have an Assembly and so what it should look like, but it will need more of the same if we are to get anywhere close to it.