Changing health care with, for, or against the public: an empirical investigation into the place of the public in health service reconfiguration

OBJECTIVES: This study sought to understand the different approaches taken to involving the public in service reconfiguration in the four United Kingdom health systems. METHODS: This was a multi-method study involving policy document analysis and qualitative semi-structured interviews in England, Northern Ireland, Scotland and Wales. RESULTS: Despite the diversity of local situations, interview participants tended to use three frames within which they understood the politics of service reconfigurations: an adversarial approach which assumed conflict over scarce resources (change against the public); a communications approach which defined the problem as educating the public on the desirability of change (change for the public); and a collaborative approach which attempted to integrate the public early into discussions about the shape and nature of desirable services (change with the public). These three framings involved different levels of managerial time, energy, and resources and called on different skill sets, most notably marketing and communications for the communications approach and community engagement for the collaborative approach. CONCLUSIONS: We argue that these framings of public involvement co-exist within organisations. Health system leaders, in framing service reconfiguration as adversarial, communicative or collaborative, are deciding between conceptions of the relationship between health care organisations and their publics in ways that shape the nature of the debates that follow. Understanding the reasons why organisations adopt these frames would be a fruitful way to advance both theory and practice.