Democracy, Deliberation and Public Service Reform: The Case of NICE

Abstract

“Statistical models are like bikinis: what they reveal is suggestive, but what they conceal is vital.” Aaron Levenstein.

What is the role of lay deliberation – if any – in health-care rationing, and administration more generally? Two potential answers are suggested by recent debates on the subject. One, which I will call the technocratic answer, suggests that there is no distinctive role for lay participation once ordinary democratic politics has set the goals and priorities which reform should implement. This view suggests that determining how best to achieve those ends, and then actually achieving them, is a matter for experts armed with the best evidence available to them, both of the subject area involved, and of management and administrative excellence. By contrast, the second – deliberative – view holds that lay deliberation has an important role in the administration and execution of government policy. This is because these latter inevitably have a political element which needs to reflect democratic norms and values, and because lay people are, themselves, a source of information, even of wisdom, that experts will want to use in fulfilling their professional responsibilities. Recent debates on the value of lay participation in healthcare provision can illuminate the strengths and weaknesses of both approaches, as can the experience of the National Institute for Health and Clinical Excellence (NICE). So, I will start by examining two articles by Albert Weale, which attempt to clarify the role that lay deliberation should have in healthcare, before turning to the dilemmas for both the technocratic and deliberative views which emerge from the experience of NICE.

Keywords: democracy, public service reform, lay deliberation, accountability, NICE, Citizen's Council, rationing of health care, patients groups, descriptive democracy, representation