There are two decision-making processes that governments tend to use. The first is ‘Decide-Announce-Defend’ (DAD), which is the traditional process in many countries, and is the top-down, expert model with which we are accustomed. From big decisions like the use of nuclear power and the route of a new train line, to local decisions like high-street remodelling, a planning decision, hospital closure and a flood-defence scheme, the arm of government with power looks at options in private, may do some public one-way consultation, reach a decision, announce it publicly and hold its breath. Often, the stakeholders of various shapes react, and the management of the government body goes into defence mode. Sometimes the decision is forced through, sometimes dropped and sometimes the battle wages for years. Defending is a very costly and time-consuming process. But it is how decisions have been taken in an authoritarian world, and it appeals of course to those taking them with high control needs in the case of ministers, or oversized intellectual egos in the case of civil servants.

Engage-Deliberate-Decide (EDD) is how the Canadian government went about its health-service changes. The first step is to engage with the public on the problem without bias. Is there a problem? If so, what is its nature? Next, start the education process so people are as well informed as reasonable before making up their minds. Surprise surprise, people often change their minds once they are properly informed. The most vociferous critics can become local champions. Then, ask the people interested to produce options. And finally, ask them to decide on one. By this means, the level of agreement reached is usually higher and consensus is achieved. Implementation is much easier and quicker with a committed public, the decisions are often better because no distant centralised government body can possibly hold all the information relevant to a decision, and whilst engagement costs money, the end-to-end cost and time is less. It is a learning journey, and the more contentious the decision to be taken, the more engagement is worthwhile.

EDD takes a fundamental shift in attitude by public sector management. The public is not stupid. The public comes in many forms. Different interests and needs underpin the stated position. But, once properly engaged and informed, the public will identify responsible, workable solutions, which reflect the whole system they experience in a way the remote policymaker or manager has neither the time nor the knowledge to replicate.
EDD has a lot going for it. Engagement has a value in itself in a modern society: it extends democracy to specific decisions and is an antidote to preferential lobbying. Closed-door deals of convenience to the business and to the politicians or civil servants cannot be done. Perhaps most importantly, contrary to the dismissive opinions of experts in government, publics are very capable of both grasping the issues and of bringing much needed knowledge and expertise to the table themselves. Properly engaged, I would trust an EDD decision much more than a DAD decision. Let’s remember our starting point for the Treaty: government fails.
Democracy is not binary – a system is not either democratic or not. Some countries and states, like Switzerland and California, have much more people control with far superior involvement in decision-making. Do they have a better time and get better decisions? Some research concludes that there is a causal correlation between the extent of democracy and happiness.

Constituency surgeries are a very odd lens on the world, representing little. Opinion polls are very limited engagement and provide little understanding of real lives. Statistical averages analysed in think-tank offices¹are not engagement, and never produce workable solutions. Talking, listening, enquiring, experiencing the lives of others by being with them; service sampling through working on the front line of services; consumer analysis and strategy; the tools of facilitation – all these will shed light and insight and produce workable solutions.

Public engagement would be appropriate in some or perhaps many cases. Proper engagement would of itself meet the stakeholder, insider, and consumer tests. For big complex changes, like reform of the health service, substantial engagement along the Canadian health reform model would be needed. The coalition government would not be having the trouble it is if it had engaged on its NHS reforms.

Reporting in 2002, a one-person Royal Commission (the only kind that works) identified four perspectives for addressing the issue of Medicare’s sustainability, and outlined the pros and cons of each. The workbook was an important component of the consultation programme because it gave the Commission insight into the values that Canadians wanted to see expressed in Medicare’s policies and programmes. The perspectives were:

• More public investment
• More co-payments and cost sharing
• Increased private choice
• Reorganised service delivery

The Commission partnered with a not-for-profit policy think tank, to organise twelve regional one-day ‘deliberative dialogue’ sessions across the country. Each session brought together forty randomly selected Canadians. At the outset of the process, participants completed a questionnaire probing their perceptions of the challenges confronting Canada’s health-care system and their preferred solutions for addressing them. They were subsequently provided with a workbook outlining four scenarios for revitalising the system that included arguments for and against each scenario. At the end of the day, participants were asked to complete a second questionnaire to assess whether their initial perceptions had changed and, if so, why. The results of the twelve sessions were analysed and common themes and directions noted.
In order to benefit from the input and counsel of individual Canadians and health-care stakeholder and advocacy groups, the Commission organised twenty-one days of public hearings across the country. To facilitate access by those in remote communities, participants had the option of presenting their submissions by telephone. To ensure breadth of perspective and balanced participation, notices were placed in newspapers across the country inviting interested individuals and groups to come forward and to submit a one-page abstract of their proposed submission. At the end of each session, the Commission opened the floor to individuals who wished to comment on the proceedings or provide additional input. Participants had the option of addressing the Commission in either official language, and in Nunavut.

In order to raise awareness of the challenges confronting the health-care system, and to encourage informed discussion during the public consultations, the Commission initiated a number of public education activities, including a series of nationally televised Policy Forums. This six-part series featured health-policy experts representing different points of view engaging in a moderated discussion of key health-care issues. Each programme was followed by an open-line call-in that allowed interested Canadians to question the participants. Topics included:

• Values: What do Canadians want from their health-care system?
• Sustainability: Can we afford Medicare?
• Leadership: Who should call the shots in Canada’s health-care system?
• Access: What health-care rights should Canadians have?
• Principles: The Canada Health Act – lightning rod or beacon?
• Innovation: Can innovation save Canadian health care?

To broaden public awareness of key issues in the health-care system and to engage the expert and academic communities in its deliberations, the Commission partnered with universities across the country to organise a series of televised, on-campus policy dialogue sessions. Each session featured a panel of health-care experts who discussed possible solutions to key health-care challenges. The topics discussed and policy options considered were based on nine issue/survey papers developed for the Commission by the Canadian Health Services Research Foundation. The topics included:

1. Home care in Canada
2. Pharmacare in Canada
3. Access to health care in Canada
4. Sustainability of Canada’s health-care system
5. Consumer choice within a publicly funded system
6. The Canada Health Act
7. Globalisation and Canada’s health-care system
8. Medically necessary care: What is it, and who decides?
9. Human resources in Canada’s health-care system

The results of all these dialogues were then compared with a national public opinion survey in order to test whether the views expressed were consistent with those held more generally in the population.

The Commissioner, Roy Romanov, concluded: ‘I am pleased to report that my Commission’s multi-faceted consultations with Canadians demonstrated their commitment to the original ideals of Medicare as well as their willingness to change basic practices and approaches in order to make the system as a whole more sustainable for the twenty-first century. I have relied upon their experience and wisdom as well as the best research and evidence available in coming to my conclusions and recommendations.’

Canada’s health-care system continues to experience funding conflicts and may have to change more than it did. But this experience shows real public engagement of a scale needed to bring about successfully the very large change entailed in a different health-service model. In pursuing its health reforms, the coalition government has not learnt this lesson.

¹ As an important aside, think tanks need to expand their repertoire to cover much more than the limited set of issues they have expertise in, including for example technical ones like tunnelling for power lines, speed of road building, and construction pollution.