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6th National Rural Health
Conference
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Jan Hall
Rural Service Development Program, Health Department of Western Australia
There is much rhetoric about community consultation, community participation and empowerment of communities. But is this myth or reality? Do decision makers actually listen to the wish of the community or are their decisions simply a response to the perceptions of health providers and historical data, both of which often demonstrate a narrow viewpoint and vested interests.
The value of community participation in strategic decision making is well documented. And given that all of the community contribute to the health care system through a collective arrangement of taxation, and eventually use the health care system extensively, it is essential that appropriate consultative practices be undertaken. For without consultation, strategic decisions can, and do result in resource wastage, and in a current climate of growing demand, this means that some areas receive lower levels of access, equity, and overall poorer health outcomes.
Too often, during the process of health priority determination, community consultation becomes a thinly designed health needs analysis with little consideration for the fundamental principles of communication. For consultation is about communication - a basic process of sharing information to reach common understanding.
Applying the philosophy of community consultation requires a communication strategy that considers the best opportunity to determine the perceptions of a community according to their values, belief systems, and social/community ethos. By applying the philosophy, decision makers will be better positioned to impose appropriate values and judgements that will maximise the quality of strategic priority setting and result in better health outcomes.
The successful implementation of a health service initiative largely relies on the early formative work undertaken by a key group such as a steering group, stakeholders and the community. A clear understanding of beliefs, attitudes, ideas and expectations between these groups, in an open and flexible communicative process, will provide a solid foundation from which the health service will develop.
People’s values and judgements are shaped by a number of factors that relate to the influence of education, occupation, life’s experiences, cultural beliefs and so on. It is from this very broad backdrop that influences profound differences in the way in which people make choices. Choices about health priorities therefore can be determined by any number of influences, and the task for decision makers is to facilitate “informed” choices without challenging the integrity of the community’s belief systems.
Early consideration for a community consultative process will prevent many difficulties and misunderstandings. Community consultative processes should encompass methodologies that will;
- include the wider community in the planning of their local health services;
- identify the health needs of the community, and optimal service delivery design that will meet these needs;
- include all stakeholders and vested interests in the health service planning process;
- communicate the opportunities for change, and allay fears and misconceptions that change can bring;
- cultivate a sense of community ownership of the proposed new or changed health service opportunities; and
- provide opportunities for the development of partnerships between community service groups that could impact on the health of the community.
Community input to the development of health services will promote innovative program design and a change in the mix of health and aged care services. This is well demonstrated in the Multi-Purpose Service initiative in Western Australia. Such community participation in developing multi-purpose services has been tantamount to the success of the program. The challenge though is to manage change issues whilst promoting new concepts. The success factor however, lays with full and open consultation, involving all of the community and key stakeholders, and acknowledging in all participants their rights as consumers.
Involving the community in the strategic decision making process is often viewed as a daunting task, and despite the rhetoric this process often does become more of a myth than the reality. So where does one start? Following are some practical steps for consideration.
- Compile a list of the key stakeholders within the community. These could include the GP, dentist, the existing health service providers and residential facilities, visiting health service providers, local government representatives and community “champions”. It is essential that this group has input to determining the health issues of the community, and endorses any proposed changes to the local health service, for without this fundamental support, change will be problematic.
- Compile a list of other stakeholders within the community. These could include the local pharmacist, police, schools, St John Ambulance, Aboriginal groups, Senior Citizen groups, community service groups such as CWA, Red Cross, religious groups, voluntary organisations, disability support services etc.
- Initiate development of a local steering committee, who are representative of the community stakeholders, to co-ordinate the community consultative process.
- Plan consultation processes with the above groups plus the general community, using the following suggested actions:
- workshop forums with key stakeholders;
- public forums with speakers from innovative health services, eminent people from a broad range of health settings, change strategists, and perhaps people from various and relevant State and Commonwealth offices;
- health services staff forums with regular updates and printed information;
- publications in local newspapers and on community information boards;
- post “flyers” and questionnaires to community members;
- invite guest speakers options to community meetings;
- street stalls to disseminate questionnaires and information; and
- establishment of an information “hot line”.
Remember, consultation is initiated through a variety of communication strategies, and therefore discussions with all community stakeholders could include the following.
- An overview of the health services to the area, and statistical data supporting morbidity and mortality patterns.
- Discussion of health service issues in the community, identifying any problems or deficiencies.
- Identification of opportunities for improved co-operation between services.
- Examination of opportunities for the community to identify health priorities.
- Determine support and identify concerns for re-development options.
Suggested activities
Public meetings
Public meetings are often viewed as a forum for those who wish to voice a concern, and there is often the very real perception that people will not attend a public forum if they have no pressing issue. However public forums are just one method in the community consultative process and should not be underestimated.Public meetings should be well publicised and held at the commencement of the consultation process, and promoted as an opportunity for local residents to express their feelings. Public meetings should provide an appropriate forum for discussion about the health profile of the community, how existing services are responding to this profile and what the perceived service gaps are. Stakeholders should be encouraged to explain the benefits of change in their local health service, and to hear the concerns and ideas of the community.
Careful planning is essential to prevent any public meeting being hijacked by special interest groups. Representatives of the State and Commonwealth health offices, key stakeholders and local “champions” should be available to provide clear information and a transparent process. The media should be invited to ensure that meeting outcomes are widely reported.
Approaches to a public meeting can include:
- a panel of key personnel (people from innovative health services, eminent people from a broad range of health settings, change strategists, various and relevant State and Commonwealth officers) to respond to questions and concerns raised by the community;
- a facilitator - preferably a local “champion”, who is able to ensure the discussion is focused and allows each party to put forward their point of view; and
- parameters should be announced at the beginning of the meeting, defining start and finish time, agenda format, objectives of the meeting, and time limit on questions.
Staff forums
It is essential that all health services staff are included in consultative processes from the beginning. It is important that staff participate to ensure eventual commitment and enthusiasm for health service development, and management are responsible for allowing staff a clear opportunity to voice their concerns.Staff forums should include:
- an overview of the health service issues experienced by rural and remote areas, recognition of opportunity for change, and the history of health service development;
- discussion of health service issues in the community, identifying problems or deficiencies;
- staff input to the identification of opportunities for improved co-operation between services, and new service initiatives; and
- discussion about how service integration or change will affect employees.
Information updates should be posted on staff information boards, and a modified anonymous questionnaire circulated to allow staff opportunity to raise further questions or concerns.
Publications
The media is a valuable resource in the consultation process, and should be kept informed and supplied up-dated information throughout the process.Media releases can be written by the Public Affairs section of the Health Department and can be sent to local media including radio, television, and newspapers.
It is also advised to post the relevant information on the Internet and on public notice boards.
Questionnaires and surveys should be used to obtain community opinion. These should be concise, simple to read, confidential, contain qualitative and quantitative questions, and consider the following.
- Current and recent health service use (both local and external) and opinions on the quality of the service obtained.
- Perceptions of what factors affect the health of individuals and the community as a whole.
- Questions about what sort of health services would best meet their needs.
- Questions about what types of health services could the local health agencies provide or improve to benefit the health of the community.
- An invitation to determine a preferred allocation of health funding within the community.
Questionnaires should be tested on a small sample of people first, before either sending them to a random section of the community, or to every household.
The application of the philosophy of community consultation is simply a practical process that encourages and includes all of the community. Spiegel and Hyman (1978) identified the application of three criteria in determining health priority setting: community participation; linking quantifiable data with community values; and fairness. Without community participation, determining priorities will be problematic and possibly inaccurate. Without linking quantifiable data with community values, strategic decision making will fail to have the desired impact on improving the health of the community. And without fairness in ensuring that the right people are empowered to make decisions for the community, any proposed changes will undoubtedly fail.
When decision makers have faith in the will of the community, community consultation will move from mythology to reality.
Rural Health Services Unit (1999). Community Consultation Manual 1.0. First edition. Department of Human Services. Melbourne.
Spiegel, A.D., & Hyman, H.H. (1978). Basic health planning methods. Maryland. USA: Aspen Publishers.
Jan Hall is a program manager for the Rural Service Development Program in Western Australia, a program that supports the development and implementation of multi-purpose services. Jan has a Masters degree in Health Service Management, is a registered nurse, and has, during the past thirty years, worked across a variety of settings including health service management, community nursing, Aboriginal health, acute care and palliative care.
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