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Involving citizens in disinvestment decisions: what do health professionals think? Findings from a multi-method study in the English NHS

  • Tom Daniels (a1), Iestyn Williams (a1), Stirling Bryan (a2), Craig Mitton (a3) and Suzanne Robinson (a4)...


Public involvement in disinvestment decision making in health care is widely advocated, and in some cases legally mandated. However, attempts to involve the public in other areas of health policy have been accused of tokenism and manipulation. This paper presents research into the views of local health care leaders in the English National Health Service (NHS) with regards to the involvement of citizens and local communities in disinvestment decision making. The research includes a Q study and follow-up interviews with a sample of health care clinicians and managers in senior roles in the English NHS. It finds that whilst initial responses suggest high levels of support for public involvement, further probing of attitudes and experiences shows higher levels of ambivalence and risk aversion and a far more cautious overall stance. This study has implications for the future of disinvestment activities and public involvement in health care systems faced with increased resource constraint. Recommendations are made for future research and practice.


Corresponding author

*Correspondence to: Tom Daniels, Health Services Management Centre, University of Birmingham, Park House, 40 Edgbaston Park Road, Birmingham, B15 2RT, UK. Email:


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Amalberti, R., Nicklin, W. and Braithwaite, J. (2016), ‘Preparing national health systems to cope with the impending tsunami of ageing and its associated complexities: towards more sustainable health care’, International Journal for Quality in Health Care, 28(3): 412414.
Anderson, W. and Florin, D. (2000), ‘Consulting the public about the NHS’, British Medical Journal, 320(7249): 15531554.
Baker, R., Thompson, C. and Mannion, R. (2006), ‘Q methodology in health economics’, Journal of Health Services Research & Policy, 11(1): 3845.
Baker, R., Wildman, J., Mason, H. and Donaldson, C. (2014), ‘Q-ing for health – a new approach to eliciting the public’s views on health care resource allocation’, Health Economics, 23(3): 283297.
Bodkin, H. (2016), ‘Street protests could halt hospital closures’ NHS Boss.[14 December 2017].
Brown, S. R. (1980), Political Subjectivity: Applications of Q Methodology in Political Science, New Haven, CT: Yale University Press.
Brown, S. R. (1993), ‘A primer on Q methodology’, Operant Subjectivity, 16(3/4): 91138.
Bruni, R. A., Laupacis, A. and Martin, D. K., The University of Toronto Priority Setting in Health Care Research Group (2008), ‘Public engagement in setting priorities in health care’, Canadian Medical Association Journal, 179(1): 1518.
Bryant, L. D., Green, J. M. and Hewison, J. (2006), ‘Understandings of Down’s syndrome: a Q methodological investigation’, Social Science & Medicine, 63(5): 11881200.
Charles, C. and DeMaio, S. (1993), ‘Lay participation in health care decision making: A conceptual framework’, Journal of Health Politics, Policy and Law, 18(4): 881904.
Church, J., Saunders, D., Wanke, M., Pong, R., Spooner, C. and Dorgan, M. (2002), ‘Citizen participation in health decision-making: past experience and future prospects’, Journal of Public Health Policy, 23(1): 1232.
Cross, R. M. (2004), ‘Exploring attitudes: the case for Q methodology’, Health Education Research, 20(2): 206213.
Dalton, J., Chambers, D., Harden, M., Street, A., Parker, G. and Eastwood, A. (2015), ‘Service user engagement and health service reconfiguration: a rapid evidence synthesis’, Southampton, UK: Health Services and Delivery Research. NIHR Journals Library. [23 November 2016].
Daniels, T. (2016), To what extent should the public be involved in health disinvestment decision making: a mixed methods investigation into the views of health professionals in the English NHS. [23 November 2016].
Daniels, T., Williams, I., Robinson, S. and Spence, K. (2013), ‘Tackling disinvestment in health care services: the views of resource allocators in the English NHS’, Journal of Health Organization and Management, 27(6): 762780.
Day, R. T., Norman, R. and Robinson, S. (2016), ‘Challenges and opportunities for disinvestment in Australia: a need to evaluate the implementation and impact of choosing Wisely in Australia’, Journal of Health Organization and Management, 30(8): 13011307.
Department of Health (2012), Health and social care act, Norwich: TSO.
Dunn, P., McKenna, H. and Murray, R. (2016), Deficits in the NHS 2016, London: The King’s Fund.
Florin, D. and Dixon, J. (2004), ‘Public involvement in health care’, British Medical Journal, 328(7432): 159161.
Gallagher, K. and Porock, D. (2010), ‘The use of interviews in Q methodology’, Nursing Research, 59(4): 295300.
Gilson, L. (2003), ‘Trust and the development of health care as a social institution’, Social Science & Medicine (1982), 56(7): 14531468.
Goddard, M., Hauck, K. and Smith, P. C. (2005), ‘Priority setting in health – a political economy perspective’, Health Economics, Policy and Law, 1(1): 79.
Greer, S. L., Stewart, E. A., Wilson, I. and Donnelly, P. D. (2014), ‘Victory for volunteerism? Scottish health board elections and participation in the welfare state’, Social Science & Medicine, 106: 221228.
Guttman, L. (1954), ‘Some necessary conditions for common-factor analysis’, Psychometrika, 19(2): 149161.
Hands, D. W. (2012), ‘The Positive-Normative Dichotomy and Economics’, in U. Mäki (ed.), Philosophy of Economics. Handbook of the Philosophy of Science, Amsterdam: Elsevier, 219241.
Harrison, S. and Mort, M. (1998), ‘Which champions, which people? Public and user involvement in health care as a technology of legitimation’, Social Policy and Administration, 32(1): 6070.
Health Foundation (2016), Changing Together: Brokering Constructive Conversations, London: The Health Foundation.
Hunter, D. J., Kieslich, K., Littlejohns, P., Staniszewska, S., Tumilty, E., Weale, A. and Williams, I. (2016), ‘Public involvement in health priority setting: future challenges for policy, research and society’, Journal of Health Organization and Management, 30(5): 796808.
Ipsos-Mori (2017), ‘Engaging the public in STPs: lessons from the past’. [16 August 2017].
Jeffares, S., Dickinson, H. and Hughes, G. (2012), ‘iPOETQ (version 1.1)’. [10 November 2016].
Kaiser, H. F. (1960), ‘The application of electronic computers to factor analysis’, Educational and Psychological Measurement, 20(1): 141151.
Kline, P. (1994), An Easy Guide to Factor Analysis, London; New York: Routledge.
Knox, C. and McAlister, D. (1995), ‘Policy evaluation: incorporating users views’, Public Administration, 73(3): 413436.
Lenaghan, J. (1999), ‘Involving the public in rationing decisions. The experience of citizens juries’, Health Policy, 49(1–2): 4561.
Litva, A., Coast, J., Donovan, J., Eyles, J., Shepherd, M., Tacchi, J., Abelson, J. and Morgan, K. (2002), ‘The public is too subjective: public involvement at different levels of health-care decision making’, Social Science & Medicine, 54(12): 18251837.
Marinker, M. (2006), Constructive Conversations About Health: Policy and Values, Oxford: Radcliffe Publishing.
Martin, G. P. (2008), ‘Representativeness, legitimacy and power in public involvement in health-service management’, Social Science & Medicine, 67(11): 17571765.
Mayer, J. and Nachtnebel, A. (2015), ‘Disinvesting from INeffective Technologies: Lessons Learned from Current Programs’, International Journal of Technology Assessment in Health Care, 31(06): 355362.
McKeown, B. and Thomas, D. (1988), Q Methodology, Newbury Park: Sage Publications.
Mitton, C., Dionne, F., Damji, R., Campbell, D. and Bryan, S. (2011), ‘Difficult decisions in times of constraint: criteria based resource allocation in the Vancouver Coastal Health Authority’, BMC Health Services Research, 11(1): 169.
NHS England (2015), Planning, Assuring and Delivering Service Change for Patients, Leeds: NHS England.
Niven, D. J., Mrklas, K. J., Holodinsky, J. K., Straus, S. E., Hemmelgarn, B. R., Jeffs, L. P. and Stelfox, H. T. (2015), ‘Towards understanding the de-adoption of low-value clinical practices: a scoping review’, BMC Medicine, 13(1): 255. [23 November 2016].
Prasad, V., Cifu, A. and Ioannidis, J. (2012), ‘Reversals of established medical practices: evidence to abandon ship’, JAMA: The Journal of the American Medical Association, 307(1): 3738.
Previte, J., Pini, B. and Haslam-McKenzie, F. (2007), ‘Q methodology and rural research’, Sociologia Ruralis, 47(2): 135147.
Robert, R., Harlock, J. and Williams, I. (2014), ‘Disentangling rhetoric and reality: an international Delphi study of factors and processes that facilitate the successful implementation of decisions to decommission healthcare services’, Implementation Science, 9(1): 123. [23 November 2016].
Robinson, S., Glasby, J. and Allen, K. (2013), ‘‘It ain’t what you do it’s the way that you do it’: lessons for health care from decommissioning of older people’s services’, Health & Social Care in the Community, 21(6): 614622.
Robson, C. (2011), Real World Research: A Resource for Users of Social Research Methods in Applied Settings, Chichester, West Sussex: Wiley.
Seymour, W. S. (2001), ‘In the flesh or online? Exploring qualitative research methodologies’, Qualitative Research, 1: 147168.
Steelman, T. A. and Maguire, L. A. (1999), ‘Understanding participant perspectives: Q-methodology in national forest management’, Journal of Policy Analysis and Management, 18(3): 361388.
Stenner, P., Cooper, D. and Skevington, S. M. (2003), ‘Putting the Q into quality of life; the identification of subjective constructions of health-related quality of life using Q methodology’, Social Science & Medicine, 57(11): 21612172.
Stenner, P., Dancey, C. and Watts, S. (2000), ‘The understanding of their illness amongst people with irritable bowel syndrome: a Q methodological study’, Social Science & Medicine, 51(3): 439452.
Stewart, E. and Aitken, M. (2015), ‘Beyond NIMBYs and NOOMBYs: what can wind farm controversies teach us about public involvement in hospital closures?’, BMC Health Services Research, 15(1): 530. [14 March 2017].
Taylor, J. (2017), ‘Why are local campaigns fighting to save the NHS from transformation?’. [16 August 2017].
VanExel, J. and DeGraaf, G. (2005), ‘Q methodology: a sneak preview’. [8 November 2012].
VanExel, J., Baker, R., Mason, H., Donaldson, C. and Brouwer, W. (2015), ‘Public views on principles for health care priority setting: findings of a European cross-country study using Q methodology’, Social Science & Medicine, 126: 128137.
Wait, S. and Nolte, E. (2006), ‘Public involvement policies in health: exploring their conceptual basis’, Health Economics, Policy and Law, 1(2): 149.
Watts, S. and Stenner, P. (2005), ‘Doing Q methodology: theory, method and interpretation’, Qualitative Research in Psychology, 2(1): 6791.
Watts, S. and Stenner, P. (2012), Doing Q Methodological Research: Theory, Method and Interpretation, Los Angeles: Sage.
Webler, T., Danielson, S. and Tuler, S. (2009), Using Q Method to Reveal Social Perspectives in Environmental Research, Greenfield, MA: Social and Environmental Research Institute.
Webler, T., Tuler, S. and Krueger, R. (2001), ‘What is a good public participation process? Five perspectives from the public’, Environmental Management, 27(3): 435450.
Williams, I., Robinson, S. and Dickinson, H. (2012), Rationing in Health Care: The Theory and Practice of Priority Setting, Bristol: Policy.
Woods, C. E. (2011), ‘Using Q methodology to explore leadership: the role of the school business manager’, International Journal of Leadership in Education, 14(3): 317335.


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