While many studies point to the importance of ‘public involvement’ in health care, most reviews examine initiatives at the micro and meso levels, with little material on the macro/strategic level. Reviews have focused on material on mechanisms such as panels, forums, juries, meetings, surveys, user groups and lay members (see Crawford et al., Reference Crawford, Rutler, Manley, Weaver, Bhui, Fulop and Tyrer2002; Conklin et al., Reference Conklin, Slote Morris and Nolte2010; Mockford et al., Reference Mockford2012). However, we know very little about direct elections, a key tool of representative models of democracy, into a field conventionally dominated by participatory or deliberative democratic modes of engagement (Greer et al., Reference Greer, Stewart, Wilson and Donnelly2014a). The study of public involvement has an air of ‘Hamlet without the Prince’ as the best known and longest lasting case of elected health boards (EHB) tend not to be discussed within the literature (e.g. Crawford et al., Reference Crawford, Rutler, Manley, Weaver, Bhui, Fulop and Tyrer2002; Wait and Nolte Reference Wait and Nolte2006; Conklin et al., Reference Conklin, Slote Morris and Nolte2010; Mockford et al., Reference Mockford2012).

Laugesen and Gauld fill this important gap in a welcome study of New Zealand’s EHB. They provide an excellent historical account of this important, but rather neglected, topic. However, they focus more on the narrower subtitle than on the broader title. Back cover writers sometimes provide hostages to fortune for authors and targets for reviewers. In this case, it provided a large bullseye: ‘the first systematic analysis of New Zealand’s elected health boards, which are unique worldwide’ and ‘contains valuable lessons for other countries interested in public participation in health care’. While it produced a clear narrative history, systematic analysis was lacking as there was no template for evaluation, and lesson learning was difficult as the book was thin on theory and context. This review will focus on the broader title.

The first problem is to define the main term of the title. There appears to be no clear definition of ‘democratic governance’ (cf. citizen governance – see Simmons et al., Reference Simmons, Birchall, Doheny and Powell2007), although this also appears to be the case for a text with the term as the title (Bevir, Reference Bevir2010). ‘Governance’ has been termed a ‘weasel word’, and can mean anything and nothing, with writing on governance ranging from the blindingly obvious to the incomprehensible. Rhodes (Reference Rhodes2007: 1246) explicitly uses the ‘Humpty Dumpty’ definition: it means ‘what I choose it to mean – neither more nor less’. This also appears to apply to ‘democratic governance’ and cognate terms such as public and patient involvement (PPI), participation or engagement (Wait and Nolte, Reference Wait and Nolte2006; Conklin et al., Reference Conklin, Slote Morris and Nolte2010). There is a brief discussion of models of governance – corporate, market, democratic and clinical (21) – but relatively little on associated debates such as autonomy, accountability, structural interests and the power of directors/executives and Chief Executive Officers vis-à-vis the elected board. This review focuses on the broader elements of the voice of citizens (Powell, Reference Powell2014), or the ‘first P’ in PPI: public participation.

The authors state that “governments and health systems around the world are increasingly promoting public participation in health care decision making for a variety of reasons”. It adds that participation can build support for increasingly complex decisions about resource allocation, service locations and service configuration; embed decision-making structures in local communities and promote community partnership and engagement; enable decision makers to learn more from the public and specific communities about their preferences and needs; and bring an element of transparency and public accountability to health care planning and decision-making’ (9–10).

Put another way, EHB are one of many ‘voice’-based mechanisms to achieve public participation, such as elected (single function) boards (e.g. Scotland); appointed single function boards (e.g. England); elected multi-function authorities [e.g. Sweden; Britain before the National Health Service (NHS)]; elected representatives on boards [e.g. Foundation Trusts (FTs) in England, Simmons et al., Reference Simmons, Birchall, Doheny and Powell2007], or elected commissioners (e.g. Police and Crime Commissioners in England. However, it is far from clear which mechanism works best to achieve which end; and how well mechanisms for public involvement also work for patient involvement. Moreover, issues such as election vs selection need to be placed within a broader context of local vs national services (Powell, Reference Powell1997); and centralized or decentralized services (Peckham et al., Reference Peckham, Exworthy, Powell and Greener2005). We first focus on EHB, and then move to broader issues.

First, it is clear that EHB tend to be rare. Laugesen and Gauld (10, 35) state that a few Canadian provinces briefly experimented with elected boards, and there is a recent pilot in Scotland (see Greer et al., Reference Greer, Stewart, Wilson and Donnelly2014a), but New Zealand’s experience is unique. The second issue concerns evaluation. It is claimed that “elected boards and the realities of public participation fall short of expectations in several ways” (10). Similarly, it is argued that the “competitive market model of the early 1990s failed … there is no evidence that appointed boards and generic managers performed any better than elected boards” (13). However, the evaluative criteria and the evaluation design are not clearly stated. Third, and linked, it is claimed that “in every reform episode from the 1920s through to the present District Health Boards (DHBs) system, governments tried but failed to overturn elected boards”. There is some discussion of why governments failed to overturn boards, but little material on why they tried. More details on the reasons behind these abortive attempts would have been useful.

This study can be welcomed for another reason in that it shines a light on New Zealand’s unfairly overlooked health care system. The Social Security Act of 1938 introduced free treatment in psychiatric and general hospitals in 1939 (54) when the better known British NHS may just have been a gleam in the eye of its creator, Aneurin Bevan. However, there are interesting parallels with the British experience. Although the terms were not used, ‘democratic governance’ and ‘PPI’ were at the heart of debates on the formation of the British NHS. Before the NHS, municipal hospitals were run by democratically elected local authorities, and municipal beds and staff were positively correlated with need (Powell, Reference Powell1995, Reference Powell1997). The British Labour Party and the Ministry of Health were committed to municipal administration of the NHS. However, Aneurin Bevan, the Minister of Health who founded the NHS, turned Labour party policy on its head, choosing nationalisation rather than municipalisation of the hospitals to form a national rather than a local service (Powell, Reference Powell1998). This led to a major debate in Cabinet with Herbert Morrison, who stressed different values and criteria (crudely, democracy and responsiveness over equity) and favoured the municipal option (see Powell, Reference Powell1997; Klein, Reference Klein2010).

Many, particularly those on the Labour left, have expressed concerns about the ‘democratic deficit’ in the NHS, and – in a mirror image to New Zealand – the Morrisonian local authority option has repeatedly been raised – and dashed. In the 1974 NHS Reorganisation, Community Health Councils (CHCs) were introduced as a community watchdog. However, the centre ensured that these dogs were firmly muzzled and could not bite as they lacked teeth. I was briefly a member of a CHC, and ‘public participation’ at most open meetings consisted of the proverbial two people and a dog – with the dog seemingly more interested in the proceedings. The Reorganisation also introduced some degree of local authority representation on the appointed NHS boards, but this was a very indirect ‘second hand’ type of democracy as councillors were not elected with this purpose in mind.

It was often unclear whether NHS boards were intended to be management or ‘representative’ bodies, but in the 1991 Conservative reforms, they were clearly regarded as management bodies, and part of ‘new magistracy’, the ‘patronage state’ or ‘quangocracy’ (QUANGO refers to quasi-autonomous non governmental organisations). Guardian columnist Ian Aitkin pointed to “the unseemly scramble to pack hospital trusts, health authorities and hundreds of other quangos with the wives, aunties, cousins, party chairmen and (more than likely) the mistresses of Tory ministers and MPs” (Powell, Reference Powell1997: 79). With some resonances of the Bevan-Morrison debate, Former Conservative Secretary of State for Health, William Waldegrave, took the Bevan position on delivery vs democracy: “there is no guarantee … that by periodically expressing his or her democratic decision at the ballot box the citizen … will necessarily obtain on a continuous basis efficient, properly accountable, responsive public services…” (Powell, Reference Powell1997: 79–80). In short, the old Health Authorities could deliver poor service so long as they were representative; the new ones could be filled with card-carrying members of the Conservative Party so long as they deliver good service (Powell, Reference Powell1997: 80). However, they must listen to ‘local voices’ in order to become ‘champions of the people’ in an initiative described as ‘the unaccountable in pursuit of the uninformed’ (Powell, Reference Powell1997: 80).

The New Labour government of 1997 attempted to address PPI in the NHS (Baggott, Reference Baggott2005). The Health and Social Care Act of 2001 made it a legal requirement for NHS organisations to involve patients and the public (Florin and Dixon, Reference Florin and Dixon2004). NHS FTs were established in 2003 as a new type of NHS hospital, with the public, patients and employees eligible to become ‘members’, and the membership electing a top-tier board of governors. After abolishing CHCs in 2003, New Labour put in place a rapid succession of complex arrangements with the appearance and disappearance of bodies before the system finally comprised Local Involvement Networks (LINks), local authority overview and scrutiny committees, and governors and members of FTs. However, these bodies were based on very different models (local ‘voluntary’ citizens; elected councillors; and citizens as elected members, respectively) and there is little evidence on the impact of these initiatives. Under the NHS Constitution, citizens have the right to be involved, directly or through representatives, in the planning of health care services commissioned by NHS bodies. The Conservative/Liberal–Democrat Coalition government aimed to synthesise the two parties’ opposing philosophies (markets vs democracy), but commentators describe the result as “a spatchcocked mess”; “a cut and shut” job (the process where the good back half of a crashed car is welded to the good front half of another wreck to produce a vehicle that may look roadworthy but is in fact potentially lethal); a “fudge” of “half horse/half donkey” (Timmins, Reference Wait and Nolte2012). The government’s reorganisation saw ‘HealthWatch’ replacing LINKs, and an increased role for elected local authorities in the scrutiny of health services (Timmins, Reference Timmins2012).

A number of wider themes arise from these debates. First, there is the issue of elected vs appointed bodies. According to Aneurin Bevan, “election is a better principle than selection” (Powell, Reference Powell1997: 87). However, as we have seen, while governments in New Zealand have tried to abolish elected boards, governments in Britain (and later England) have considered but failed to introduce them. Greer et al. (Reference Greer, Stewart, Wilson and Donnelly2014a) explored the elected Scottish Health Boards. They point out that turnout was low, from 14 to 23%. Elected members broadly consisted of the ‘usual suspects’ of retired and professional people, who are unlikely to challenge boards and represent a limited shift in power. Boards are still accountable to the Minister despite a majority of members being elected. They conclude that it is not clear if governments will get significantly different results from elections as compared with other mechanisms of public participation. Elections to health bodies have failed to deliver the transformational change promised in policy rhetoric.

Second, there is the issue of single function elected boards (New Zealand, Canada, Scotland) vs multi-function elected local authorities (Sweden and before the NHS, Britain). One of the criticisms of single function boards is the possibility of low voter turnout as electors may not bother to go to the polls. This appears to be justified in the case of the elections for English Police and Crime Commissioners where the ‘Apathy Party’ came romping home. In New Zealand, voting took place at the same time as local government elections, and roughly half the voters turned out between 1970 and 1986 (17) and in the four elections between 2001 and 2010 (145). However, the number of candidates per seat reduced from 7.4 in 2001 to 2.6 in 2010 (145). During the earlier period, Board members had weak ties to political parties, with most candidates standing as independents (18). In the later period, many of the elected members were from the professions, especially the ‘health professions’ (e.g. 37% in 2001). Maori representation increased from 3 to 8% between 2001 and 2007 as against some 15% in total population (146–147). In short, it appears that the ‘usual’ criticism of the ‘usual suspects’ and ‘medical domination’ were valid to some degree. The gender balance appears to be more equal than many bodies, being between 54 and 58% male between the years 2001 and 2010. However, it is difficult to speculate whether elections resulted in boards that were less ‘male, pale and stale’ than appointed boards. Finally, following the 2001 elections, the government released its list of chairs and appointed members. A number of appointees had stood as candidates but failed to win seats (148–149), which seems to be a rather novel interpretation of re-cycling.

However, these issues need to be placed within the wider context of centralised and decentralised and national and localist systems. There is a discussion of centralised vs decentralised systems (33–34) but it is rather brief and thin. It is pointed out that federal systems exist in countries such as Canada, Australia and the United States, while national systems exist in countries such as Britain, Spain, Sweden and New Zealand (34) (but these appear to be very different systems in many ways). Britain is said to have ‘centralised hospital governance’ within a ‘highly centralised state’, while regional or local control of services exists in countries with a long history of local government (Sweden) as well as in countries that are supposedly highly centralised politically (France, New Zealand). Some federal (Australia, Canada and the United States) systems are also decentralised (35). However, Sweden’s hospital system is the most decentralised (41).

The terms seem to be used rather loosely, with no clear indication of criteria. There is some discussion of finance. It is stated that after the introduction of New Zealand’s NHS in 1938, funding moved centrally, and government assumed complete financial responsibility for the public hospitals by 1958 (54–55). Moreover, although ministerial control over boards did increase, boards retained autonomy and national funding (19) However, the degree of centralisation of finance is only one possible dimension of centralisation (Peckham et al., Reference Peckham, Exworthy, Powell and Greener2005). For example, the British NHS has always been funded by centrally allocated resources, yet has also experienced moves between centralisation and decentralisation. Moreover, the contrast between the reality of centralization and the rhetoric of devolution reflects tensions built into the very design of the NHS: tensions that derive from the fact that the design incorporated competing, possibly irreconcilable, goals (Klein, Reference Klein2010). An ‘acid test’ can be seen in reactions to the ‘post code lottery’ in health care (i.e. differential treatment can be based on the place of residence). For the centralist, this is ‘bad inequality’, but for the localist – if it results from political choice based on fair funding – this is ‘good responsiveness’ (cf. Powell, Reference Powell1998). The Bevan/Morrison normative (what should be) debate is mirrored by the Crossman/Powell ‘what is’ debate. According to Labour Minister, Richard Crossman, writing in 1972, the Regional Hospital Boards did not contain obedient civil servants carrying out the orders of ‘Elephant and Castle’ (the headquarters of the Department of Health), but rather a ‘number of powerful, semi-autonomous Boards whose relation to me was much more like the relations of a Persian satrap to a weak Persian Emperor’. On the other hand, in 1966 Conservative Minister Enoch Powell had no doubts about authority flowing from the centre: “the boards and committees represent an administrative chain for the transmission of central policy and decisions” (both in Klein, Reference Klein2010).

Laugesen and Gauld state that “the jury remains out on how best to involve the public in local decision-making” (25) with no research on whether involving the public in decision making makes a difference to service performance and outcomes. These are remarkable claims given the centrality placed on PPI by many governments, yet fit with other commentators (e.g. Crawford et al., Reference Crawford, Rutler, Manley, Weaver, Bhui, Fulop and Tyrer2002; Florin and Dixon, Reference Florin and Dixon2004; Wait and Nolte, Reference Wait and Nolte2006; Conklin et al., Reference Conklin, Slote Morris and Nolte2010; Mockford et al., Reference Mockford2012; Stewart, Reference Stewart2013). It is concluded that DHBs are far from ideal and they offer only ‘tokenistic’ public participation (171). This appears to mirror the position in the NHS. Over the long term, contrary to much rhetoric, politicians appear unwilling to ‘let go’ and continue to indulge in political micro management (Greer et al., Reference Greer, Jarman and Azorsky2014b). Many initiatives can be seen as ‘talking a good game’ and forming an ‘Iron law of symbolic politics’ or an ‘inverse involvement law’: the more it is talked about the less seriously it is taken (compare ‘Equality and Diversity’).

Laugesen and Gauld have provided some important detail on an important but overlooked case within the important but overlooked wider issue of democratic governance and health. They have sketched out a valuable research agenda that now requires to be broadened out with material on (the few) other cases and on wider concepts and issues.