Gibson et al. Revolution or evolution: the challenges of conceptualizing patient and public involvement in a consumerist world. Mapping the impact of patient and public involvement on health and social care research: a systematic review. Through open discussion, meetings would inform the public of service developments and provide opportunity for questions about issues under debate. The balance of power in healthcare Meeting patient needs and keeping pace with technological advances So much of what we do is oriented to healthcare professionals, it leaves me a little worried about just how good many patients' experiences are when it comes to … The growth of PPI and the resulting increased potential it brings for patients and the public to have a voice in healthcare decision-making might potentially counteract this view. At times meetings did not feel open to public participation: […] so if [they] think it's not a relevant question, [they'll] close down quite quickly I think on the question. Revija Za Sociologiju. The issue of power imbalances between the different groups of individuals involved in the CCG can be explained by ownership of particular resources, relating to Gibson et al. Res. Usually the people at the top are given more importance than the rest. A multidimensional conceptual framework for analysing public involvement in health services research. This corresponds with the views of some public and lay members in our study who believed that the CCG would act on PPI only if it corresponded with its own plans. The patient/public with historically less power such as women, minority groups, and the poor would have been more vulnerable playing “second fiddle” to medical authority and lacked the resources to question medical decisions or challenge prescribed care (Foucault, 2003). Shared decision-making has become a critical aspect of patient-centered care goals. The status of professionals gives them power as professionals in the realm of healthcare services and provisions. This led to some frustration about the type of involvement lay and public members could or should expect to have. Direct PPI in CCG decision-making was not evident and neither was there feedback to the PPI CRG from the CCG or outcome measurement of actions resulting from PPI CRG discussions. The aim of this paper is to explore the differences between individuals in their potential to influence the work of the CCG and to consider these differences in terms of the positions they occupy in a hierarchical structure. Health Expect. Health Expect. Front. Potrata, B. Central to shared decision-making is the ability for the patient to participate during care encounters. Clarifying power, domination, and exploitation: between “classical” and “foucauldian” concepts of power. Med. Commanding leadership. The PPI CRG terms of reference stated the overall purpose of the group was to “ensure effective PPI and to deliver to the CCG a vision for PPI.” However, the document lacked detail and was unclear in terms of the role of group members, for example expected achievements and who they were representing and informing—questions that were repeatedly raised by PPI CRG lay members during meetings. Theoretical directions for an emancipatory concept of patient and public involvement. Fol… Medical professionals see hierarchy between different types of clinicians such as doctors, nurses, or other clinical workers. Patients also said they did not know how to report a healthcare concern in this setting. Can. During researcher observations of PPI CRG meetings two lay members consecutively occupied the role of chair, the first leaving the position when research observations were at an early stage. 16, 289–303. 2, 151–175. 1. Author Information. To make sense of bossiness, we need to tease apart two fundamental aspects of social hierarchy that are often lumped together: power and status. Issues emerging from our study relating to imbalances of power support findings of previous research regarding the control and restrictions of statutory bodies over public involvement (Baker, 2007; Stern and Green, 2008; Peckham et al., 2014). (2013). ^Available online at: (accessed September 10, 2018). It is widely recognized that social structures can fashion and influence social interactions and that social interactions can influence, reproduce, and sometimes alter social structures (e.g., Giddens, 1984; Turner, 1992). Other lay members sat on the lower end of the PPI CRG sub-stratification system. There are various definitions of power that have emanated from different theoretical and conceptual perspectives. Permission for conducting observations was obtained from the clinical commissioning group, the patient and public lead, and from lay members of meetings. This should reinforce the notion of equal partnership, rather than a hierarchical system between patient and provider. It is a single case study set in a large, diverse inner city. The authors conclude that a hierarchy of power exists, with some professionals and public and lay members afforded more scope for influencing healthcare service development than others—an approach which is reflected in the ways and extent to which different forms and holders of knowledge are viewed, managed, and utilized. Many of our research participants were lay and public members. Power is a core theoretical construct in the field of sociology. Such an organization with responsibility for making impactful and complex decisions around healthcare service provision would need a level of social orderliness in order to achieve outcomes necessary to provide a service that meets bureaucratic and practical demands. Regulations stipulate that all NHS organizations must have PPI in the planning, development, and operational aspects of healthcare services (Barnes and Schattan Coelho, 2009). Power hierarchy is conceptualized as the relative power differences between group members, and power is defined as the degree to which an individual can influence or control other group members (Halevy, Chou & Galinsky, 2011a; Schmid Mast, 2001). 17, 17–34. “She did, he said”: the use of ethnography in CAM research. A main aim of our study was to explore PPI in CCG decision-making. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Evidence-based medicine strives to make health-related decisions based on the best available evidence. London: Routledge. Kerckhoff, A. C. (2001). It is widely accepted that quality in the delivery of healthcare is more than purely good clinical care. Expressing one's concern while navigating the power hierarchy requires formal training that targets both the speaker's emotional and verbal skills and the receiver's listening skills. Hospital Nurse Hierarchy. Available online at: (accessed August 9, 2018). Guzzini, S. (2005): The concept of power: a constructivist analysis. ... advocate for a redesign of the health care system that utilizes their knowledge, that results in health promotion for the entire population, including underserved and This is where the hierarchy of evidence comes in, it is used to judge the efficacy of a treatment or intervention. doi: 10.2307/2673250, Martin, G. (2008a). Patient reluctance to speak up during care encounters also carries with it dangers to patient safety. (2008). This paper draws on data from a qualitative study of PPI in a clinical commissioning group (CCG) in the UK. This affords some lay members a higher status (as in the case of the lay chair) but not equal to that of the professionals due to the relativity of the positions they occupy. A study of community participation in two Healthy Cities Projects. At times PPI CRG lay members perceived their input as “low level”: Some discussions have come to the [PPI] reference group for input at an early stage […] but they tend to be slow-burning, less high profile issues. (2004). 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