Is there such a thing as Citizenship in relation to public services?

I attended a couple of seminars on health recently. Both acknowledged that there are massive problems with resourcing health care, whether nationally or globally. At both seminars, I asked how the speakers thought we might better engage as citizens with the questions of how we structure and finance our health system – and in neither case got an answer. A former colleague suggested to me that perhaps that is because my question has no answer. It would be a sad day for Citizenship if there is no answer to the question of how we the citizens can help decide what kind of health care system we want and are willing to pay for. This is especially so as, at the point of need, our desire for care is so urgent and critical that there is no way we would do anything other than argue that our need is absolute, and the health care system must do everything it can to provide for us. But hospitals and governments have budgets, and they must prioritise what they do in order to stay within budget. A debate about health care could easily set the young against the old, the chronically ill against the mainly healthy, smokers against non-smokers. And yet we all have to live – and eventually, die – in the same society.

One of my concerns is way in which much current government support of ‘engagement with public services’ consists of the ‘make your voice heard’ and ‘have your say’ messages which help establish a culture where the mark of success in civic engagement is having secured resources for one’s own cause, rather than having helped in a deliberative process that looks at how resources are raised and distributed. While I believe that it is extremely important to have some form of promotion of voice to enable those characteristically excluded from public space to feel confident in their own voice, the voice is only the beginning. How do we ensure that as well as owning our voices, we listen actively and consider the impacts of choices on our wider communities? Government, in its intentions to improve the delivery of public services and offer more choice casts us all as consumers, not citizens. Yet, voices from health care quietly assert the importance of Citizenship. Neil Churchill, Chief Executive of Asthma UK wrote recently in the ‘Healthy Futures’ pamphlet published by the Smith Institute:
‘Most people I meet are conscious of our duties as citizens towards the “public good” represented by the NHS and the claims of others on its resources. Good citizenship should be encouraged in healthcare and we need to engage patients in things they have in common, and not set them apart by arbitrary distinctions between different conditions.’

And Martin Dockrell, Director of Policy and Research at ASH, highlights an example where a campaign that took a citizenship model of social and economic inquiry was more effective than the traditional individualised messages of health promotion:

“Virtually the only youth tobacco campaign to make a significant impact on teen smoking did not even mention the health consequences, instead it focused on the behaviour of the industry and its role in child labour, environmental harm and marketing manipulation. In short, it engaged with young people’s sense of social justice.’

It is perhaps not surprising that these voices on the importance of Citizenship within the public service of health, come from the NGO community, which is perhaps more disposed to collective action. Nevertheless, they are important examples to us in theCitizenship community precisely because the main concern of these experts is better health, not the promotion of Citizenship learning, and yet they strongly make the case for the need for Citizenship thinking in health.