Background, initiator and participants

The Danish health care system was under political and public pressure to implement more, better and faster treatments but was lacking the required financing.

In 2008, the Health Committee of the Association of the Danish Regions established a project on “The Future Health Care System”, which consisted of two elements:

• Simultaneous Citizen Summits in four of the Danish Regions comprising 800 citizens, on 1 November 2008,
• a Policy Summit based on the outcomes of the Citizen Summits, with politicians, stakeholders, experts and health care system officials, on 1415 January 2009.

The Danish Board of Technology (“Teknologirådet”) and the secretariat of the Health Committee formed a common secretariat to execute the project.

Objective of Citizen Summits

Under the heading “values and challenges”, the Danish Regions sought the informed and considered judgements of citizens as to how, for example, technologies could be used to increase productivity, notably whether the prioritisation of the treatment of disease was acceptable at the cost of other procedures, for example certain plastic surgery procedures, whether private insurances could be used for financing certain treatments, and whether patient compliance with treatment could be demanded etc.

Objective of Policy Summit

To make consensus decisions on new developments and prioritisation in healthcare between actors in the Danish health care system, based on the assessments of citizens.

Outcome

Some notable results of the initiative:

• At the time, it was possible to get tax refunds for private health insurance, which was expensive for the health care system, but there was uncertainty about the public reaction if it were to be abolished thereby resulting in a lack of courage among politicians to abolish it. However, at the Citizen Summits some 80 % of participants expressed their support for a fully public health care system or private insurances without tax refunding. This resulted in a political shift of attitude. Shortly after the Policy Summit tax refunding was abolished.
• There was citizen support for requiring patients to adopt lifestyles that did not compromise their treatment. This was discussed intensively at the Policy Summit and received much more focus in health care policy afterwards.
• Capacity building for healthcare personnel was supported by 71%, in order to qualify personnel across disciplines. Decisions were made to reduce the barriers between disciplines (e.g. so that specialised nurses can perform certain tasks previously only conducted by doctors).

Method

Citizen Summit: 4 full-day meetings with approximately 200 citizens in each, selected to reflect the composition of the Danish population. Information materials were sent to participants 1 week before the summits; the program and questions were exactly the same in all meetings. The 6-hour programme was separated into 5 thematic sessions, each beginning with an introductory video, and prompt questions, which citizens discussed in groups sitting at tables with 8 citizens and a chairperson.

The sessions were about:

• The most important challenges (each table identified two challenges, which were voted on by all at the end of the meeting),
• how to give health the right conditions,
• personal contribution (from the patient),
• resources available for health care,
• what should the health care system be able to deliver in the future?
• principles for prioritisation,
• the extent to which treatment should be seen as a common responsibility or a commercial good.

Each session ended with citizens voting on 3-5 questions using ‘clickers’. For example, in session 2a, the questions were:

• Who should take responsibility for our health?
• how should we deal with unhealthy impacts from working conditions and environment?
• how should we deal with unhealthy lifestyles?
• should the treatment be adapted to the patient’s lifestyle or the other way around?
• should citizens contribute to the health of others by becoming donors?

For each question, there was a set of alternative answer options.

The Policy Summit lasted 24 hours – from 12 to 12. During the first day, policy actions were brainstormed and discussed, which could follow-up on citizens’ judgements. The second day involved workshops in order to explore the actions in more depth and to share the responsibility for actions concerning them.

Notable features and lessons learned

The exercise showed how public debate can make a significant contribution to a policy-making process. A key to creating impact is to consider the decision-making processes as a whole, in which citizen participation methods are one step. A very important next step is to provide a process for political follow-up, and from the beginning to commit policy-makers to that.

The cost/benefit ratio of public debate should be reviewed across many debate activities. Public engagement may seem like a costly affair and not every activity offers the same rewards in economic terms. However, over time some single projects release decision-making power/courage that has very high impact on productivity, quality of decisions, and on the economy. This is particularly true in the case of abolishing tax refunds on private health insurances. To quote the organiser: “The abolishment of the tax refund would probably not have happened without the clear statement from citizens – and it has saved the public budget by an amount that manifold exceeds the total accumulated cost of public engagement activities in Denmark.”

Public debate promotes deep reflection, which gives different results than polls/surveys. An important difference between polls and public participation methods is that the latter often bring unexpected results in terms of willingness to break with what is assumed to be “public opinion” as stated by e.g. media, polls or lobbyists. The opinions are informed, reflected upon and debated rather than remaining personal views of an or the official line of one party. An example is the answer to the compliance problem, which introduced a new approach, namely that patients should have co-responsibility for their treatments. This was not supported by patient organisations, lobbyists or polls, which normally reflected that everyone had an unconditional right to the same treatment. However, the majority of the participants supported the approach.