Abstract
A democratic deficit is often assumed where the local community has little direct influence on local policy decisions and where change is unresponsive to the community's needs (Murat and Morad, 2008). The UK government embodied patient and public involvement (PPI) in a wide range of activities and a variety of purposes. Patient involvement and public involvement are distinct and are achieved in different ways. However, the conflation of these distinct terms and the confusion about the purpose of involvement has led to muddled initiatives in the UK and uncertainty about what should be done to achieve effective PPI (Cowden et al. , 2007). Nevertheless, patient and public involvement had the potential to play a key role in NHS services by bringing about service improvement and improving public confidence via engaging democratic procedures (Le Grand, 2007). In Greece, the health care system is highly centralised and removed from welfare principles such as equity, responsiveness and efficiency. Virtually every aspect relating to health care financing and provision is subject to control by the ministry of health (Karassavidou and Glaveli, 2007). The state never got involved in ongoing design of the health sector at a local level instead its role was one of exercising strong regulatory control over insurance funds and public hospitals (Karrasavidou and Glaveli, 2007). Additionally, the existence of out of pocket expenditure within the NHS, which mainly consisted of informal payments for care, was developed as a complement to public funding (Mossialos and Davaki, 2002). Hence, several reform plans during the 1980s concerning fair provision of services failed owing to an array of the aforementioned interrelated economic, political and social factors that channel potential changes towards failing to employ democratic procedures and transparency (Davaki and Mossialos, 2005). These conditions create unfavorable conditions for the introduction of mechanisms such as PPI. The aim of this study is to explore the effectiveness of patient and public involvement mechanisms, employed in the UK and Greece, in respect of reducing a perceived democratic deficit within the respective NHS structures. The main objectives of this study are to investigate the meanings that different stakeholders give to PPI in the UK and Greece, to explore stakeholders' opinions of effective ways of involvement, to identify motivations in getting involved; and to compare and contrast effectiveness of involvement mechanisms in both countries. This study employed qualitative research methods. Focus group discussions were the main data collection method. Initially 11 focus group discussions in total were conducted and analysed, two in the UK and nine in Greece with a total of 92 participants involved. The empirical findings of this research have added to our understanding about patient and public involvement as a mechanism of strengthening democratic values within the NHS and of making health care service more responsive to patients' needs. This study found that patients and members of the public perceive that there is a 'democratic deficit’ within the NHS due to the dominance of the health professionals in decision making and the patients' and the citizens' limited power in changing health care policy. Current involvement mechanisms in the UK were not considered to be powerful enough to affect policy at a local or at a national level. In contrast to England, in Greece there appears to be no formal patient and public involvement structures in place, nor was there any real appetite to create formal structures. This was as a consequence of a number of factors including the centralised nature of state public services provision, the perceived corrupt and unequal power relationships between various sections of society, the power of the medical profession and its expert knowledge and citizens lack of enthusiasm for involvement unless the issues were personally relevant.