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Does Return on Investment help improve Public Involvement in the NHS?

June 14, 2017


I recently gave a talk at the annual NICE (National Institute for Health and Care Excellence) conference on a review Leeds Beckett University did of the Bradford District Care NHS Foundation Trust public engagement strategy ‘Involving You’.

NICE has published an account of our work here. Our full report is here.

As I went in to the workshop with my co-presenter Cathy Woffendin (Deputy Director of Nursing at the Trust) I noticed that the sub title to the workshop was “Demonstrating the Return on Investment of patient and public involvement” I should probably have clocked this earlier! When the workshop kicked off I made it clear that we were not going to be looking at this, instead we were going to talk about how we reviewed the actions the Trust was taking to strengthen their relationship with the public and what actions they had taken after our report.

After our presentations one of of the audience asked whether a Return on Investment approach would help decision makers in health take public engagement more seriously.

At the time I was unconvinced by this argument – on the basis that I think we should expect that leaders of NHS organisations have a value base that emphasises the importance of individual and collective relationships with members of the public.

Nonetheless it is perfectly possible to argue that there are financial benefits to having a strong relationship with the public – these include:

  • reducing cost of delays to proposed changes or innovations due to public challenge
  • added value arising from patient/public ideas about how services could be improvement
  • increase in reputation due to being seen as a good responsive health organisation
  • Accountability to local people – strengthening quality of governance

After the conference and prompted by the question I did do a bit of searching and came across a good paper titled Patient and public involvement: how much do we spend and what are the benefits? published in 2015. This is a thoughtful review of current state of play and I recommend that people read it.

The paper recognises the position that I and others have taken:

“Many PPI practitioners are sceptical about any attempt at ‘valuing’ participation practice and see economic and monetary analysis of the costs and benefits as reductions or simplistic”

Nonetheless, the paper’s premise is that it important to measure the cost of Patient and Public Involvement (PPI) with a view to determining its added value.

I remain unconvinced for three reasons – which are all to do with context.

If its small we must measure it!

It seems to me that innovative and low cost activities are too often subject to the greatest demand for evidence on impact and cost. They have to prove their value in a way that mainstream parts of the health infrastructure do not. For example I suspect that more is invested in Quality Assurance teams in Clinical Commissioning Groups than in Patient and Public Engagement – yet there is no call to demonstrate their Return on Investment.

The system is not listening

Sometimes it is too easy for health systems to say that PPI produces little added value – when the reason for this is actually because the health system has not framed its engagement in a way that allows the public to contribute in an effective or powerful way, or even worse when the system lacks the ability or will to respond to challenge from the public.

Deliberative Democracy

Finally, PPI is about deliberative democracy. The UK is a democracy – talking with the public is part of our culture –  we do not need to prove that this brings a ‘Return on Investment’ in order to do it.

Where next

The paper concludes with some ideas about how to measure the cost of PPI. Its a useful list – because it gets us thinking – although I am not sure how practical it is.


I think that local health organisation should consider:

  1. What is our vision for building our relationship with the public?
  2. What are the actions we are taking to move towards our vision and what resources (number of staff, their grade) we put into this?
  3. How are we changing our organisational culture in order to make it easier for the the public to work with us?

What do you think?


6 Comments leave one →
  1. Daphne Ingham permalink
    June 14, 2017 09:21

    Hi Mark. I agree with your questioning attitude to social return exercises and it’s refreshing to see some of their drawbacks pointed out. I suspect many people are sceptical, but feel they have to go along with it. Austerity has rendered these exercises relatively meaningless anyway, as so many decisions have been far more influenced by the urgent need for cashable savings. I’m not condemning the principle outright but as you say, it’s applied so unevenly, asked of small services but not larger ones, and the cost of the actual exercise is then disproportionately high. Thanks, Daphne

    • June 14, 2017 09:44

      Thanks Daphne – that’s reassuring (seriously!) I think that one of the other reasons that this can happen is that middle managers only have a limited set of tools available to them – they don’t set the vision and values of an organisation – so when they search around for tools to make the case one of the ones that appears to be attractive is ROI.

  2. June 14, 2017 11:01

    On this, I think organisations need to consider their orientation to being and doing people centred, engagement etc.very differently – what structural changes they make and what process approaches they take that enable voice and agency to develop, inform and lead. That would then lead them to think about new approaches to evaluating benefits etc. that won’t be purely statistical/numerical (£) focused.
    I think the SROI on all things engagement is a perhaps a horse before the cart type approach.
    Let’s demonstrate benefits beyond (purely) cashable returns!
    What do you think?
    Ps – I like your illustration too – I think you may have used it before though (Lol).

    • June 14, 2017 11:45

      Cheers Simon – good points – I think that an important question is what relationship do NHS organisations want with the public? Of course this is a problem for commissioning organisations because they tend to only be around for a few years – barely time to bring up the children!

      More importantly – I have NEVER used this illustration before! ;o)

  3. June 21, 2017 19:14

    1Great blog Mark (and love the drawing). Agree with your reasons for being unconvinced. There can be a tendency to reduce the body of health economics as a discipline to a set of ‘tools’ which you then aim at stuff to determine ‘value’ regardless of context. ROI being the most obvious where it is often said ‘Can we do an ROI on x’. Two perspectives to add from my limited understanding of health economics:

    – Firstly economic evaluation is useful for deciding what we should invest in and how we prioritise spending. It’s not an exercise in where we can save money. The pharma industry is not held to this (at £30,000/QALY) so why is it so often public health which is held to expenditure according to so-called cashable savings? Public health and PPI is an investment.

    – Secondly you cannot derive ought from is. ROI is a positive exercise involving analysis and counting numbers. But choosing to do PPI is a normative choice based on social value i(since it’s about deliberative democracy) and can be justified by other means. PPI ought to be done (within realistic budgets) because it has worth to society aside of money. (Maybe there is some way of ascribing monetary value to this for the purposes of doing ROI to PPI but surely economists’ time can be spent on something more cost-effective!)

  4. June 29, 2017 20:55

    Rob – lovely to hear from you – I think your second point is particularly powerful – “ROI is a positive exercise involving analysis and counting numbers. But choosing to do PPI is a normative choice based on social value i(since it’s about deliberative democracy) and can be justified by other means. PPI ought to be done (within realistic budgets) because it has worth to society aside of money” I will have to think of a way of using this! All the best – Mark

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