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


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:

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?


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