Participation Now

Could volunteering be bad for our health?

Discussions of volunteering in British health-care organisations rarely discuss the possible downside. But we need awkward outsiders.

Ellen Stewart
20 November 2013

A few years ago, while observing a meeting of a Public Partnership Forum in the Scottish National Health Service, I was privy to an exchange which surprised me at the time. It has fuelled my continued fascination with the field of public participation since. A member of staff responsible for the local Health Board’s application to an accreditation scheme called Investing in Volunteers began a presentation to the group by stating, ‘You might not know it, but the public involvement you are doing is volunteering.’ Afterwards, a member of the group exclaimed to me in furious tones ‘I am NOT a volunteer!’

What is the difference between volunteering within a public organisation, and taking part in a ‘public participation’ initiative in that same organisation? The two certainly share some characteristics, such as time freely given, and most likely a belief in that organisation’s mission. However there are some key differences in orientation, and I believe that the gradual elision of the two categories of activity risks a dulling, or blunting of the radical potential of public participation initiatives.

‘Public involvement’ is the somewhat vague policy term used to describe the roles members of the public play in decision-making about our health services. Its theoretical antecedents lie in radical work like Arnstein’s ‘ladder of participation’ and the World Health Organisation’s Alma Ata declaration, in which they declared that health systems should create opportunities for citizens to help shape decision about health-care, and that citizens should take them up. Volunteering suffers from similar definitional uncertainty but one excellent overview places it within “a cluster of ‘helping’ activities”. It is this subtle distinction between an empowered and change-oriented model of participation, and a helping ‘volunteerist’ response to organisationally predefined needs, which continues to exercise me in my research into health-care organisations.

This concern is rather out-of-step with much current debate in my field. Discussion of volunteering in health-care organisations almost always mentions the thorny political issue of (paid) job replacement but rarely discusses the risks of public activism being diverted, or blocked, by the dominance of volunteerist models of engagement. Earlier this year, the King’s Fund think-tank offered us a glowing report card for the role of volunteering within National Health Service organisations, stating simply that ‘strategic roles’ are one facet of volunteering in health and social care organisations, but a ‘separate issue’.

A recent book by academics at Leeds Metropolitan University reported research into the role of ‘lay health workers’ delivering services in English communities, describing this as a form of citizen participation. In a lively blog piece one of the authors, Mark Gamsu, stated “I think that there is a strong relationship between the number and quality of volunteers and the effectiveness of work to increase participation.” He may be right (and we certainly need more evidence on the relationship between these two sets of activities). But might there also be risks to the easy way in which roles holding managers to account are discussed in the same breath as the work of citizens who offer information, advice and support to current patients?

Research repeatedly shows that some members of the public want to contribute to organisations in a range of ways, and many (even most) may not want to contribute at all. Emphasising the activist end of the involvement spectrum might risk intimidating some volunteers who want to make a more straightforwardly supportive contribution. But in the wake of the Mid Staffs scandal in the English NHS, and with moves to enable whistleblowers high on the agenda, we must be vigilant that cooperative, even deferential, practices of volunteering don’t drive out those members of the public who cooperate with public involvement while maintaining a critical, ‘outsider’ stance.

In my doctoral research I have developed a typology of three roles within public involvement: volunteers, consultants, and activists.  Activists are rarely popular within the spaces of public involvement, prone to ‘jumping on their soapbox’, interrupting at the wrong time and playing havoc with orderly meeting agendas. And yet in the wake of damning evidence that the careful systems of governance built up within the NHS don’t protect us from profound organisational failure, the awkward outsider who asks annoying questions starts to look like a resource we can’t do without. 

This contribution has been commissioned for an editorial partnership between openDemocracy and Participation Now, a project that aims to support exploration, innovation and debate about contemporary forms of participatory public engagement. Participation Now is an Open University project supported by OpenLearn, the Creating Publics project in the Centre for Citizenship, Identities and Governance, and the RCUK-funded Public Engagement with Research Catalyst project. Explore the initiatives here.


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