The Citizens' Assembly brought together a representative cross-section of local residents for discussions around health and care services in the London Borough of Camden. The objective was to give residents the power to inform Camden’s new Joint Health and Wellbeing Strategy.
Problems and Purpose
The Assembly’s objective was to invite residents to shape the common purpose of Camden’s new Joint Health and Wellbeing Strategy. The Assembly was charged with developing three principles for the local health partnership to consider when implementing future change to the health and care system.  By giving residents agency over planning health and care, the three principles produced may be seen as legitimate and defensible as they were produced by citizens through deliberative means. The initial purpose was for residents to deliberate solely on health and care. However, the Assembly’s focus shifted slightly after the first session to explicitly include Covid-19’s effects on the participants. 
Background History and Context
Camden Council has recently run several citizens’ assemblies as part of its plan for the borough’s future, known as Camden 2025. In 2017, an Assembly considered the borough’s future planning.  In 2019, another Assembly considered climate change.  In 2020, health and care was the focus of an Assembly. Citizens’ assemblies have been used to increase the deliberative processes in the borough and encourage communities to be part of the political process collectively. 
The leader of Camden Council, Councillor Georgia Gould, advocates for using citizens’ assemblies to support policy development.  The wide-scale funding reductions to local governments as part of the national Government’s austerity measures are part of Councillor Gould’s motivation for using citizens’ assemblies. Councillor Gould has stated that the assemblies can provide a sense of alternative to austerity at the local level and help build civic power.  The health and care assembly was run as part of a commitment to put the voice of residents at the heart of health and care transformation in Camden.  To realise this commitment, Camden Council, alongside local health and care partners, chose to use this deliberative approach to ensure residents are actively engaged in the process of developing and improving health and care services. 
Organizing, Supporting, and Funding Entities
The Assembly was commissioned and sponsored by Camden’s Health and Wellbeing Board. The board’s role also included listening and responding to the Assembly’s output and ensuring the local health and care partnership is held to account.  The task of Camden Council included providing the Assembly’s strategic oversight and direction. The Council worked with a range of NHS and voluntary and community sector (VCS) partners to prepare and deliver the assembly.  The Council’s role also extended to recruiting and liaising with residents. Additionally, the Council supplied the necessary technical equipment and support and facilitated the online small group discussions (known as breakout groups) when the assembly moved online.  The health and care consultancy Kaleidoscope was the independent lead facilitator of the Assembly’s sessions. The consultancy organised the post-event synthesis and also provided technical expertise.  University College London (UCL) advised and supported the Assembly’s approach with academic input and provided a developmental evaluation.  An expert advisory panel helped frame the process and guide the approach. The panel also advised on the next steps, the implementation of the Assembly’s outputs, and was tasked with holding the partnership to account.  The panel included experts from Camden’s health and care system, and experts in deliberative engagement from UCL, Kaleidoscope, and Involve, a charity specialising in public participation.  The role of members was to draw upon their personal experiences, participate in group discussions, and share what they had learned from the process to develop the three policy principles. 
Participant Recruitment and Selection
The procedure for participant recruitment began in January 2020 and involved Camden’s community researchers, a group of local people trained to do engagement and consultation for the Council.  The researchers recruited participants through door-to-door and on-street recruitment. Recruitment also took place in various VCS and health and care community settings. Recruitment was not advertised to all Camden residents.
Over 150 Camden residents were initially recruited, and 60 were invited to attend the Assembly. The 60 selected were stratified based on census data to reflect Camden’s population; an internal data team completed this process. The variables used for the stratification process were Camden wards, age, ethnicity, gender, sexual orientation, housing status, disability, and caring responsibilities. 
The participants' age groups were three 16-24 year olds, six 25-29 year olds, eight 30-44 year olds, twenty 45-64 year olds, and seven people aged sixty-five or older. The breakdown of the members’ ethnic groups was: five Asian or Asian British, nine Black or Black British, twenty-two White, three Mixed/Multiple Ethnic Groups, three identified as “Other Ethnic Group”, and two participants who preferred not to say. The gender breakdown was 28 participants identifying as female and 16 as male. The sexual orientation was 33 individuals identifying as heterosexual/straight, three as gay or lesbian, and eight members who preferred not to say. 15 participants identified as having a disability, and 29 did not. The housing status of the participants was 14 rented from the Council, one buying on a mortgage, eight owned their home outright, 13 rented from a housing association/trust, five rented from a private landlord, one was listed as “other”, and two members did not provide this information. 34 participants stated they did not have unpaid caring responsibilities, while six stated they did. 42 of the individuals were from 15 different Camden wards, while two stated that they preferred not to say. 
The members were given vouchers for their participation.  Councillor Gould stated that she believed it is important to remunerate people to show that their time is valued.  Alongside the residents who participated in the assembly, speakers from various charities, Camden Council, and health and care services also participated by sharing their perspectives and experiences. 
Methods and Tools Used
The overarching method used was a citizen’s assembly.  The process worked by residents meeting to hear from experts, deliberating on health and care and then providing a set of principles to be considered by policymakers. The method of citizens’ assembly was chosen to give Camden residents a voice in the formulation process of health and care policy.  One theory of change behind a citizens’ assembly is that allowing citizens to learn, consider evidence, and deliberate on a policy issue may help justify the policy decisions taken due to the assembly.  The use of a cross-representative sample means the recommendations made by the Assembly were produced by citizens that reflect the whole community. So, instead of only having a certain socio-demographic involved in policy-making decisions, Camden’s Citizens’ Assembly was intended to be inclusive and ensure different voices are heard.  This method, then, can produce policies that are not solely guided by powerful voices but are representative of the community at large. 
A key tool used in the Assembly was small group deliberation. The purpose of the deliberation was initially, in session one, for residents to deliberate on health and care in Camden. Sessions two to five also included deliberation of the effects of Covid-19 on the participants’ lives. Due to the United Kingdom’s lockdown, the latter session conducted deliberation through online breakout groups. 
Deliberation was used in conjunction with talks from local experts on health and care in Camden, who shared their perspectives on the need for a citizens’ assembly.  The residents then participated in a question and answer period with the speakers.  So, deliberation allowed the members to learn the necessary information to make informed decisions later. Another tool used was an expert advisory panel.  The role of this tool was to advise and guide the organisers. The panel was also used to provide feedback on the priorities and expectations decided by the Assembly and to guide the next steps. 
A novel tool used in this Assembly was labelled the ”Citizen Scientist” process. This tool involved participants investigating two tasks. First, participants considered how Covid-19 had affected them as individuals. Second, the members spoke to people in the local community to find out how Covid-19 had affected them and others.  The purpose of this tool was to gather information on the public’s positive and negative experiences of the pandemic and lockdown. This information was anonymised and used to inform the Assembly’s expectations for improving health and care.  An advantage of the Citizen Scientist process was that it encouraged deliberation from participants outside of their own experiences and to learn from people in the community.  The tool of deliberation and this process are linked by the need for members to reflect and carefully consider the information available to them.
What Went On: Process, Interaction, and Participation
The Assembly involved five sessions between February and September 2020, where the participants produced three priorities for guiding health and care policy in Camden.  In each session, the members also discussed their expectations for achieving the priorities. Expectation was defined as the standards the Council and its partners should adhere to when delivering services and affecting change.  Before each event, the organisers distributed information packs to provide background details and instructions on how to join in on the event. 
The first session was face-to-face and started with members being introduced to a citizens’ assembly process. Local speakers, as noted previously, then talked about their experiences of health and care in Camden and a question and answer session followed this.  After hearing from the expert speakers, the participants were encouraged to deliberate and discuss their thoughts about the most important health and care issues that need addressing in Camden.  The participants deliberated on what they believed a successful assembly would lead to.  The residents discussed their individual top priorities for health and care and then collectively deliberated to come up with some group top priorities.  These conversations were assisted by trained facilitators to help with members’ participation.
The second session was conducted online after a three-month delay due to Covid-19. The focus shifted to include the effects of the pandemic and lockdown on the members. The members deliberated on the challenges they and their communities were experiencing related to health and care.  The residents were then presented with some adapted versions of the priorities from session one, which took Covid-19 into account. The first priority was: “Reduce health inequalities in the borough. Ensure that local services can tackle the impact of the pandemic on the most affected groups.” Priority two stated: “Ensure my family, friends, neighbours and I can stay healthy, safe, and well in Camden, particularly our mental health and emotional wellbeing.” The final priority was: “Ensure local services work together to meet the needs of residents, and communicate effectively with residents.”  The participants deliberated in small groups on the adjusted priorities, allowing residents the opportunity to give their opinions on the priorities. It seems a range of different views were provided following the deliberation. 
In session three, the members learned about the first priority in detail. To improve their knowledge, expert speakers from local organisations gave their view on health inequalities experienced by the groups they work with. The participants deliberated on what they had heard and shared their own experiences of how Covid-19 had affected them as individuals in breakout groups.  To facilitate this dialogue, the members had been asked to conduct the Citizen Scientist process in the previous session. This process involved members reflecting on how the pandemic had affected them as individuals. Members were asked to produce a piece of media (e.g., written notes, a photograph, a recording, or a film) discussing their experience.
The fourth session involved the members learning more about the second priority. Similar to the third session, expert speakers discussed preventative care to help improve the members’ knowledge. The participants were then asked to deliberate on what they heard and discuss their own experiences. 
The final session was split into halves. First, the Assembly explored the third priority in detail. This process involved the group refining the expectations from the previous sessions. The members then shared their Citizen Science findings on how Covid-19 was affecting their communities. The second half was intended for participants to rank the expectations in order of importance. Many expectations were produced, typically stating what the participants believed was necessary for health and care services to deliver good outcomes. However, the decision was taken to hold all expectations of equal importance as no consensus emerged.  It is not clear which, if any, voting mechanism was used here. Finally, the participants individually, and then in small groups, deliberated on how local services, community groups and charities, and individuals can help achieve the expectations.
Influence, Outcomes, and Effects
Impact on Policy
The Assembly intended to help guide health and care policy to reflect the priorities and expectations of Camden’s citizens by creating three priorities to be considered by policymakers when implementing future change.  Notably, the task of the Assembly was not to produce specific actions for local services to take but rather principles to follow. As no specific actions were produced, it is hard to establish the impact of the Assembly on policy. Furthermore, the Assembly was not tied to any binding public ratification process. The product of the Assembly was solely recommendations for policymakers, with no requirement for the recommendations to be enacted. Hence, the recommendations may be ignored. Nonetheless, if the policymakers do follow the recommendations, then the Assembly certainly influenced policy.  It should be noted that the Assembly was held last year (2020), and so it may become apparent with time that the priorities were followed.
Some steps were taken to ensure the priorities are followed. Both the expert advisory panel and the health and wellbeing board were tasked with holding the health and care partnership to account in delivering the priorities. The participants were asked to provide recommendations for the next steps. Recommendations noted in the report include information being disseminated so the success of the process can be measured as well as hosting regular citizens’ assemblies to assess the impact of the Assembly. 
Impact on the Community and Individuals
It appears that the process increased social capital in Camden. Social capital is hard to quantify, but the final report provides some evidence that the Assembly impacted participants and their links to the community through data from evaluation forms and statements. For each of the five sessions, the number of participants who stated they would recommend the event ranged from 78%-100%. However, the number of individuals who answered was low, ranging from three to 27. 
Anecdotally, participants described how the process was rewarding and enjoyable. Participants stated that the process had increased their knowledge. Additionally, some individuals stated that they were keen to participate further in related activities. A question on future involvement answered by 11 participants suggested the Assembly had some impact on individuals. All 11 stated they would like to participate in a future one-off citizens’ assembly on “trade-offs” in resource allocation in health care. Seven stated they would like to participate in other co-design exercises, and five stated they would like to join their local NHS patient group.  However, the fact that only 11 members answered the question might suggest there was little or no impact on most participants. Overall, it seems the Assembly had some positive impact on individuals and the community. 
Impact on Democratic Goods
Another way to evaluate the outcomes of the Assembly is to consider its effects on democratic goods using Smith’s framework.  The democratic goods of inclusion, considered judgment, and popular control will be considered here as these goods are most relevant to the method of citizens’ assemblies.
The Assembly's organisers took several steps to ensure the good of inclusiveness was well promoted. Inclusiveness can be understood as how voice and presence are enabled in participation to realise political equality.  The first step was to ensure the participants accurately reflected Camden’s population. This step was achieved through stratification, and this helped ensure a cross-representative sample was present. However, advertising recruitment more widely in the future may attract a greater range of participants. 
To ensure the sessions ran inclusively, an understanding of the members’ needs was generated. Information packs were also distributed to participants with background details and instructions for the Assembly. An additional challenge was presented by the Assembly moving online due to the pandemic. To ensure this change did not prevent inclusiveness, equipment was lent to members to connect to the internet. The option of connecting via a phone was also possible, and slides were distributed in advance. These steps will have helped minimise exclusion in both access and competence for members participating online. 
During the events, British Sign Language, Albanian, and Somali interpreters were provided. Facilitators were provided to help ensure the sessions were accessible. A helpline was also available to support members’ participation. After each session, feedback questions and evaluation metrics were analysed to ensure the following events were accessible.  Also, using small group deliberation, as opposed to larger groups, has been shown to increase participation by women.  To sum, using a cross-representative sample and facilitating access helped to realise the democratic good of inclusiveness. 
The democratic good of considered judgment relates to the capacity of citizens to make reflective decisions. This good is contingent on the participants’ understanding of the technical details of the issue and the perspectives of other citizens.  Of course, the Assembly could not ensure citizens achieved considered judgment, but the processes of providing information and supporting the understandings of others can help develop this good.  Measures taken to achieve this include the participants hearing from and asking questions of local experts who discussed their knowledge and experience. The Citizen Scientist process was also a way to promote an understanding of other citizens’ perspectives. By discussing the impacts of the pandemic on others in the community, the participants could gain relevant knowledge on other, diverse perspectives. These learning processes provided information to the individuals to help them develop considered judgments. 
It is less clear how well the democratic good of popular control was achieved. Popular control requires scrutiny of the degree to which participants can influence different aspects of the decision-making process. Smith distinguishes between problem definition, option analysis, option selection, and implementation.  For problem definition, it seems citizens had no control or even participation. The topic of health and care was put to the members rather than residents setting the agenda. In terms of option analysis, the individuals participated in discussing and feeding back their views to create the expectations and priorities for shaping policy. Hence, they had some degree of control in shaping these. Similarly, for option selection, the participants’ feedback helped draft the revised priorities.  However, citizens were not given control over any of the implementation of the priorities. Implementing the priorities was left to the health and care partnership. 
It is not transparent how, or even whether, the Assembly increased popular control in broad political-decision making. The Assembly has received very little media coverage, and there is minimal academic literature so far. So, it seems likely that few non-participants are aware of the Assembly’s deliberations, recommendations, or even its existence. 
Analysis and Lessons Learned
A productive feature of the Assembly was the Citizen Scientist process. This feature increased participants' knowledge and understanding by asking them to deliberate on their own experiences and those of other community members. By understanding others’ perspectives, the Assembly may have been suited to reaching judgments in the public interest.  This process also empowered the citizens to actively deliberate outside of the Assembly, which may encourage their participation in political activity. 
A lesson learned was that the Assembly was able to continue after moving online. The Assembly continuing was achieved by the pragmatic steps taken to ensure inclusiveness was unaffected, such as technological assistance and the helpline to assist participants.  The process of regular feedback and evaluation to assess members’ needs helped to ensure the Assembly’s continuation. While the online adaptation appears positive, it would have been interesting for the organisers to discuss whether efficiency was affected in their final report. 
A second lesson learned is that the participants benefited from the Assembly shifting its focus slightly after returning from the Covid-19 enforced pause. The initial focus of the Assembly was solely on the health and care system. After the pause, the effects of the pandemic on individuals and the community were also considered. A criticism could be made that this disrupted the overall focus.  However, it seems beneficial that some of the discussions considered the effects of the pandemic due to the extraordinary circumstances the participants found themselves in.  Additionally, this change in focus allowed the Assembly to reflect the world’s changing circumstances and consider how the pandemic may relate to health and care in Camden. This change in focus also did not disrupt the Assembly from succeeding in its purpose of finding recommendations for the health and care system. 
The Assembly’s sampling was positive in its inclusiveness by stratifying relevant variables to create a cross-representative sample. Stratifying the ethnicity of participants helps to ensure the Assembly’s results are not skewed against the interests of ethnic minorities.  Using an internal data team also helped achieve inclusiveness. If a survey company (e.g., YouGov) had been used, it is plausible that people who are already highly attentive to politics may have been overrepresented due to participants being on these companies’ contact lists.  Also, only having around 50 members is a fairly low standard, and having 100 or more may have strengthened the Assembly’s validity.  However, the costs necessary for increasing participants may have made the process prohibitively expensive. 
Despite the many positive features of the Assembly, a few recommendations for improvement can be made. First, one way to analyse a democratic innovation is to assess whether it achieved its purpose. The purpose was to shape health and care policy in Camden.  It seems this purpose was never meaningfully achievable as the Assembly had little ability to affect policy. The Assembly was never tasked with producing actionable recommendations.  This is likely the case because the power of the Council to change health and care policy is constrained due to the control of the national government and NHS, who hold the responsibility for policymaking. This raises the question of whether the process genuinely had any power or whether it functioned like a consultation.  If it was akin to a consultation, Smith notes that misusing the term can have a detrimental effect on the public’s understanding of citizens’ assemblies.  For future endeavours, it may be more productive to address problems the Assembly can genuinely affect. This would also allow for a form of public ratification, which would increase the future Assembly’s popular control. Even if the recommendations had been defeated, the Assembly’s publicity might be increased and popular control would be better achieved. 
Second, greater media coverage would have increased the Assembly’s wider impact. Camden’s Climate Assembly achieved impressive media coverage.  However, this was not replicated in the health and care Assembly. Although, the focus on local health and care policy may have been less appealing to journalists. 
Third, the Assembly was likely significantly too brief compared to Involve’s recommended minimum of 30 hours.  It seems the sessions were shortened due to the Assembly moving online and so the reduction in time may have been necessary. Nonetheless, the allocated time was likely not proportionate to the Assembly’s purpose. 
Fourth, Smith notes that it is important for citizens’ assemblies to be impartially facilitated.  Kaleidoscope Health and Care were the independent lead facilitators of the Assembly’s events. However, Camden Council facilitated the breakout groups. Hence, the process was not run entirely impartially, and this ought to be avoided. 
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