The original Ladder of Participation devised by Sherry Arnstein in 1969
Some of you may know that, in 1969, Sherry Arnstein looked at citizen control and how citizen participation helps people achieve it. As she worked in America she used the word ‘citizen’ – an American term for our ‘general public’ or ‘people’. The word ‘citizen’ has now been adopted in the NHS.
Sherry studied different citizen campaigns in different parts of the USA and published her conclusions in an academic paper. Her work shook up both the political thinking of the time and its comfortable democratic principles.
She talked about the ‘have nots’, as citizens/people without power, and about how citizen participation was a means for them to gain some influence over the affluent society they lived in, and a share in some of its benefits. Her Ladder shows the different levels of citizen participation that measure how much control people are allowed to have over aspects of their lives.
She also described how, the closer the ‘have nots’ got to achieving full citizen control, the more barriers and excuses were introduced by those holding the power to make the decisions that affected their lives. And, how these barriers and excuses showed the discrimination that existed at the time.
Sherry was working on this at the end of the ’60s, a time when there was the American civil rights movement, the anti-Vietnam War movement and student unrest everywhere. A poster she saw created by French students in the 1968 Paris uprising particularly inspired her.
‘I participate, You participate, He participates, We participate, You participate, They Profit’
It’s uncanny how relevant the words from her paper are today – nearly half a century later.
“The heated controversy over “citizen participation”, “citizen control”, and “maximum feasible involvement of the poor”, has been waged largely in terms of exacerbated rhetoric and misleading euphemisms.”
“The idea of citizen participation is a little like eating spinach: no one is against it in principle because it is good for you. Participation of the governed in their government is, in theory, the cornerstone of democracy-a revered idea that is vigorously applauded by virtually everyone.”
“And when the have-nots define participation as redistribution of power, the American consensus on the fundamental principle explodes into many shades of outright racial, ethnic, ideological, and political opposition.”
This version of her Ladder of Participation clearly summarises her analysis:
Only a decade ago people in many places across the country experienced participation in the NHS at rungs 6 and 7 of the Ladder of Participation which Arnstein describes as Citizen Power.
Whereas in today’s NHS in England ‘citizens’ are allowed no more than rungs 3, 4 and 5 of the Ladder of Participation, which Arnstein describes as Tokenism.
But the NHS, in England, is now introducing the two lowest levels of Arnstein’s Ladder of Participation (1 ‘manipulation’ & 2 ‘therapy’) by encouraging people to manage their own health. As part of the Sustainability and Transformation Plans and New Models of Care we are now expected to change our lifestyles and to ‘self-manage’ any long term conditions we may live with. The NHS describes this new expectation as ‘patient involvement, or participation, in their care’ but Arnstein describes it very clearly as Nonparticipation.
Even worse – only a few weeks ago – NHS England’s Patient and Public Participation Team introduced their new, supposedly improved, ‘Citizen’ Participation programme. But this will only work at levels 1 – 5 of the Ladder – which is ‘Nonparticipation‘ and ‘Tokenism‘.
The people’s voice in the NHS has been taken away – why?
A decade ago the NHS was proud of working with patients, and the public, to improve services which then began to work better than they had for a long time. Why are the ideas and suggestions of the people using the NHS now considered so dangerous that they need to be silenced? It is really disappointing that the level of Participation in the NHS has sunk so low in such a relatively short time.
Why is this necessary – why is the public voice so dangerous?
The Ladder below describes a modern version of Arnstein’s Ladder of Participation created by a French student in 2009 showing how ‘citizen control’ is seen as dangerous by those holding the power and control. The 1968 Paris student slogan is included (top right), and the spelling is interesting but the message is perfectly clear.
Arnstein’s Ladder, created to describe how people could gain power and control over their lives, has been ‘diluted’ over the years by those holding the power.
Each time her Ladder is simplified its meaning is diluted as there is no reference to her clear analysis. The very simplified version shown here is often used to show Arnstein’s Ladder.
But when compared to the detailed one shown earlier it tells us very little.
The one the right is a New Economics Foundation version, many ‘co-‘ words, but no clear explanation or analysis!
N.B. It was included, on P20, in the Northern Ireland Health Minister’s 10 year plan to save their health service ‘Health & Wellbeing 2026, Delivering Together’ that was published last Tuesday (25/10/16).
This is produced by Governance International, a consultancy set up in the ’00s, one of the new Involvement Industry. They help public services to ‘focus on smart savings and innovations to achieve better citizen outcomes‘!
Well they have a tree surrounded by all the ‘co-‘ words – so they must be good!
Finally – Arnstein’s Ladder of Participation, created to describe how people could gain power and control over their lives, has now been adopted by big business.
There is now a Ladder of Participation for On-line Customers.
Another about Loyalty to a Brand, for the marketing department.
There is even a ‘success’ Ladder for all those ambitious middle managers!!