In the wake of Menadue’s call for setting principles to underpin our health care system,1 one key principle that members of “citizens’ juries” advocate is that the appropriate group to set the principles are citizens! Health services are first and foremost social institutions — that is, not just there for the people, but to be based on the values of the people.

I have facilitated a number of these citizens’ juries.3 They are a form of deliberative democracy.4 They bring together randomly selected citizens; and it is crucial that they are randomly selected, not hand-picked or self-selected. It is emphasised to the members of these juries that they are there as citizens, not consumers, and if the focus is, say, the Western Australian health service, that they are there as citizens of Western Australia, and not just of their home towns of Bunbury or Broome. They are given good information by experts whom they can quiz about health, health care services and resource availability. They are then asked to deliberate on what sorts of principles they want to guide their health services.

It seems difficult to argue against this idea of “the people” setting these principles. The issues involved are not technical ones. These principles might include value for money (efficiency); equity (and how this is defined and how important it is); transparency in decision making; prevention and its relative importance compared with treatment; and so on.3

Interestingly, in my experience, the people on these juries just love to act as citizens! They act responsibly and with pride in the role.

Two things are clear on the basis of the results of six juries in which I have been a facilitator.3 First, the citizens’ values and the relative weights they attach to them are broadly consistent across different juries. They want better access to services, especially a reduction of the barriers caused by a lack of awareness of where and how to get services; improved equity, particularly for Aboriginal people; and more emphasis on public health and prevention.

Second, if built on the principles arising from these six juries, the health care service would be rather different. For example, the citizens place less weight on hospital care and more on equity than the health service does currently.

Care needs to be exercised when choosing the issues about which citizens’ values are elicited. Citizens appear to feel comfortable when they are asked to consider principles and broad priorities. They argue that anything more detailed or at a more operational level is better left to others.

For the nation as a whole, I propose that there be 20 juries, each with 15 members (“20.15”), each covering a metropolitan, rural or remote geographical area and ensuring a good mix of these. Having just 15 members allows “a conversation” to be conducted within each jury, which is the ideal. These juries might be followed by a “National Citizens’ Summit” (NCS) at which one representative from each jury would present his or her jury’s findings; the NCS would then seek to achieve a consensus at a national level. Metropolitan, rural and remote juries may not be able to agree, but that is to be expected — what people in these different areas want from their health services is quite likely to be different.

The other advantage of establishing these principles — or a “constitution” (as I, along with my colleague, health economist Virginia Wiseman, have called these5) — is that this provides a base, indeed an incentive, to establish a more rational and systematic priority-setting system.6

Sadly, one of the most serious methodological failings of the Australian health service is the lack of such a system. This needs to be put to rights and to be based on what Australian health economist Stephen Jan has called long-term “credible commitment”.7 What is needed in setting these values and the subsequent priorities is to ensure that whoever sets them has a genuine long-term credible interest in wanting the system as a whole to function well. Citizens are the only stakeholders who fit this description.

There may be opposition to citizens’ juries. The former Health Minister, Tony Abbott, opposed citizens’ juries, believing, wrongly, that they would take power away from politicians and government.8 When I called for a citizens’ jury to look at the funding of aged care, the then President of the Western Australian branch of the Australian Medical Association was quoted as saying: “I don’t think a focus group [sic] debating it is the way you make big decisions.”9 However, these juries are not intended to be decision-making bodies; their role is to set the constitution. The idea will, however, have to be sold to those suspicious of using the lay public’s values in this way.

The approach has been adopted in other countries, most notably Canada10 and the United Kingdom.4 Menadue has argued that we badly need principles to guide our health care system.1 I endorse that view. Ethically and politically there is no group that is better placed to do this than the (informed) citizens whose health is at stake.

Citizens’ juries provide a tried and tested way to elicit these values. Let’s get on with them — and soon!