Reality or rhetoric? Community involvement in primary care in north inner city Dublin.
Irish Primary Care policy sees community involvement as a principle to guide the development of services. This study explores how the policy arena was reflected in the lived reality of community and Primary Care in north inner city Dublin. Meaning of community involvement in health is explored through an analysis of the evolution of the construct. The policy arena is described particularly in relation to the Irish context. Against this backdrop spatial practice and power relations are described and analysed to understand what community involvement in Primary Care means in the context of Dublin's north inner city.
An ethnographic approach was used, involving participant observation in different social settings. These included the community sector, a Primary Care Partnership and an action research project with drug service users. Cornwall and colleagues' conceptualisation of spaces for participation is used to describe and analyse these spaces in order to identify influence on decision-making in Primary Care.
In contrast to the aims of national policy this study finds that communities did not influence formal Primary Care planning or decision making in the study area. It finds barriers to the involvement of community voice in Primary Care planning and development and concludes that these barriers are even greater for the socially marginalised group - drug users. Barriers to local influence (including influence by GPs), included top down decision making, covert health service planning, fear of confrontation, a historical lack of health service development and the lack of an identifiable 'system' of Primary Care. Barriers to involvement from the community side included the prioritisation of more critical issues for community action. Health status and services were not considered as targets for community action. GP were not involved in community agendas nor were they seen, either by themselves or the community, as relevant to them.
In practice community action through the formalised community sector addressed the underlying social determinants of health. Primary Care (as framed in policy) places community actions outside the frame. The design of the system and structure of Primary Care is being played out away from the public arena, and without inclusion of frontline Primary Care providers.
If community is to be involved in a meaningful way it will be necessary for Primary Care to be reframed to include efforts to tackle the underlying social determinants of health. This would therefor include the range of actions, projects, and services important to communities at least in deprived areas. I suggest that without such reframing, the aim should be to democratise decision making in spaces where decisions occur rather than supporting broad development ideologies which become meaningless in practice. I argue that the spatial conceptualisation of participative practice is useful for identifying opportunities to democratise decision making.