What do community representatives want to achieve and how do they operate in a health service context?

The evidence base is poor in demonstrating that community participation in health services can improve effectiveness and appropriateness of care and address equity in access. This extended case study research addresses this recognised gap. The study examines the action and effects of community participation in a large area health service with a long-standing policy framework, and environment, supporting participation. The perspectives of the key stakeholders involved are explored alongside this action. The methodological limitations of past research informed the study design which employed mixed methods (observations, including 32 meetings; a survey of 142 staff and 42 community representatives; 36 interviews; and documentary analysis) in an ethnographically-informed three year case study. Analysing and triangulating data sets provide the platform for a number of significant, novel contributions with implications for the development of community participation models and practice. The empirical contributions include findings that show: community representatives (CReps) can have a wide range of impacts within health services, many deriving from their own agendas; CReps opportunities to effect change are neither limited to a direct challenge to health service staff nor to action within health service-controlled meetings, instead CReps tactically capitalise on opportunities which appear over time. Further, a forum for CReps to share their experiences and develop their own agenda as well as a Community Participation Coordinator (or facilitator) are important to support CReps capacity to take effective action. The analysis utilises and adapts new conceptual ideas to this field to understand CReps actions. One is to conceive of power as a complex web of relations, rendering visible CReps tactical use of diverse opportunities to effect change. A second is a model articulating how a facilitating role can work to support CReps. To realise the potential of community participation those seeking participation need to provide critical resources, including dedicated facilitation to support CReps actions. In order to broaden participation to include a more diverse range of perspectives the emphasis should not so much be on more formal mechanisms of representation, but on using a range of strategies to connect those who directly participate with those who do not