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The classic accounts of deliberative democracy are also accounts of legitimacy: ‘that outcomes are legitimate to the extent they receive reflective assent through participation in authentic deliberation by all those subject to the decision in question’ ( Dryzek, 2001, p. 651 ). And yet, in complex societies deliberative participation by all those affected by collective decision-making is extremely implausible. There are also legitimacy problems with the demanding procedural requirements which deliberation imposes on participants. Given these problems, deliberative democracy seems unable to deliver legitimate outcomes as it defines them. Focusing on the problem of scale, this paper offers a tentative solution using representation, a concept which is itself problematic. Along the way, the paper highlights issues with the legitimate role of experts, the different legitimate uses of statistical and electoral representation, and differences between the research and democratic imperatives driving current attempts to put deliberative principles into practice, illustrated with a case from a Leicester health policy debate. While much work remains to be done on exactly how the principles arrived at might be transformed into working institutions, they do offer a means of criticising existing deliberative practice.

This chapter outlines the theory of deliberative democracy and deliberative institutions, highlighting the legitimacy problems — to do with the scale of the deliberations and the motivation to participate — as experienced by the organizers of a citizens’ jury in Leicester, England, in 2000. It explains the approach and methods, outlines the argument, and summarizes five cases of deliberation in the UK’s National Health Service.

A number of organizations in Britain's National Health Service (NHS) have been experimenting with ‘deliberative’ techniques of citizen involvement, techniques that were designed with democratic imperatives in mind. However, political practices are moulded by their institutional settings and the goals of their proponents, so it is unlikely that they have been left ‘pure’ following their encounter with public management imperatives.This paper offers an explanation for the interest in deliberative processes in the NHS by comparing deliberative and public management imperatives, as well as discussing more case‐specific motivations, drawing on interviews with health policy actors between May and July 2001. I then use those insights to highlight gaps between the deliberative ideal and deliberative practice, showing what has been gained and what has been lost in the encounter between deliberative democracy and new public managers.

This book attempts to solve two problems in deliberative democratic theory and practice: How can agreements reached inside deliberative forums be legitimate for those who did not take part? And why should people with strongly-held views participate in the first place? The solution involves rethinking deliberative theory, but also draws on lessons from practical experience with deliberative forums in Britain’s National Health Service. The book discusses the competing representation claims that different participants make, the pros and cons of different approaches to democratic accountability, and different conceptions of rationality and public reasoning. It concludes by rejecting the idea that we can have authentic, legitimate deliberation in any one forum. Instead, authentic, legitimate deliberation can only result from linkages between different kinds of institutions, drawing on different kinds of participants, at different points of a decision-making cycle. That is, it promotes a macro, society-wide view of deliberative democracy quite different from the micro, deliberative-forum view which dominates thinking on the subject in the UK. The book sketches the outline of such a deliberative system, suggesting how various institutions in civil society and elected government might link together to create public decisions, which are both more rational and more democratic.