Chapter 3: From Tokenism to Trust: Transforming Public Engagement in Local Authority Research and Practice Through Health Determinants Research Collaborations

Health inequalities disproportionately affect the poorest and most marginalised communities, making it essential that their voices are not only heard but actively engaged in research aimed at addressing these challenges (Parbery-Clark et al., 2023). Since 2013, the transfer of public health responsibilities to local authorities has intensified the emphasis on evidence-based decision-making and public involvement in shaping health policies (LGA, 2022). Although evidence has always been central to council priorities, its use has often been constrained by politics, financial limitations, and the need for rapid decision-making, resulting in its underutilisation (Boaz et al., 2019; Cheetham et al., 2022; Kneale et al., 2017). In response, local authorities are formalising their research structures, building internal capacity, and fostering a research culture that prioritises collaboration with residents (Homer et al., 2022). This represents a crucial shift from conducting research on communities to working with them, fundamentally transforming public involvement.

Despite these changes, achieving meaningful public engagement remains challenging due to local authorities experiencing substantial and sustained periods of austerity (Gray & Barford, 2018). However, the establishment of in-house research capacity, supported by external research partnerships, offers hope for building more consistent, and impactful PICE.

The National Institute for Health and Care Research (NIHR) has launched 30 HDRCs across the UK. These HDRCs, in partnership with regional universities, aim to embed a research-driven culture in local authorities, enhancing their capacity and infrastructure to tackle health inequalities through evidence-based decision-making (NIHR, 2023a). PICE are central to this initiative, reinforcing the importance of collaboration. As public bodies, councils must remain accountable to their communities. Genuine public involvement ensures that decisions reflect residents’ needs and that public funds are spent wisely. However, with the growing demand for public involvement in research, there is a risk of tokenism: engaging communities merely to meet funding or regulatory requirements rather than fostering meaningful collaboration. Moving from tokenism to trust requires ongoing transparency, reflection, learning, and a sustained commitment to engagement (Jackson et al., 2020).

HDRCs were established as part of an NIHR initiative. Our team operates across all council departments, and a key goal is to drive health-focussed research and build long-term research infrastructure. We have extensive staff and resources, including a multi-disciplinary team comprising research leads, a knowledge broker, a data scientist, a training lead, and a PICE lead. Most of our independent researchers hold PhDs and come from multi-disciplinary academic backgrounds.

The HDRC's roles are integral to strengthening relationships with the community, Voluntary, Community, and Social Enterprise (VCSE) organisations, stakeholders, and underrepresented groups to collaborate on our research efforts. We work extensively with a PICE board that includes community members and marginalised groups who review and shape our research priorities. Our work is underpinned by equity, and we ensure that public contributors are fairly compensated for their time, demonstrating our commitment to meaningful involvement. This approach to PICE work marks a positive and significant shift within the council, aiming to deepen engagement with residents and aligning our research more closely with community needs.

As evidence-based practice gains momentum in local authorities, opportunities for original research grow, and so do the challenges of integrating PICE meaningfully. While PICE is widely recognised as essential for robust research (Liabo et al., 2020), concerns about tokenism arise when power imbalances remain unaddressed or when engagement serves primarily to satisfy funding criteria (Ocloo & Matthews, 2016).

Grant applications now often require evidence that PICE has shaped the research proposal (Wilson et al., 2015). This requirement introduces financial and practical challenges, as PICE involvement incurs costs – such as remuneration, room hire, travel, and VCSE support – that local authorities may struggle to justify without secured funding. Although some small bursaries exist, substantial PICE funding usually becomes available only after grant approval (Jackson et al., 2020). This creates a paradox: while PICE is necessary to secure research funding, the lack of upfront funding often restricts its implementation, compromising both the quality and authenticity of the engagement.

This paradox became evident during a recent funding application, in which we collaborated with local authority and university colleagues to explore the integration of domestic abuse awareness into relationships and sex education (RSE) in schools. While the HDRC could draw on professionals such as practitioners and academics to ensure research feasibility, the success of this public health initiative depended on early engagement with VCSE groups. These groups were critical for shaping the project's direction, navigating the sensitive topic, and ensuring the research was both relevant and welcomed by children and young people. However, the funders required evidence of engagement before approving the grant, and the HDRC lacked immediate resources to facilitate this. The HDRC leveraged its partnership with the university, which provided the remuneration for PICE activities, enabling the project to proceed without delay. This early involvement aligned the research with the lived experiences of those affected, demonstrating the value of meaningful PICE. This example underscores the importance of proactive, early stage PICE funding and the value of established partnerships in overcoming potential barriers. Without this early stage engagement, the quality and authenticity of the project would have been diminished, reducing both its impact and likelihood of funding success.

However, it is important to recognise that incorporating PICE into research requires strategic planning across multiple stages. Involving and sharing decision-making power with communities carries financial implications at both individual and organisational levels. At the individual level, PICE members must be remunerated for their time, with reimbursement costs increasing based on the level of involvement required. At the service level, funding may need to be reallocated to accommodate PICE costs – a significant challenge for local authorities during periods of austerity. Nevertheless, the long-term benefits of empowering communities and improving health equity far outweigh these costs (Ocloo & Matthews, 2016).

Our team seeks to address these challenges by forming ongoing partnerships with universities, pooling resources, and generating networks that strengthen grant applications. By establishing community-informed foundations, we aim to balance financial risks while ensuring that PICE remains meaningful and impactful.

Those who use PICE should proactively avoid and prevent tokenism by ensuring it is a genuinely integrated process, underpinned by a shared commitment to meaningful engagement among all stakeholders (Brett et al., 2014). Our team has facilitated this by engaging in early stage community involvement to ensure research outcomes align with real-world needs. This collaborative approach leverages local authority insights and academic expertise, building trust and demonstrating the value of PICE in creating impactful, sustainable policy interventions (Staniszewska et al., 2018).

One of the main challenges we experience is that certain funding streams are exclusive to higher education institutions. Without HDRC's collaborative relationships, these funding opportunities would remain inaccessible, limiting research progress within local authorities. Collaborating with universities has provided valuable learning opportunities by pooling resources and expertise, reducing financial risks, and ensuring that PICE remains credible and ethical throughout the funding process. Through these partnerships, universities can provide remuneration where local authorities lack internal funding for PICE, but this highlights a need for local authorities to develop their own PICE funding strategies to prevent over-reliance on external support. For this collaborative model to succeed, local authorities, and community representatives must co-create scalable project frameworks that include clear PICE budgeting, particularly when engaging marginalised populations.

NIHR guidelines (NIHR, 2023b) provide a useful starting point for establishing baseline remuneration rates. It is important to recognise that disadvantaged individuals may encounter additional barriers to involvement such as childcare needs or income loss, making standard remuneration inadequate. Context-specific assessments and solutions are necessary to navigate these financial, logistical, and ethical challenges if we are to move towards ensuring inclusive and effective engagement. Sustainable and proactive funding models are essential to making PICE a fundamental part of the research process, not an afterthought (De Simoni et al., 2023). By prioritising these changes, local authorities can move beyond tokenism, ensuring that PICE empowers communities and drives equitable, impactful research outcomes.

Public mistrust of councils has been identified as a significant barrier to effective engagement. In 2022, trust in local authorities stood at just 54% (APSE, 2022), reflecting a broader decline in confidence across UK government institutions, contributing to a ‘crisis of trust’ (Hardin, 2008; Llewellyn et al., 2013; O’Neill, 2002). For council-affiliated researchers, this mistrust complicates efforts to engage communities, as negative experiences with council services – such as housing or social care – often deter participation.

As a research team, we have encountered situations where residents have shared their frustrations with our researchers, stemming from difficulties navigating health and social care systems. It is not unusual for community members to feel frustrated, ignored, or marginalised, and such encounters underscore the challenges of conducting public engagement from within the council, where political decisions and systemic inefficiencies can fuel public animosity (Bagozzi et al., 2022). To build trust, the HDRC prioritises transparency and the creation of safe spaces for community feedback, ensuring residents see how their input influences outcomes (NIHR, 2023a). By fostering consistent and meaningful participation through iterative processes, the HDRC aims to shift perceptions and rebuild trust in the council's role. Overcoming public mistrust is essential for successful PICE; without it, even the most well-intentioned efforts risk being perceived as tokenistic.

Our HDRC often uses qualitative methods, such as interviews and focus groups, to embed residents’ voices in council work. However, involving marginalised and underrepresented communities repeatedly can lead to participation fatigue, creating a risk of over-relying on the same groups (Attree et al., 2011; Baines et al., 2022). This has been echoed by participants within our local community who have expressed frustration, feeling their voices were used in previous research without seeing tangible benefits or recognition, either through feedback or remuneration.

As part of our work, we engaged typically underrepresented groups, including gay and bisexual men, transgender individuals, ethnic minorities, and youth under 19 years. However, representatives of these groups reported to us as having participated in a similar consultation previously, but felt their input was merely used to meet diversity requirements. Additionally, participants noted a lack of follow-up, with no feedback on how their contributions impacted services. The repeated engagement by different council directorates left them feeling overused and undervalued.

To rebuild trust, HDRC researchers co-designed focus group activities with community members to ensure cultural relevance and sensitivity. We implemented a clear remuneration policy, following NIHR guidelines (NIHR, 2023b), and established a feedback process in which council representatives returned to the community to demonstrate how their input shaped service delivery. This approach aims to repair relationships and ensure participants feel genuinely valued. Sharing this case study with staff promotes a shift in public involvement practices and demonstrates how embedding research values into engagement can make every interaction meaningful.

These efforts align with the HDRC's broader goal of transforming council culture. While systemic change takes time, incremental improvements in engagement can have a significant impact. As a researcher, you may encounter representatives of marginalised communities who express scepticism, rooted in prior negative experiences with other teams. Having clear, unambiguous goals, outlining the scope of involvement, and following through on commitments will help you build trust and leave the door open for future collaborations.

A significant concern related to participation fatigue is the overreliance on individuals with lived experience. While co-creating services with those affected offers invaluable insights by grounding public services in their realities (Strokosch & Osborne, 2020), this approach can become unsustainable without careful management. The council's duty of care extends not only to the public but also to its employees and wider PICE network. Overburdening individuals with lived experience risks compromising their well-being and reducing meaningful engagement to tokenism. Effectively managing contributions is crucial to avoid criticism about exploiting these individuals, whose perspectives are critical yet often overstretched, particularly in sensitive research areas that may cause emotional strain (see Adams and Ramsey's chapter on Trauma in this collection).

Multi-disciplinary support within research teams is essential. For example, in a recent focus group with individuals in recovery, participants were asked to share their experiences of deaths related to drugs, alcohol, and suicide – deeply personal and emotionally heavy topics. To mitigate potential harm, the sessions were co-designed and co-delivered with trusted VCSE organisations, ensuring support was provided both before and after the focus groups.

Insights gathered throughout this PICE work were essential for shaping the council's strategic approach. This example highlights the delicate balance between gathering input and safeguarding the well-being of vulnerable groups. It underscores the importance of ensuring every engagement is necessary, conducted sensitively, and offers clear benefits beyond meeting procedural requirements. Additionally, it emphasises the ethical responsibility of protecting participants throughout the PICE process.

Engaging seldom-heard groups requires addressing power dynamics effectively. Arnstein's (1969) ladder of citizen participation provides a framework for understanding and addressing these dynamics, urging researchers to move beyond tokenism and redistribute power to communities. The ladder illustrates varying degrees of citizen power, from manipulation at the lowest level to full citizen control at the highest, emphasising the importance of equitable involvement (Arnstein, 1969). The HDRC, uniquely positioned between the university and the council, bridges these hierarchies and advocates for public empowerment, ensuring a balanced approach.

Historically, power in research has often been concentrated in the hands of researchers (Mitchell et al., 2023). PICE offers a pathway for a more equitable approach, shifting power to the public and making them central to research design and implementation (Bidwell & Schweizer, 2020). This shift is crucial in public health research, as the public's perspectives must guide the research process to ensure its relevance and impact, and their needs directly shape the outcomes.

Navigating power dynamics in research, particularly when engaging seldom heard groups, requires a commitment to equity (McAreavey & Das, 2013). This involves reflexivity, transparency, and adaptability to prioritise public voices (Mitchell et al., 2023). Arnstein's ladder underscores the importance of this commitment, with the HDRC emphasising early PICE activities to review and shape research proposals to reflect community input and needs.

The complexities of engaging seldom-heard groups often intersect with the role of gatekeepers, which must be handled with care. During the project seeking the integration of domestic abuse awareness into RSE in schools (mentioned in Section 2.1), the critical role of gatekeepers became apparent. Despite efforts by HDRC colleagues to maintain transparency through regular meetings, the gatekeeper chose to conduct engagement activities independently, providing the research team with summaries afterwards. While this approach limited direct engagement between researchers and the public, it reflected the gatekeepers’ desire to manage the community's involvement in a way they deemed protective of community interests.

This situation underscores the dual role of gatekeepers: they facilitate access to seldom-heard groups and help prioritise their needs, but their decisions can also present challenges for researchers. Without direct interaction, researchers may lack the depth of understanding needed to respond fully to public feedback (Clark, 2010; Kay, 2019; McAreavey & Das, 2013).

To ensure the gatekeeper's role supports equitable power redistribution, clearer frameworks are necessary. These frameworks should include training and guidelines for gatekeepers to foster collaborative, transparent processes. Building trusting relationships and co-creating strategies can help researchers balance these dynamics, ensuring that power is genuinely shared and that public engagement remains central within the research process (Singh & Wassenaar, 2016).

The HDRC, with its unique position and ongoing advocacy for robust PICE practices, is well-placed to establish these frameworks and ensure future projects realise PICE's full potential. This ongoing commitment helps ensure research authentically empowers communities and reflects their needs, making a lasting impact.

A core aspect of cultural change within PICE is effectively managing representation to ensure diverse and/or seldom-heard communities are meaningfully included. However, managing representation alone is not enough; overcoming cultural resistance and systemic barriers is equally important. By expanding public involvement and including underrepresented voices, the council can more equitably and effectively address the root causes of health inequality. For instance, our council's sexual health needs assessment brought together diverse groups to co-design the council's sexual health offer, ensuring the solutions were inclusive and reflective of varied community needs.

Cultural transformation within local authorities requires commitment, cultural sensitivity, and competence; it also takes time and demands negotiation, sustained effort, and collaboration within and across council departments. Our team within the HDRC plays a pivotal role in this transformation. However, progress necessitates an ongoing critical appraisal of our practices and the dismantling of institutional barriers. These include budget constraints, bureaucratic inertia, and conflicting priorities across council sectors. Securing long-term buy-in from all areas of local government involves proactive stakeholder engagement, ongoing staff training opportunities on PICE values, and alignment with regional and national priorities to gain policy support.

This ongoing challenge demands resilience and a commitment to seeing through the slow but essential work of creating systems where PICE is a genuine priority to improve health equity. Rather than focussing solely on consultation, researchers must examine their overall PICE strategy and explore opportunities to embed collaborative practices more deeply in their work. More recently, we have initiated training workshops on all aspects of research delivery – from shaping an idea to disseminating findings – to facilitate cross-directorate collaboration and build a unified approach to PICE that strengthens health equity in the region.

Incorporating peer researchers and community champions is one way to address the inherent power imbalances of conducting research within political institutions. By empowering individuals from communities most impacted by health disparities, HDRCs can ensure that research reflects lived experiences and addresses real-world challenges. This approach not only amplifies marginalised voices but also helps dismantle systemic inequities, fostering a more democratic research process that directly engages the communities we aim to serve.

However, this approach also raises another challenge: while inclusivity in PICE cannot be overstated, over-reliance on a small number of voices risks perpetuating exclusion and undermining PICE's goals. Our HDRC has implemented strategies such as partnerships with VCSEs to diversify participation, ensuring that networks are representative, inclusive, and respectful of contributors’ time and expertise.

Regardless of the approach, mobilising knowledge effectively requires PICE to be collaborative, co-created, co-designed, and co-produced. These practices must go beyond procedural requirements to deliver meaningful change.

Austerity has shifted the focus of many public services from proactive and preventive to reactive and restrictive measures, worsening health inequalities. Budget cuts and limited resources have hindered councils’ ability to prioritise PICE and develop long-term, inclusive strategies for community engagement. For example, funding reductions for preventative services, such as smoking cessation (Anderson et al., 2018), have made it increasingly difficult to engage proactively with communities.

However, in times of financial constraint, PICE becomes even more critical. Engaging marginalised groups in designing services ensures their needs are properly considered, especially when resources are stretched. The HDRC provides additional resources to strengthen public engagement efforts and enhance the council's evidence base. By embedding PICE into service delivery and design, these efforts help mitigate the impact of austerity on health outcomes and the social determinants of health. By amplifying community voices and leveraging HDRC's resources, councils can take steps towards minimising health disparities, even when faced with financial and structural barriers.

The HDRC's work is already beginning to influence local policy by embedding research findings into decision-making processes. This is not merely an academic exercise but a tangible effort to shape policies that better respond to community needs. The HDRC's work signifies a call to action for researchers, policymakers, and community members within local government. It offers a transformative opportunity to deepen and expand PICE, positioning PICE not as a procedural obligation but as a necessary and powerful framework for co-designing services that genuinely reflect the needs and priorities of residents (Jackson et al., 2020). By fostering authentic and sustained engagement, HDRCs can build partnerships that promote more sustainable, equitable, and healthier outcomes for our communities.

Trust is central to this transformation. When communities witness clear and measurable outcomes from their involvement, engagement deepens, and a stronger, more resilient relationship between the council and the public emerges. This trust is especially crucial for reducing health inequalities, as it helps ensure the voices of those most impacted by systemic disparities are heard, validated, and acted upon. By building trust through transparent and iterative engagement processes, the HDRC is helping the public take control of their communities and address the wider determinants of health that affect their lives.

Achieving this vision requires an ongoing, collective commitment to embedding inclusive practices, fostering shared responsibility, and ensuring equitable representation in every aspect of research and decision-making. The HDRC is integral in facilitating this shift, working closely with the council and community members to ensure PICE evolves into a model built on trust, collaboration, and meaningful impact. Through this work, HDRC is enhancing the council's capacity to deliver evidence-based policies while cementing PICE as a central element of our long-term strategy to address health inequalities.

In doing so, our HDRC is moving the council beyond traditional, top-down models of engagement, embedding a culture of partnership and co-production where communities actively shape decisions that affect them. This cultural shift prioritises collaboration and shared ownership, encouraging communities to participate fully in addressing local challenges. This transformation is not just about improving processes; it is about fostering a legacy of trust and empowerment that goes beyond tokenism. By empowering the public to take an active role in addressing the wider determinants of health, the HDRC is building a foundation for sustainable, community-led change, ultimately shifting the relationship from tokenism to trust.