Health Policy 76 (2006) 156–168 The snakes and ladders of user involvement: Moving beyond Arnstein Jonathan Quetzal Tritter a,* , Alison McCallum b a Institute of Governance and Public Management, Warwick Business School, Coventry CV4 7AL, UK b National Research and Development Centre for Welfare and Health (STAKES), PL 220, 00531 Helsinki, Finland Abstract For 35 years, Arnstein’s ladder of citizen participation has been a touchstone for policy makers and practitioners promoting user involvement. This article critically assesses Arnstein’s writing in relation to user involvement in health drawing on evidence from the United Kingdom, the Netherlands, Finland, Sweden and Canada. Arnstein’s model, however, by solely emphasizing power, limits effective responses to the challenge of involving users in services and undermines the potential of the user involvement process. Such an emphasis on power assumes that it has a common basis for users, providers and policymakers and ignores the existence of different relevant forms of knowledge and expertise. It also fails to recognise that for some users, participation itself may be a goal. We propose a new model to replace the static image of a ladder and argue that for user involvement to improve health services it must acknowledge the value of the process and the diversity of knowledge and experience of both health professionals and lay people. © 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: User involvement; Patient participation; Patient empowerment; Citizen engagement; Expert patient; Health service reform 1. Introduction Recent health service reforms in Western coun- tries emphasise public and patient involvement [1,2]. Increasing participation of users in decisions around treatment, service development, and evaluation has been central to this process. The consequences are becoming clear as relationships between the state and citizens and between the public, patients and organi- sations within the healthcare system are redrawn. This * Corresponding author. Tel.: +44 2476528217. E-mail address: j.tritter@warwick.ac.uk (J.Q. Tritter). shift in health policy has generated significant debate in both Government and the media. The key document that continues to shape the theoretical framework for user involvement is Arnstein’s “A ladder of Citizen Par- ticipation” published in 1969 [3]. Despite its important in shaping thinking this model continues to be applied uncritically, despite thirty-five years of progress in our understanding of the factors that drive engagement. In this article, we explore the relevance of Arn- stein’s typology of user involvement to current devel- opments in healthcare, particularly within the English National Health Service (NHS), and draw on com- parisons from the Nordic countries, the Netherlands 0168-8510/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2005.05.008