NHS England plans to create a national Citizens’ Assembly to “put people at the heart of everything the NHS does”. The Assembly will be “digital by default”, meaning that online participation will be the primary way in which people can take part. Unfortunately, in the current draft of the design, there’s a curious parallel between the way the Assembly is designed and the way websites are designed, which could make the Assembly vulnerable to hackers.
There’s a brief overview of the Assembly’s design, and a link to a paper that provides more detail, on the Democratic Society website, here: Overview of NHS Citizen
To explain what I mean about hackers, bear with me while I tell a story…
WordPress and the botnets
This website and others that I run use community-supported software called WordPress, which is estimated to run more than 60 million websites worldwide. Back in April it was reported that hackers were attacking WordPress sites. My sites were never vulnerable to this particular attack, but the way the attack works is instructive.
The hackers first attacked individual people’s PCs, installing a “robot” or “bot” in each PC. The robot does nothing until it’s told to by the hacker. It does no harm at all to the PC, and the PC’s owner doesn’t notice it. When the hackers had a vast network of robots, a “botnet”, numbering nearly 100,000, they moved on to the next stage.
The hackers then instructed all the bots to log in to WordPress sites pretending to be the site administrators. Of course, they didn’t know any of the passwords, but they had a list of common passwords to try. (Here’s a list of the worst 25 passwords of 2012, but the hackers’ list contained thousands: Scary Logins )
Inevitably, some of the bots guessed the passwords and were able to log in to WordPress sites. Each time a bot guessed a password correctly, it reported the password back to the hackers. What the hackers will do with the sites they’ve got into isn’t yet clear, but one theory is that because websites run on computers that are much more powerful than PCs, the hackers might use them as an super-botnet to attack financial institutions.
This attack on WordPress sites relied on having a large botnet. Sites can easily protect themselves from a single hacker, but when up to 100,000 bots attack, it’s very hard for sites to distinguish between genuine users and bots.
Note, too, the sophistication of this attack, whose real objectives are long-term and difficult to guess.
NHS England and citizens
This story illustrates the kinds of problem that NHS England faces in allowing a citizens’ assembly to influence its decisions. Hackers are not necessarily lone weirdos simply out to cause trouble. They may be well-resourced and highly-skilled teams with long-term financial or political objectives and complex, subtle strategies for achieving them.
The Discovery layer
In the discovery layer of the proposed NHS Citizen model:
“…information and opinions are gathered through social media, public comment, online and offline tools. This gives a picture of the “state of the conversation” on health, allowing issues of public concern to bubble up.”
In social media and other online environments it’s inherently difficult to distinguish between a citizen with a genuine, independently formed point of view and a bot. (Twitter bots and Facebook bots, for example, are readily available.)
And in addition to actual bots there will be real people whose views are not independently formed — people who behave like bots to further some cause or other. As soon as a fabricated point of view starts to gain momentum, other people who have no connection with the underlying long-term objective will inevitably join in.
An imaginary example
For example, an unscrupulous charity that wants to grow its state funding could use a combination of bots on Twitter, Facebook and elsewhere, together with its volunteer supporters, to make it look as if an issue of public concern has bubbled up. NHS Citizen would not be its only target. Local Healthwatches, CCGs and other bodies would be targetted at the same time. Ordinary public relations, lobbying and advertising activities would support the campaign.
Members of the public and the press with no connection to the charity might well join in, unaware of the hidden agenda. The long term objective would not be to get NHS England to fund the charity directly. It would be to enlist NHS England in a subtle shift of policy throughout the NHS towards the charity’s way of thinking and away from its competitors’.
The Discussion layer
The NHS Citizen model’s discovery layer feeds in to a discussion layer:
“…intended to take ideas and concerns which have emerged from the Discovery layer and to create the relevant evidence base and background that will be needed to present it to the Assembly and from there to the Board.”
But this layer, too, is vulnerable to hackers:
“The definition of ‘expert’ and ‘evidence’ is kept deliberately open in order to ensure that debate is not unduly prejudiced towards establishment experts.”
The model deliberately sets the standard of evidence in the discussion layer below the already sloppy standards of academic research and expertise.
The Assembly layer
Finally, the NHS Citizen model’s assembly layer brings issues to an offline meeting with online participation, both of which are vulnerable to activists with hidden agendas.
The assembly can convene panels to look into difficult issues, but in the current model the panels are deliberately made susceptible to the kind of hidden agenda that most members of the public would be unable to spot:
“People with greater expertise in the Panel topic than a well-informed citizen are barred from serving on that Panel, but may give evidence.”
I’m excited by NHS England’s vision of public participation and the NHS Citizen model. Indeed, I’ve already suggested elsewhere that councils of governors of NHS foundation trusts might want to consider adapting the model for trust members’ participation in the governance of trusts.
But I’m fearful of the unintended consequences of a model that’s vulnerable to sophisticated hackers, who may be better resourced and have more expertise than the NHS Citizen secretariat, and who might as a result run rings round them.