The snakes and ladders of user involvement: moving beyond Arnstein

Jonathan Q. Tritter, Alison McCallum

Research output: Contribution to journalArticlepeer-review


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.
Original languageEnglish
Pages (from-to)156-168
Number of pages13
JournalHealth Policy
Issue number2
Publication statusPublished - 1 Apr 2006


  • user involvement
  • patient participation
  • patient empowerment
  • citizen engagement
  • expert patient
  • health service reform


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