Throughout this book, evidence has been presented of ways in which lay people are improving community health and what needs to be in place to enable them to do this effectively. This chapter takes a step back to consider whether citizen involvement is necessarily a ‘good thing’ and to explore and challenge some of the counter-arguments about lay health workers and active citizenship in health. These counter-arguments can be broadly categorised into four:

• 1. ‘It's a diversion, as only addressing structural inequalities will improve health and address inequalities.’

• 2. ‘Involving lay people is too risky – professionals are needed.’

• 3. ‘If it's work, people should be paid for it – involving lay people threatens jobs.’

• 4. ‘It might be nice to do, but where's the evidence?’

These four arguments have been called myths because the authors believe that while there are important issues and concerns underpinning some of them, they are all fundamentally flawed. By contrast to these four myths, which are all sceptical of citizen involvement, there is a fifth, neoliberal argument that is dominant in UK politics, which is that citizen involvement is good because it makes it possible to cut services and ‘shrink the state’ as people take more responsibility for themselves. While the reality of a smaller public sector is all too real, the appeal that community activism will spontaneously grow once the Big Society replaces big government is another myth (see Hunter, 2011). This chapter critiques all five myths and sets out some alternative arguments supporting citizen involvement in the context of current public health challenges. These arguments are developed further in the final chapter, which explores some new ideas that are gaining currency and sets out a manifesto for change.

Citizen involvement is a diversion from addressing structural inequalities

Health is socially determined, and macroeconomic conditions are powerful forces that shape population health (World Health Organization, 2008a). Recent publications such as The Marmot Review (2010a) and The spirit level (Wilkinson and Pickett, 2009) have demonstrated that the social gradient of health is damaging to all sections of society. Put more simply, more unequal societies have worse health outcomes for all.