Evolution or revolution?
A critical analysis of Digital Era Governance in the National
Health Service
Master’s Thesis
Political Science: Public Policy & Governance
Completed June 2019
Student name: William Pett
Student number: 12166901
Supervisor: Dr Imrat Verhoeven
Second reader: Prof John Grin
This thesis is dedicated to the memory of my grandmother, Gwynne Bradstreet, who
devoted her life to education.
With special thanks to Dr Imrat Verhoeven, whose enthusiasm, wisdom and curiosity
brought out the best in me. Dank je wel.
ABSTRACT
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The 21st century has brought significant advancements in online and digital technologies. For some scholars of the welfare state, such technologies hold the key to modernising bureaucratic processes and moving beyond the ‘New Public Management’ (NPM) framework that has become dominant in many countries across the world. Over recent years, a new model for reform – ‘Digital Era Governance’ (DEG) – has been formulated specifically to harness the potential of digital
innovations to improve public services, and to reverse the damaging effects that NPM is thought to have had on welfare states.
While the optimism for DEG among advocates is welcome, this thesis identifies a concerning absence of any critical analysis on the model within the literature. There is a notable lack of evidence demonstrating either that DEG does indeed challenge NPM principles, or that the three elements of the model can work seamlessly together when applied in practice.
With the National Health Service in England set to implement a series of DEG reforms over the coming years, this thesis looks to provide this critical analysis. Through examination of policy documentation and government discourse, as well as seventeen interviews with experts and professionals working in the health sector, this thesis contends that DEG only challenges NPM to a limited extent. As such, it should arguably be considered evolution, not revolution, of the welfare state. In addition, this thesis highlights several obstacles that policymakers may need to overcome if DEG reforms are to be effective. It is hoped that the conclusions presented will pave the way for further theoretical development of DEG, while the recommendations set out at the end of the thesis may be useful for policymakers looking to DEG as a basis for modernising the welfare state.
CONTENTS
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Introduction ……… 1
Chapter 1: Analysing welfare states: A theoretical framework ………. 3
i) Models of bureaucracy: New Public Management (NPM) and Digital Era Governance (DEG) ………..… 3
ii) The state-citizen relationship & the role of active citizenship ……….….. 10
Chapter 2: Case selection and methods ………. 13
i) Case selection ……….……….. 13
ii) Case study design ……….………..………..……….……….. 14
iii) Methodology ………..………..………..……….………… 16
Chapter 3: The National Health Service in England: A shift to Digital Era Governance? ………….… 19
i) The NHS and the need for new solutions ………..……….….. 19
ii) Governance in the NHS ………..………..………..………….. 21
iii) DEG and the state-citizen relationship ………..……….. 23
iv) Conclusion ……….… 27
Chapter 4: Digital Era Governance as a new model of bureaucracy ……….………. 28
i) DEG’s interaction with NPM ………..………..……….……….. 28
ii) The state-citizen relationship under DEG ………..………..……….. 33
iii) Conclusion ………..………..………..………..………….. 35
Chapter 5: The obstacles to Digital Era Governance ………..………... 37
i) Obstacles to digitisation ………..………..………..……….. 37
ii) Obstacles to reintegration ………..………..……….…. 44
iii) Obstacles to needs-based holism ………..………..….………..……… 46
v) Conclusion ………..………..………..……….….…….. 50
Chapter 6: Implications and conclusion ………..………..………..…….. 52
Chapter 7: Policy recommendations ………..………..………..……….. 57
Bibliography .………..………..………..……….………….. 61
Appendix 1 ………..………..………..………..…..……….. 67
GLOSSARY OF ABBREVIATIONS
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DEG ………. Digital Era Governance
DHSC ………. Department for Health & Social Care
JUG ………. Joined-up governance
LTP ………. Long Term Plan
NHS ………. National Health Service
NICE ………. National Institute for Health and Care Excellence
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INTRODUCTION
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Innovations in digital technology have brought, and will continue to bring, significant changes across civic life. From online banking apps to ‘one click’ shopping to how we find love, we are now accustomed to using digital tools for a multitude of everyday tasks and leisure activities.
International organisations such as the Organisation for Economic Development (OECD) refer to the wave of digital innovations over recent decades as ‘the digital revolution’ (OECD, 2019), and one may consider us to be living in ‘the digital age’ (Bildt, 2017).
For some scholars of the welfare state, this revolution represents a significant turning point for how we understand and interact with public services. While for decades the literature on welfare states has been dominated by New Public Management (NPM), the development of interactive and web-based digital tools has formed the basis of a new model, or ‘framework’, of bureaucracy – Digital Era Governance (DEG) (Dunleavy et al, 2006). As shall be explored, advocates see this as a post-NPM framework for the delivery of public services and have enthusiastically outlined the potential of DEG to challenge the perceived NPM consensus.
This thesis hopes to assist the development of DEG by highlighting where there are current gaps or weaknesses in the literature around the concept. The enthusiasm and ambition of those advocating DEG is certainly welcome as scholars look beyond the NPM consensus that has
permeated welfare state literature in recent decades. However, if the model is to be considered a viable alternative to NPM then it must stand up to scrutiny, both in terms of its theoretical
coherence and opposition to NPM, as well as the potential for its successful implementation in welfare state services.
To provide such scrutiny, this thesis looks to closely examine the theoretical underpinnings of the model as well as some potential obstacles to its successful implementation across the National Health Service (NHS) in England. The research question it seeks to answer, therefore, is:
‘To what extent are digital era governance (DEG) reforms in England set to challenge NPM and what obstacles do experts and professionals foresee to the success of DEG in healthcare?’
Supported by analysis of government documentation and data from seventeen semi-structured interviews with experts and professionals, it hopes to provide direction for further theoretical development of DEG, demonstrating how and where the model may be most effective in the field of healthcare.
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This thesis is a relevant one to undertake in light of current social and scientific discourse. If we are considered to be in the early days of a new, digital age then the future of how we organise society, what we expect of government and what type of relationship individuals have with the state should be seen as matters of uncertainty. The research presented over the coming chapters seeks to provide some clarity on such issues in relation to one of the key social, political and civic institutions in England, the NHS.
To establish context for the reader, Chapter 1 shall outline the theories and concepts that are explored and analysed throughout the thesis. This provides a background to how NPM and DEG should be understood, as well as how each may influence the nature of the state-citizen
relationship.
Following this, Chapter 2 outlines the rationale behind case selection as well as the methods used for research. This sets out how a discourse analysis will be used to demonstrate the continuation of active citizenship under DEG and why this is relevant in relation to the research question. It will also explain how interviews will be used to identify potential obstacles to the model in healthcare. Chapter 3 then gives a brief background to the NHS and provides evidence that the British
Government is seeking to implement DEG reforms across the service. Following this, the discourse analysis of government statements and other policy documentation will provide evidence to support the assertion that such reforms are to be accompanied by state promotion of ‘active citizenship’.
Analysis of the data gathered through interviews is presented in Chapters 4 and 5. These chapters relate to the first half of the research question (‘To what extent are digital era governance (DEG)
reforms in England set to challenge NPM?) and second half (‘What obstacles do experts and professionals foresee to the success of DEG in healthcare?’), respectively.
After setting out the key implications from the data for the literature on the welfare state
(Chapter 6), the thesis shall conclude with a set of policy recommendations (Chapter 7). These are intended to provoke consideration among policymakers of how the shortcomings of DEG
presented throughout this research can be translated into practical ways of implementing DEG reforms more effectively over the coming years.
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CHAPTER 1
Analysing welfare states: A theoretical framework
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This opening chapter shall outline the models, concepts and theories that this thesis seeks both to critically examine and contribute to in the literature. There are several areas within the academic literature on Digital Era Governance where there is a notable lack of theoretical clarity. These will be highlighted to the reader, as they will help to provide context to why the set research question has been chosen.
i) Models of bureaucracy: New Public Management (NPM) and Digital Era Governance (DEG)
a. New Public Management
Perhaps the most fundamental change to the structure of the welfare state in the UK since its inception in 1945 came under the administrations of Margaret Thatcher in the 1980s. While for many decades the state had delivered the vast majority of the ‘cradle to grave’ services across areas such as health, employment support and community maintenance (Hemerijck, 2013, p.120), Thatcher was ideologically highly sceptical of the state’s predominant role in delivering services, writing critically about the large welfare state she inherited in her memoirs (Thatcher, 1993, pp. 7-8).
Driven by a desire to reduce the size of what she saw as a burdensome public sector, she introduced private sector management practices into welfare state services, for example by introducing competitive tendering between providers across many areas of public service provision (Burton, 2013, pp.18-19). This new ‘performance-driven’ approach to public sector organisation was to become known as New Public Management (NPM) (Pollitt, 2003a, pp.28-29). Thatcher was initially hesitant to carry out large-scale NPM reforms in healthcare due to the rising popularity of the universal, state-led NHS (Burton, 2013, p.19). However, eventually she did seek to increase private sector provision in the NHS (ibid) and strengthened management controls across the service (Clarke and Newman, 1997, p.20). Chapter 3 shall outline that while the
development and implementation of NPM reforms across the English health service began under Thatcher, it certainly did not end under her reign as Prime Minister. The legacy of NPM has survived well into the 21st century.
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As its influence has increased across Europe and other developed nations over recent decades (John, 2011, p.70), NPM has been adopted in various ways. Different scholars, and indeed
governments, have drawn upon different component parts of the model. This is demonstrated by Bach and Givan (2011) in their analysis of how NPM reforms in public service employment
relations have varied significantly between the UK and the USA. There is, they argue, a notable degree of malleability in how NPM has been developed and implemented (idem, p.2350). For the purposes of this thesis, therefore, NPM shall be defined according to the three components set out below in Table 1.1.
Component Description
Disaggregation of public services
• Break-up of public sector by contracting out functions and/or bureaucratic processes where possible
• Identification of where comparative advantage exists between the state and external providers
• Reduction of red tape to encourage
entrepreneurialism amongst new providers of services
Competition between providers
• Use of market or market-like mechanisms in the public sector to incentivise efficiency and performance • Breakdown of bureaucratic monopolies
• Contracting out of services to the private sector, ranging from limited private sector involvement to complete privatisation of services
• Procedures to allow consumer choice between services
Incentivisation • Competition and efficiency incentivised through
publication of performance evaluation criteria
• Continuation of contracts based upon service offer and performance
• Use of incentives, rewards and sanctions
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There is some consensus on these three elements forming the basis of NPM. While John (2011) is cited for Table 1.1, the ‘disaggregation + competition + incentivization’ model is also referenced more widely in the literature (Dunleavy et Margetts, 2000, as cited in Pollitt, 2003a, p. 27). There is, of course, an ideological aspect to NPM. In his work on governance, Klijn (2008, pp.509-510) argues that there are no a-political means for the government to ‘get the job done’; rather, there is an inherently political nature to the frameworks under which governments make and implement policy. While this thesis is not focused specifically on governance, at least as described by Klijn, it will seek to explore the link between bureaucratic models and the political ideologies that accompany and legitimate them.
In the case of NPM, it has been argued that the model has in recent decades served as a reflection of the rise of neoliberal political and economic ideologies – a rise arguably triggered by the demise of Keynesian economics in the 1970s (Leicht et al, 2009, p.584). Certainly, NPM reforms have tended to be implemented by economically right-leaning governments. In the case of the UK, recent Conservative administrations have made no secret of their desire to reduce the size of the central state. George Osborne, the former Conservative Chancellor of the Exchequer, presided over NPM reforms across government during his time in office between 2010 and 2016 (Hyndman & Lapsley, 2016), and these reforms reflected the ideological belief in a small state he outlined frequently in interviews and speeches (see, for instance, Osborne, 2012).
It is important to note here that the expansion of NPM across many parts of the developed world in recent decades has been accompanied by widespread criticism. These criticisms will not be explored in depth as they have already been well-established in the academic literature, but prominent among them are that: NPM leads to reduced accountability and an erosion of
democratic control (Pollitt, 2003a, p.47); it increases opportunities for corruption and unethical practices (Hughes, 2003, p.68); and that in most cases it has failed in meeting the goals of achieving more effective and efficient public services (Dunn & Miller, 2007, p.350).
Indeed, with doubts expressed in recent years about the effectiveness of NPM, academics have begun to discuss alternate models to replace it and to ensure that the welfare state is fit for the 21st century. One such model is Digital Era Governance.
b. Digital Era Governance: A background and key components
Digital Era Governance (DEG) was first formulated and proposed by Dunleavy et al (2006). In their view NPM is in crisis, a view justified through use of similar NPM criticisms as those outlined above (idem, pp.496-478). A post-NPM regime should therefore be sought to address the fundamental flaws in the NPM model and ensure that services meet the demands of the digital age. Indeed, the
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very title of the article in which DEG was first outlined – ‘New Public Management Is Dead: Long Live Digital-Era Governance’ – is reflective of Dunleavy et al’s ambition to leave behind the NPM consensus and look to a future framework, or as they say look ‘over the horizon’ (idem, p.488). The emphasis on ‘digitisation’ is, of course, key. In fact, it should arguably be seen as the
fundamental basis of the DEG concept. Two passages in particular are illustrative of this:
‘What is different in the current period is the growth of the Internet, e-mail, and the Web and the generalization of IT systems from only affecting back-office processes to conditioning in important ways the whole terms of relations between government agencies and civil society’ (idem, p.478)
(Emphasis added) And:
‘By digital-era governance we signify a whole complex of changes, which have IT and information-handling changes at their center, but which spread much more widely and take place in many more dimensions simultaneously than was the case with previous IT influences. And, we would argue for the first time, it now makes sense to characterize the broad sweep of current public management regime change in terms that refer to new information-handling potentialities, which make feasible a transition to fully digital modes of operating for many government sector agencies.’
(ibid) (Emphasis added)
To help facilitate a clear comparison between DEG and NPM, the key components of DEG are set out below in Table 1.2. This table is important as a point of reference for the reader, as specific components below will be referred back to throughout this thesis.
Component Description
Digitisation • Electronic public service delivery
• New forms of automated processes such as zero touch technologies (ZTT)
• Radical disintermediation (use of web-based processes to allow citizens to connect directly to state systems without having to go through an intermediary)
• Active channel streaming (displacing service users to electronic channels through incentivisation or legislation)
• Facilitating isocratic administration and co-production (allowing citizens to direct their own interactions with government)
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• Moving toward open-book government, under which there is increased access to one’s own data, transparency around digital processes and greater self-administration
Reintegration • Rollback of agencification (decreased outsourcing of services)
• Joined-up governance (JUG), specifically referring to a narrow focus upon major departmental amalgamations at central level
• Re-governmentalization (the reabsorption into the public sector of activities that had previously been outsourced to the private sector) • Reinstating central processes
• Radically squeezing production costs • Reengineering back-office functions
• Procurement concentration and specialization • Network simplification
Needs-based holism
• Client-based or needs-based reorganization • One-stop provision
• Interactive and "ask once" information-seeking
• Data warehousing (holding and making case-by-case data available across multiple services)
• End-to-end service reengineering
• Agile government processes (improving efficiency of services through identification of best practice)
Table 1.2 (Source: Dunleavy et al, 2006, pp.481-483)
While digitisation has been emphasised, the importance of the other two components should also be explained as these relate closely to the ambition of reversing elements of NPM. ‘Reintegration’ refers to the processes of reversing the fragmenting effects of NPM on public services, instead seeking to bring corporate functions, processes and agencies back into the public sector in a centralised and integrated way (idem, p.480). This is made clear by Dunleavy et al (2006), who outline that:
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‘The element of DEG that most directly contradicts its NPM predecessor (rather than developing at a tangent to it) is the reintegration of government into more coherent public sector or
government-wide processes.’ (idem, p.470)
The ‘needs-based holism’ component, however, stresses that reintegration under DEG does not just mean re-nationalising services. The digital era will allow far more responsive and efficient public services than in previous decades, and under needs-based holism the state would integrate services as part of an attempt to widen state institutions’ ability to meet the many needs of individuals, rather than simply one need in particular (idem, pp.480-481). This would be facilitated by, for example, improving and widening the collation and use of data, as well promoting the notion of ‘one-stop shops’ where citizens can undertake multiple welfare state functions in one place or through one channel (idem, p.484).
While some have written at length about the transformative effects of digital technologies for democracy and the notion of ‘e-government’ (see Milakovich ,2012; Weerakkody & Reddick, 2012), DEG is distinct for seeking to offer a comprehensive post-NPM bureaucratic framework. Since it was developed over ten years ago, Margetts and Dunleavy (2013, pp.7-14) in particular have advocated the model within the literature and in recent years have sought to demonstrate where there have been examples of DEG-influenced reforms in any one of the three components outlined above. It should be noted, however, that these are isolated cases that relate to an individual component of the framework. They outline, for example, that there have been instances of digitisation, reintegration or needs-based holism in specific areas of public service delivery in countries such as Sweden, Canada, the UK and Australia (idem, pp.10-11), arguing in fact that social media and the interactive nature of the ‘internet of things’ opens up potential for a ‘second wave’ of DEG (idem, pp.11-12). Yet other than the work led by Margetts and Dunleavy, evidence of DEG’s applicability as a coherent model to real-world settings is extremely limited. Doustaly (2013, pp.23-37) presents an account of how DEG reforms had been carried out within one governmental organisation in the UK – Arts Council England, but this appears to be the extent to which it has been comprehensively applied to a state framework.
This thesis does not seek to contest the validity of the examples cited above. Nor does it seek to contend that DEG is ineffective or lacks potential as a model of bureaucracy. However, it does note the considerable optimism within the literature on DEG; optimism that is yet to be counter-balanced by critical analysis. The academics referenced above have done an admirable job of articulately setting out DEG as a response to NPM, structured according to clear components. As mentioned, there also appear to be instances where individual elements of the DEG framework have been successfully implemented. However, this should strike the critical observer as an
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insufficient basis upon which to make claims that DEG could work as a post-NPM model for bureaucratic reform. Regardless of normative standpoints against NPM, or the evidence of it leading to poor outcomes in various policy areas, it has proven to be at the very least a framework that can work in practice across multiple welfare state services and in a range of environments (see Ferlie, 2017a). If the same is to be said of DEG then some fundamental questions need to be answered. What will the obstacles be to DEG being implemented effectively? Could DEG work not just in one policy or governmental organisation, but across a whole area of policy (and, if so, where are its limits)?
These are questions that are notably absent from the current literature on DEG. This thesis will therefore attempt to contextualise why they are important and seek to answer them, at least in part.
c. Digital Era Governance: Questions around theoretical foundations
There are two implicit assumptions that appear to be accepted when DEG is discussed as a post-NPM model of bureaucracy. These are that:
• DEG directly challenges NPM
• There is compatibility between the three distinct components of DEG
However, there may be grounds upon which both assumptions could be challenged, and this section shall briefly explore these.
If we first take DEG’s relationship with NPM, the previous section noted that both the
reintegration and needs-based holism components are intended to reverse the effects of NPM (which instead seeks to open up opportunities for private sector involvement and disaggregate bureaucratic processes). As such, it appears as though these components would be difficult to reconcile with NPM. But what about digitisation? Does this run contrary to NPM? Responding to Dunleavy et al’s (2006) assertion that DEG marks the death of NPM, De Vries (2010) instead argues that there is no reason why NPM would prevent digitisation processes. By contrast, he contends that in fact DEG should be considered ‘an (integral) part of the NPM movement’ (idem, p.3). While this argument is not thoroughly developed by De Vries, it is nevertheless an important one for the debate on DEG and the extent to which it diverges from NPM. It is also an argument that this thesis seeks to test.
It should be noted that Dunleavy et al (2006, p.488) acknowledge that a transition to DEG is unlikely to be quick, and that existing aspects of the NPM framework may continue through that
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transition. However, could it be that this is not just a transitional issue or evidence of ‘teething problems’? Could it be that there are elements of NPM that will necessarily live on through DEG? In regard to the second assumption, the key consideration here is coherence. Again, putting aside normative criticisms, it should be noted that the three respective components of NPM outlined on page 4 are theoretically compatible. It should be questioned, therefore, whether the same is true of DEG. This is what this thesis will look to explore and, should it be the case that the model is indeed coherent, this will add weight to the notion that DEG is a credible alternative to NPM. ii) The state-citizen relationship & the role of active citizenship
In addition to how welfare state services are structured and delivered, however, this thesis is also interested more broadly in how bureaucratic models affect the dynamics of the relationship between the state and the citizen. This section therefore looks to establish what relationship has developed under NPM and then question what implications the introduction of DEG reforms may have for this relationship.
a. NPM & active citizenship
Assessing the state-citizen relationship under any given bureaucratic model is of course a somewhat interpretive exercise. It is a difficult assessment to measure or demonstrate
empirically, however it is an important aspect of studying welfare states. After all, where does the public benefit lie in analysing welfare states if not to aim to improve citizens’ relationship, and engagement, with public services?
To this end, Newman’s (2011, p.108) research into the state-citizen relationship under NPM is useful. She identifies Thatcher’s reforms to the welfare state as the point at which citizens in the UK were ‘invited to become market actors’ in public services, a development that serves as a necessity if the marketisation aspects of NPM are to work effectively in the form outlined earlier in this chapter. Active citizenship – which encourages citizens to do more for the wellbeing of themselves, their family and their community – itself evolved as a way to temper the
individualistic excesses of Thatcher’s NPM reforms, with successive governments embracing it through into the 21st century (idem, pp.108-109).
How, then, can we understand active citizenship? According to Newman & Tonkens (2011), there are three key components that constitute a state-citizen relationship predicated upon active citizenship. These are:
Responsibility Citizens are expected to take on responsibility for one or more areas of wellbeing.
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care of themselves or those within their community, or economic responsibilities, with individuals expected to save or make payments towards services that
previously may have been state provided (idem, pp. 180-181)
Participation Citizens are encouraged to be active participants within the public service system,
for example as members of councils or forums, or as ‘co-producers’ of welfare state services (idem, pp. 186-187)
Choice Citizens are viewed as active consumers of services, with an expectation that they will evaluate competing providers and choose services on the basis of which is able to best meet their needs (idem, pp. 192-193)
It should be noted that throughout the active citizenship narrative runs the theme of
‘empowerment’, with citizens being encouraged to empower themselves by embracing the three respective components outlined above (idem, pp. 182-183).
With active citizenship advocating the value of communal duty, the link between NPM reforms and the promotion of active citizenship is arguably a natural one and there are several examples of this link that can be drawn upon in the literature. To take the UK, the New Labour governments under Tony Blair are often associated with the concept of ‘joined-up government’, which was seen as an attempt to improve the co-ordination of services and differentiate the Labour administration from the ‘fragmentizing policies’ of previous Conservative governments (Pollitt, 2003b, p.36). However, Blair’s governments also presided over several NPM reforms. Entwistle et al (2007, p.1573) have argued that New Labour ‘breathed new life’ into the NPM agenda by rolling out private finance initiatives in education, while Whitaker (2015) outlines how Blair introduced NPM reforms by implementing market mechanisms across health services.
In turn, and as identified by Newman (2011, p. 117), such reforms were accompanied by state promotion of active citizenship:
‘New Labour also drew on the mobilisation of concerns about the health of civil society and the polity, giving rise to notions of ‘responsibility’ for practical participation. As a result, multiple discourses of active citizenship swirl across the policy landscape’
More recently, NPM reforms were carried out under the Coalition Government between 2010 and 2015, with examples including marketisation within university funding and further competitive measures introduced in healthcare (Hyndman & Lapsley, 2016, p.403). Again, such reforms were accompanied by state attempts to promote citizen activation. Verhoeven & Tonkens (2013), for instance, discuss how the ‘Big Society’ narrative employed by the Coalition aimed to promote elements of active citizenship.
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There is evidence, therefore, that structuring the welfare state according to NPM principles may lead to the state cultivating a relationship with citizens based upon ‘activating’ citizens. It should be noted that this thesis does not believe this to be an inevitable outcome, and of course not all states that have embraced NPM reforms will have looked to promote citizen activation. However, applying a focus upon welfare state services in England, this section has sought to highlight that welfare state services across the country have in recent years been subject to NPM reforms and demonstrate that these have been accompanied by a narrative promoting the three components of active citizenship outlined above.
b. DEG & the state-citizen relationship
With the literature on DEG in its infancy, there is not just a limited amount of material on DEG’s applicability to real-world settings. As far as this thesis understands, there has also been no research undertaken on what type of state-citizen relationship may accompany the model. The previous section has established that active citizenship has been promoted to temper the individualistic excesses of NPM; what narrative may therefore evolve to complement DEG reforms?
Chapter 3 will explore this question and examine the extent to which the state-citizen relationship under DEG will differ than under NPM within health services in England. For welfare state scholars interested in how models of bureaucracy can influence state-citizen narratives (and vice versa), as well as where responsibilities lie between the state and the individual, the relatively new
introduction of DEG should be considered an interesting new area for research. Will moves towards DEG require more or less of the individual, in terms of responsibility, than NPM? What might the shift towards DEG mean for active citizenship as we understand it above?
It is hoped that this thesis will, if not provide comprehensive answers, at least open the debate on such questions. The following chapter sets out how.
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CHAPTER 2
Case selection and methods
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The opening chapter of this thesis provided the reader with some theoretical context to NPM, DEG and active citizenship, highlighting where there are notable weaknesses or gaps in the literature. The aim of this thesis is to go some way in plugging these gaps, by providing new research that critically examines DEG as a post-NPM bureaucratic framework and identifying where, how and why it might not be successful. This is reflected in the research question presented in the Introduction (‘To what extent are digital era governance (DEG) reforms in
England set to challenge NPM and what obstacles do experts and professionals foresee to the success of DEG in healthcare?’).
This chapter sets out why the NHS in England has been selected as an area of focus, what case studies will be assessed to help answer the research question, and what methods are adopted for research.
i) Case selection
To undertake a critical analysis of DEG, it is of course necessary to have a topic of focus within which to conduct primary research. In this case, it was decided that analysis would focus upon a country and area of policy in which there is evidence that DEG reforms are being implemented. To have a wider focus than this – to study, for example, DEG at an international level or across
multiple policy areas – would be beyond the scope of this thesis, requiring significantly more time and space. Rather, limiting the parameters of the research was considered important to ensure that the data gathered would have sufficient depth and nuance.
It should be noted that given the relatively new nature of DEG compared to other frameworks such as NPM, there is not a wide range of cases that would provide fertile ground for research. The NHS, however, represents such a case, allowing an examination of DEG within the confines of health policy in England. There is good evidence indicating that DEG reforms are going to be widely implemented across the NHS over the coming years. This evidence will not be detailed here, as it is set out and explained in Chapter 3.
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Within the broad focus of this thesis on health services in England, specific case studies are useful for demonstrating how theory manifests in policy, and indeed how reforms affect stakeholders such as clinicians and patients. This section details the criteria for selecting such case studies, and outlines those that have been chosen for examination.
Case studies have been selected according to two criteria. The first is that each case study should be considered a valid example of DEG in practice. Seawright & Gerring (2008, pp. 299-300) would refer to such cases as being ‘typical’, in that they are representative of the cross-case model of focus – in this case DEG. Under their argument, demonstrating that case studies are typical cases of a model is not considered an end in itself, rather they argue that ‘the puzzle of interest to the research lies within that case’ (idem, p. 299) (Emphasis in original). This is of relevance to the research undertaken in this thesis, which seeks to understand not just what each case tells us about digitisation, but also what each case reveals about the other concepts explored in Chapter 1.
The second criteria for case selection is that, as well as being considered ‘typical’ cases under Seawright & Gerrings’ classification, they should also be considered ‘most likely’ cases in accordance with the work of Flyvbjerg (2006, p. 231). With respect to case selection, he argues that ‘it is a good idea to look for either “most likely” or “least likely” cases, that is, cases likely to either clearly confirm or irrefutably falsify propositions and hypotheses’ (ibid). For this research, the case studies chosen should be considered ‘most likely’ to demonstrate the applicability of DEG. Those ‘most likely’ to confirm the efficacy of DEG would be cases of DEG that the
government is not simply looking to implement, but ideally ones where progress has already been made towards implementation.
Upon consideration of these two criteria, therefore, the following case studies were selected for examination:
1. Digital tools for diabetes
And
2. Online therapies for common mental health conditions
These can both be considered ‘typical’ case studies as they have been specifically highlighted by the government as areas in which digitisation is to be focused:
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‘For those people living with a diagnosis of type 1 or type 2 diabetes the NHS will enhance its support offer. We will support people who are newly diagnosed to manage their own health by further expanding provision of structured education and digital self-management support tools’
(NHS England, 2019a, p.65) (Emphasis added) And
‘As part of wider moves to what The King’s Fund has called ‘shared responsibility for health’, over the next five years the NHS will ramp up support for people to manage their own health. This will start with diabetes prevention and management, asthma and respiratory conditions, maternity and parenting support, and online therapies for common mental health problems.’
(idem, p.25) (Emphasis added) The third case is:
3. Digital GP appointments
Again, this will be a key focus for the government’s DEG reforms in healthcare over the coming years:
‘Under this Long Term Plan, digital-first primary care will become a new option for every patient improving fast access to convenient primary care … Over the next five years every patient in England will have a new right to choose this option – usually from their own practice or, if they prefer, from one of the new digital GP providers.’ (idem, p. 26) (Emphasis added)
Here, ‘digital GP appointments’ refer both to appointments that take place via online fora (such as through instant messaging or email) and via online video link (similar to Skype). Thus, three case studies have been identified, each with evidence (in the form of government documentation) to show why it should be considered a ‘typical’ case. Specifically, they
demonstrate how the government intends the element of digitisation of services to take place over the coming decade. Yet how do each of the above meet the criteria of being a ‘most likely’ case?
While space denies me from demonstrating this in detail, evidence can be provided to show that (aside from the commitments set out in recent policy documentation) the government has already made progress towards each case study. It has already begun to ensure public access to digital tools for diabetes (see NHS England, 2019b), online therapies for common mental health conditions (see Public Health England, 2018), as well as online GP appointments (see NHS GP at Hand, 2019).
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With progress already made towards each of the three, these case studies can therefore be judged as having as high a chance of success as is possible at this stage in the government’s DEG reforms. Certainly, one can argue they are more likely to be successfully implemented than other reforms that will require starting ‘from scratch’. This is important for the research question at hand, as if obstacles can be identified to these three case studies being successful, then this would have concerning implications for the other DEG reforms that the government has committed to.
It should briefly be noted here that, rather than explore each case study individually, this thesis shall interweave all three into the same points of analysis in Chapters 4 and 5. As such, each shall be drawn upon when it is deemed relevant for proving or disproving a certain point. This allows for easy cross-comparison and a convenient means of providing context to points of analysis, however it limits the extent to which this thesis will explore each case study in depth.
iii) Methodology
a) Research methods
This thesis adopts two key research methods to answer the set research question.
First, in Chapter 3 a discourse analysis is undertaken to demonstrate that, alongside DEG reforms, the government intends to promote a state-citizen relationship based upon active citizenship. This is important in relation to the research question as this relationship would represent continuity of, and not challenge to, the state-citizen relationship established under NPM. As Newman highlights, the active citizen is ‘a discursive construct, constituted through political and policy texts that draw on different forms of mobilising rhetoric’ (Newman, 2011, p.110). Therefore, to contend that DEG reforms in England will involve a continuation of active citizenship will require use of an
interpretive method to prove – in this case a discourse analysis of a storyline adopted and conveyed by the government.
Subsequent chapters (4 and 5), meanwhile, set out the results of primary research, which took the form of semi-structured interviews. As a qualitative method, interviews do not just allow for the identification of obstacles to DEG being successfully implemented, they also enable the researcher to question why these are obstacles and how they are expected to manifest in real-world settings. It was decided that interviews would be semi-structured to allow conversations with interviewees to have a degree of flexibility. The use of a topic list ensured that interviews had some structure and a short set of ‘fixed’ questions were asked across all interviewees. This topic list is included for reference as Appendix 1 at the end of the thesis. Crucially, however, there was also room for follow-up questions. In this way, semi-structured interviews provided a platform to delve further into particular points of interest, which in turn helped to yield richer data.
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There are, of course, limitations to the methodological approach chosen. These will not be explored here, as they are considered in the Conclusion in Chapter 6 as part of an attempt to guide future research.
b) Selection of respondents
Interviewees chosen for primary research fall into one of two target groups – experts and professionals.
Experts refer to those who work in health policy and who have expertise in digitisation generally or in one or more of the three case studies. Experts are considered to work for ‘neutral’
organisations, meaning they provide a degree of impartiality. Specifically, this means organisations that are not either linked directly to the NHS or a political party.
Professionals, meanwhile, refer to those working within the health service – either directly for the NHS or for a provider of services.
These target groups were chosen firstly because they possess the necessary degree of knowledge and experience of digital services in healthcare to provide an informed view. Members of the public and politicians cannot reasonably be expected to have specific expertise on how health services are set to be digitised over the coming years. Experts and professionals, however, do possess such expertise. And secondly, a significant amount of research and literature has been produced in recent years exploring the views of politicians (particularly around the Health & Social Care Act 2012) and the public towards health services. While one can argue that the views of experts and professionals should hold significant weight in debates on the future of the NHS, they are much less prevalent in the academic literature and public discourse. This thesis therefore looks to provide a platform for both groups to contribute their expertise to the debate on changes to service delivery in the NHS.
To find interviewees, a ‘purposive sampling’ approach was adopted. This refers to using expertise or knowledge to produce a sample that can be logically considered representative of a population, as opposed to random sampling (Lavrakas, 2008). The author worked for several years in health policy in England prior to undertaking this thesis and so purposive sampling allowed for this experience to help direct the selection of experts and professionals. Several organisations of relevance were identified and approached with requests to contribute to this thesis. These were considered nationally- rather than regionally-focused organisations so as to provide the breadth of perspective required to ensure that the resulting data is relevant for England as a whole. These included NHS bodies, health policy consultancies, universities and think tanks.
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This was not, however, the only sampling approach used. As certain respondents were secured, this led to some recommending other colleagues and contacts who may also have relevant expertise. This approach – whereby participants enlist others to take part in research – is known as ‘snowball sampling’ (Maruyama & Ryan, 2014, p. 236), and this helped to further broaden my sample of interviewees.
In total, seventeen respondents were secured. These are listed at the end of the thesis in Appendix 2, with information included on each respondent’s expertise as well as which target group they fall into. One of the seventeen (Mr Graham Silk) should be considered an outlier, in that he has a regional rather than national focus. His contributions, however, were felt to be valuable to the debates this thesis explores, and so they are included. It should be noted that this thesis features quotes from all seventeen interviewees and full transcripts of the interviews are available upon request.
c) Data collection and analysis
Before interviewing each respondent, a briefing was sent to them a week before the interview. This provided background to the research, some example questions and a statement outlining that permission to record the conversation would be asked for. On the day, permission was asked at the beginning of each interview and, providing this was agreed to, conversations were recorded through an iPhone. The recordings were used to write up transcripts of the interviews, which typically lasted for around half an hour. The transcripts were then examined as text sources, with common themes and views identified across interviewees through cross examination of the texts by the author.
While this did not occur for any of the interviews, key quotes would have been written down manually during interviews should permission have been refused by any interviewees.
Finally, it should be noted that one key ethical issue arose from data collection and this concerned ‘off the record’ remarks. With a small minority of interviewees, they wanted to speak frankly and critically about the government’s DEG reforms but were wary of doing so publicly, asking for such comments to be considered ‘off the record’. In some cases, this did not prove to be a problem as such remarks were not used in this thesis, however for one interviewee there were many topics discussed that he considered sensitive. So that quotes from this particular interviewee could be included, he has been anonymised. Mr James Smith (not his real name) works for a private
provider of digital GP appointments and following the interview anonymisation was agreed to due to concerns about comments on NHS reforms being available in the public domain.
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CHAPTER 3
The National Health Service in England: A shift to Digital Era Governance?
______________________________________
To identify how DEG can be applied to healthcare and explore the obstacles that exist to it
working effectively, it must first be demonstrated that there is indeed a will from policymakers to move towards the model. After all, DEG reforms do not materialise by themselves.
This chapter shall provide a background to the National Health Service (NHS) in England and outline some of the reasons why reforms, both in terms of policy and infrastructure, are considered necessary. Using recent government documentation, it will then set out how the Department of Health and Social Care and the NHS intend to adopt elements of DEG through such reforms. Finally, a discourse analysis of ministerial statements and government rhetoric will be undertaken. This will demonstrate that under DEG the government intends to construct a state-citizen relationship based upon active state-citizenship, which Chapter 4 will argue represents
continuation of (rather than challenge to) NPM. i) The NHS and the need for new solutions
The NHS was established as one of the fundamental pillars of the British welfare state through the National Health Service Act 1946. This committed the state to providing medical care to all
citizens, with health services to be free at the point of use (Jones, 2015, p.77). The universal, tax-funded model that has been used to fund the NHS since its inception has generally proved to be a success. This can be judged in terms of international care standards, with the NHS considered the best-performing world healthcare system by the Commonwealth Fund (Schneider et al, 2017), but it can also be judged with respect to its popularity among the British population. It is hard to overstate the pride that is felt by citizens towards the NHS, with a poll of the public conducted last year by YouGov (2018), a leading British polling organisation, showing ‘creating the NHS in 1948’ to be the country’s single proudest achievement.
It should be noted here that throughout this thesis reference shall be made to the actions and policies of the British Government but in relation to the English health service. Healthcare is a devolved issue in the UK, meaning that while the British Government has authority over NHS England, the Scottish, Welsh and Northern Irish Governments are responsible for NHS Scotland, NHS Wales and Health & Social Care in Northern Ireland, respectively (Grosios et al, 2010). As
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such, the reader should understand references made over the coming chapters to the ‘NHS’ as ‘NHS England’ specifically.
In recent years, successive British governments have begun to emphasise the unsustainable nature of the funding, structure and delivery of the health service. During his time as prime minister, Tony Blair argued that the public must do more to take on responsibility for their own health and ease pressure on health services. In a 2006 speech, for example, he stated that:
“In the future, healthcare cannot be just about treating the sick but must be about helping us to live healthily; this requires more from all of us, individuals, companies and Government” and that “government should play an active role in the way the enabling state should work: empowering people to choose responsibly.” (Blair, 2006) (Emphasis added)
His government’s solution was partly to increase public expenditure on the NHS but also to implement NPM reforms, with Labour’s ‘any qualified provider’ initiative an example of how the government marketised many parts of the health service, opening them up to the private sector (Whitaker, 2015). The quote above is illustrative of the ‘empowerment’ focus that permeates active citizenship, as outlined in Chapter 1, with citizens empowered (and expected) to choose responsibly between competing service providers under NPM.
While governments have changed since Blair, the narrative around sustainability has continued, and arguably intensified, under recent administrations. If we take the current government, the Health Secretary Matt Hancock used one of his first speeches in office to draw attention to the need to improve the sustainability of the service:
“With demands rising, we must find a way to make health and care – by which I mean the whole health and social care system – sustainable for the long term.” (Hancock, 2018)
This is not, perhaps, a surprise when you consider current academic debates around the welfare state in developed countries. As Taylor-Gooby (2017, pp.815-822) argues, modern welfare states are facing what he calls a ‘double crisis’: services are having to adapt to an increasingly globalised world and ensure they are meeting rising productivity standards, while at the same time being overwhelmed by ageing populations that are putting intense strain on health and care services. However, rather than focusing reforms on NPM like previous administrations, there is evidence that the current government is beginning to turn to DEG to help improve the sustainability of the health service. Yet this is not to say that NPM is being replaced, as subsequent chapters will show.
21 ii) Governance in the NHS
The NPM reforms under Blair’s governments have already been outlined and so it is not necessary to further demonstrate that the structure and delivery of health services in England has in recent decades been structured upon NPM principles. Scholars such as Simonet (2013) have articulately outlined how and why NPM has become deeply embedded in British healthcare services. Neither will this section outline in depth the notion that until recently DEG has not been prevalent in health services in England: Ferlie (2017b, pp.622-623) has examined the influence of competing models of bureaucracy, concluding that while NPM continues to have strong and sustained presence, DEG has had a weak influence since its formulation in the academic literature. However, what should be demonstrated here is that both these things may be beginning to change. Since Ferlie’s research in 2017, the current Conservative government has come to power and focused reforms around DEG. To evidence this, numerous examples can be drawn upon from recent policy documents and government statements.
Earlier this year, the government published the NHS Long Term Plan (LTP) and this sets out the broad strategy to ensure that the health service in England is both effective and sustainable over the next ten years (NHS England, 2019a, pp.6-10). The Plan has a strong focus on implementing DEG reforms according to the three components set out on pages 6-7.
If we first consider the component of digitisation, there are clear signs in the Plan that the government intends to expand the use of digital technology in service provision to improve efficiency:
‘All providers, across acute, community and mental health settings, will be expected to advance to a core level of digitisation by 2024.’ (idem, p. 96) (Emphasis added)
And:
‘A new wave of Global Digital Exemplars will enable more trusts to use world class digital technology and information to deliver better care, more efficiently’ (ibid.) (Emphasis added)
It is also clear to see the more specific aspects of digitisation under Dunleavy et al’s definition evidenced in policy documents released in co-ordination with the LTP. The government has, for example, demonstrated its pursuit of ‘open book government’:
‘The data and technology standards we agree to will be open so that anyone can see them and anyone writing code for use in the NHS knows what the standards are before they start’
(Department for Health & Social Care, 2018a) (Emphasis added)
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‘Public-facing digital services should support and empower people to stay healthy and independent for longer. This will include … secure online access to clinicians, personalised and relevant health information, and digital tools and advice that meet the growing expectations of consumers.’ (ibid)
(Emphasis added)
Similarly, if we take the reintegration component of DEG, there is evidence in the LTP that there is certainly an intention to promote ‘joined up governance’ and ‘network simplification’:
‘[The NHS will be] more joined-up and coordinated in its care. Breaking down traditional barriers between care institutions, teams and funding streams so as to support the increasing number of people with long-term health conditions, rather than viewing each encounter with the health service as a single, unconnected ‘episode’ of care’ (NHS England, 2019a, p.12) (Emphasis added)
The above quote illustrates the desire for an integrated, rather than disaggregated, health system, with a focus on ‘joined up’ and ‘co-ordinated’ services. This new direction of travel towards DEG is not only evident in government documentation, however. It has been noted among health policy commentators, with one recently writing that:
‘The rise of multi-morbidity … demands integration and joined-up services, ‘so the policy mix has to evolve’ [Simon] Stevens [Chief Executive, NHS England] said. And, as pretty much everyone from the Prime Minister down has acknowledged, Andrew Lansley’s 2012 Health and Social Care Act, with its total embedding of the choice and competition model, is getting in the way of that. ‘Hence NHS England’s proposals for changes to the law set out in the long-term plan and a subsequent document. These are … a set of changes aimed at getting integrated care to work better.’ (Timmins, 2019) (Emphasis added)
Finally, it is also worth noting the focus on the third element of DEG, too, namely needs-based holism. The LTP makes clear commitments to the exact aspects of needs-based holism set out by Dunleavy et al (2006). Again, numerous examples could be provided here but to take one in relation to ‘one-stop provision’, the Plan sets out that in maternity care:
‘The NHS is supporting a culture of multidisciplinary team working and learning ... Twenty
Community Hubs have been established, focusing on areas with greatest need, and acting as ‘one stop shops’ for women and their families’ (NHS England, 2019a, p.47) (Emphasis added)
It is apparent, therefore, that in recent policy documentation and specifically the LTP – the very document setting out the government’s strategy for a sustainable and effective health service – elements of DEG are being widely adopted. As mentioned, an interesting consideration is whether or not the introduction of DEG reforms necessarily comes at the expense of NPM mechanisms, and this is a consideration that this thesis explores later.
23 iii) DEG and the state-citizen relationship
The third and final section of this chapter seeks to establish through a discourse analysis that alongside the DEG reforms to health services, including (but certainly not limited to) the examples given above, the government is set to continue the active citizenship narrative that has so often accompanied NPM reforms. This may represent a key limit to the degree of challenge that DEG poses to NPM. First, however, a brief background is provided to interpretive methods.
a) Interpretive analysis
Interpretive analysis allows scholars to assess how key messages and emotions can be conveyed through discourse, as well as explore how individuals respond to different rhetorical instruments. It stems from the understanding that language and interpretation ‘informs sense making in complex situations’ (Hajer & Laws, 2006, p.254), and that one can begin to understand underlying power dynamics between actors through the study of language.
Interpreting the underlying meanings behind discourse can be conducted in a number of different ways. One may look, for example, to how issues are framed and what this can tell us about the dynamics of a conflict (Gray, 2003), or to the way in which metaphors are used to convey meaning (Yanow, 2000, pp.41-48). However, in this instance the government’s recent promotion of an active citizenship narrative can best be understood as an attempt to construct a storyline about the future of the NHS. As such, the interpretive analysis technique developed by Hajer can be adopted.
Hajer (2006, p.69) identifies the important role that storylines can play in conveying meaning, promoting a particular message or highlighting facts in a way that resonates emotionally with an audience. To illustrate this, he uses the process of rebuilding Ground Zero in New York as an example, with the process itself becoming a significant part of a wider narrative that galvanised and united people:
‘The process of rebuilding Ground Zero was often described as a way to show the world that
America would not accept the terrorist attack on democracy: we must rebuild as a democracy. It
would be a travesty, if in the aftermath of an attack on our democracy, we circumvent our basic democratic procedures’ (ibid) (Emphasis in original)
How, then, does the concept of a storyline apply to how the current British Government is promoting the concept of active citizenship alongside DEG in healthcare? As Hajer (ibid) outlines, ‘the essence of a story is that it has a beginning, middle and an end’ and so this structure shall be applied directly to the case over the course of the next section.
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b) Constructing active citizenship through a storyline
Through an interpretive analysis it can be identified that the government seeks to construct a storyline in which citizens are required to take on more responsibility for managing their own health. This story can be summarised as follows:
‘The NHS is in trouble and is unsustainable. Citizens must take more responsibility for their health to ease pressure on services, which will allow the NHS to continue offering excellent care to the public.’
The beginning, middle and end of this storyline shall be demonstrated in turn, with evidence to support each taken from recent policy documents and interviews with relevant government officials.
The beginning: ‘The NHS is in trouble and is unsustainable’
The story that the government seeks to construct starts in response to a problem, one that is set to affect all citizens: the NHS is not financially and logistically sustainable and cannot continue in its current form. Portraying this as a problem is certainly not something that the government has had to do single-handedly and concerns around the sustainability of the NHS feature prominently in mainstream British media. A recent headline on Sky News, for example, reads ‘NHS faces 'endemic, unsustainable' financial problems, says National Audit Office’ (Kelso, 2018), with the article stating that ‘The NHS is currently in the tightest financial squeeze in its history.’ (ibid) Equally, leaders within the NHS have frequently sought to draw public attention to the huge pressure that the health service is under. Niall Dickson (Chief Executive of the NHS Confederation and one of the interviewees in this thesis), for instance, has outlined this view in very frank terms, stating that the service is “under intolerable strain” and that “This is now the day-to-day reality of life at the clinical coal face, but it cannot go on.” (McKee, 2018)
Government documentation does not attempt to hide this and acknowledges the strain the health service is under. In the very first paragraph of the LTP, it states that: ‘There’s been concern – about
funding, staffing, increasing inequalities and pressures from a growing and ageing population.’
(NHS England, 2019a, p.6)
The problem, therefore, is clear. Pressure on health services has reached breaking point and there is concern that it cannot continue.
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The middle: ‘Citizens must take more responsibility for their health to ease pressure on services’
In response to the identified problem, the government then actively promotes its desired solution: that citizens need to take on more responsibility and be more proactive in maintaining their own health.
This is a message that senior government officials have consistently sought to promote over the last year. The Health Secretary Matt Hancock, for example, presented the message very clearly in a leading national newspaper through quotes in an article entitled ‘People must take responsibility for own health, says Matt Hancock’ (Campbell, 2018). One quote reads:
“Prevention is also about ensuring that people take greater responsibility for managing their own health. It’s about people choosing to look after themselves better, staying active and stopping smoking. Making better choices by limiting alcohol, sugar, salt and fat.” (ibid) (Emphasis added)
Similarly, in a recent policy paper produced by the Department of Health & Social Care (DHSC) the Ministerial foreword reads:
‘Prevention cannot be solved purely by the health and social care system alone. Everyone has a part to play, and we must work together across society. This includes recognising the responsibilities of individuals and families in reducing the chances of becoming unwell in the first place, but also how the wider environment we live in determines our health.’ (Department for Health & Social Care,
2018b, p.2) (Emphasis added)
This is a clear promotion of active citizenship, as set out on pages 10-11, particularly in relation to the ‘Responsibility’ component. The specific terms highlighted in the quote above stress urgency and promote action – the public ‘must’ play their role. To borrow John F Kennedy’s famous
inauguration quote, the Health Secretary is in essence urging the public to ask not what the health service can do for them, but what they can do for the health service.
It should be noted that, linking this back to DEG, digitisation and technology innovations are seen as the key way in which the public can meet the responsibilities that active citizenship expects of them. In the same policy paper, for instance, it states that:
‘Technology has a significant role to play in helping people to live healthier, more independent lives. It also allows us to target support far better to those that need it most.’ (idem, p.10) (Emphasis
added)
This is a consistent theme across recent government policy documentation. To take another example, in the LTP (in relation to the introduction of digital technologies) it reads that:
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‘Over the next ten years they will result in an NHS where digital access to services is widespread. Where patients and their carers can better manage their health and condition.’ (NHS England,
2019a, p.9) (Emphasis added)
The solution, therefore, is presented to the public. The government will commit to rolling out digitisation, but this comes with an expectation that the public will take on responsibility for being proactive in managing and maintaining their health (a responsibility that is at the heart of active citizenship).
The end: ‘The NHS is able to continue offering excellent care to the public’
The desired outcome, and ‘end’ to the story, is that the health service is able to prosper. Crucially, the key message here is that if citizens take more responsibility for their own health rather than rely on the NHS then services will be able to deliver high quality care. This is the underlying justification for the active citizenship narrative. To draw again on a recent government policy paper:
‘We need to see a greater investment in prevention - to support people to live longer, healthier and more independent lives, and help to guarantee our health and social care services for the long-term’
(Department of Health & Social Care, 2018b, p.3) (Emphasis added)
The ‘future vision’ has also been set out directly by the Health Secretary in the House of Commons:
‘That is the approach that we will be taking to support the NHS over the next decade, but what does it mean for patients and the wider public? … It means supporting our growing elderly population to stay healthy and independent for longer … It means empowering people to take greater control of, and responsibility for, their own health through prevention and personal health budgets. It means accessing new digital services to bring the NHS into the 21st century.’ (House of
Commons, 2019, col. 63)
To achieve this vision, the government is therefore inviting the public to play their role in what they call ‘shared responsibility for health’ (NHS England, 2019a, p.25). The ‘empowerment’ narrative discussed earlier is again apparent here, but the emphasis is on the public ‘enabling’ a sustainable NHS to happen and thus this is presented as a responsibility. While this has been discussed in broad terms over this chapter, Chapter 4 shall demonstrate how this form of active citizenship is likely to manifest in the specific case studies selected for research.
A key question that the continuation of active citizenship poses is to what extent is the public ready to take on the responsibilities of active citizenship that DEG will require? If there are concerns about citizens’ willingness or ability to use new digital innovations to better manage
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their own health then this, surely, should be seen as an obstacle to DEG working effectively across the health service in England. Through primary research, set out over Chapters 4 and 5, this thesis will explore and test this notion.
iv) Conclusion
This chapter has demonstrated both that the government is set to implement DEG reforms across the health service in England over the coming decade, and that the narrative around active citizenship is set to continue despite the change of direction towards DEG in health policy. It is hoped that this helps to illustrate why the case is a relevant one for scholars of DEG and provided some context to how and why the government is continuing to promote the notion of the active citizen.
This thesis now turns to the evidence gathered through primary research, examining this in relation to each part of the research question in turn.
