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Citizen participation. Bargaining over boundaries in the organization of care services
Abstract and Figures
Hailed as a way to grant citizens more control over the services they use, advocates often portray citizen participation as a crucial ingredient for service improvement. At the same time, and despite widespread support for participation as a policy imperative, its pursuit often proves contentious. Critics consider participatory efforts to be something of a Trojan horse, noting they are often used to legitimize decisions that have already been made or to compensate for cutbacks in public spending.
In this doctoral thesis, Ludo Glimmerveen investigates how these disparate accounts of citizen participation—and the organizational practices associated with them—interact within concrete participatory efforts. Approaching participatory efforts as instances of boundary work, his research focuses on the inclusionary and exclusionary actions people use to open up or narrow down the space available for participation. How do participatory initiatives evolve as people bargain over participation’s parameters?
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... There is the community approach that seeks connection with formal care and the formal care facilities that need to strengthen their connections with society. Glimmerveen [6] interestingly found in his empirical research, that although citizen participation aims to blur the lines between citizens and professional workers, these boundaries often then become the subject of tough discussions. Internal power balances within healthcare settings define which topics citizens are allowed to speak and participate in. ...
... In practice this can lead to defining 'constructive participation' as the norm, whereas citizens who act as 'critical opposites' are excluded. Without the 'top' support within organisations, their role in decision making stays marginal [6]. Besides developing a diversity of connections between formal and informal care, understanding the role of rebalancing powers is also important to bridge the gap. ...
... This created a context in which the exact scope and objectives of public participation (i.e., pursuing inclusive participatory governance versus cost-containment) remained contested throughout the trajectory. The rise and eventual fall of the efforts to safeguard the care home's continuity is described in more detail elsewhere (see Glimmerveen, 2020;Glimmerveen et al., 2018Glimmerveen et al., , 2020. This article builds on our empirical investigations of employees' attempts to involve a group of participants that could "reasonably be considered to constitute a public engaged in the process" (Martin, 2012(Martin, , p. 1852, and, in turn, of citizens' attempts to legitimize their abilities to indeed represent this public. ...
Highlighting public-service actors’ deliberately tokenistic or self-serving efforts, existing literature has shown that public participation often involves the co-optation of sympathetic citizens. In contrast, our study demonstrates that participatory advocates may discredit and marginalize critical voices despite their own inclusive, democratic ideals. We analyze the entangled legitimacy claims of participating citizens and “inviting” public-service actors, capturing (a) the often-unintended dynamics through which the inclusion of particular participants legitimizes the exclusion of others, while illuminating (b) the tenacious propensity of participatory initiatives to establish “constructive cooperation” as the norm for participation and, subsequently, to normalize exclusionary practices.
What happens when people try to ‘transcend’ organizational boundaries and engage with so-called outsiders? Current boundary-work literature does not fully account for the processual, dispersed, and political dynamics triggered by such efforts. To address this shortcoming, this article builds on an ethnographic study of a professional care provider’s attempts to engage local citizens within one of its care homes. We analyze how actors negotiate the parameters of outsider engagement – that is, how they interactively (re-)erect and (re-)efface boundaries between actors (Who is engaged?), issues (What is their engagement about?), and positions of authority (Does local engagement affect central decision-making?). We contribute to extant theorizing by, first, explicitly scrutinizing boundary work’s temporal and spatial dynamics. Testifying to the importance of analyzing temporal sequences, we show how attempts at transcending boundaries intensified boundary work on multiple organizational platforms. Paradoxically, inclusionary efforts evoked exclusionary effects (and vice versa) as actors came to contest and, eventually, redefine ‘appropriate’ insider–outsider relations. Second, our analysis highlights how the political effectiveness of an inclusive and non-hierarchical approach still, ironically, depends on ongoing hierarchical support and managerial enforcement. Third, our article makes a case for the adoption of long-term, multi-sited methodologies when studying the everyday dynamics of boundary-work processes.
Policy makers, practitioners and academics often claim that care users and other citizens should be ‘at the center’ of care integration pursuits. Nonetheless, the field of integrated care tends to approach these constituents as passive recipients of professional and managerial efforts. This paper critically reflects on this discrepancy, which, we contend, indicates both a key objective and an ongoing challenge of care integration; i.e., the need to reconcile (1) the professional, organizational and institutional frameworks by which care work is structured with (2) the diversity and diffuseness that is inherent to pursuits of active user and citizen participation. By identifying four organizational tensions that result from this challenge, we raise questions about whose knowledge counts (lay/professional), who is in control (local/central), who participates (inclusion/exclusion) and whose interests matter (civic/organizational). By making explicit what so often remains obscured in the literature, we enable actors to more effectively address these tensions in their pursuits of care integration. In turn, we are able to generate a more realistic outlook on the opportunities, limitations and pitfalls of citizen participation.
Introduction
To meet the needs of vulnerable people, the integration of services across different sectors is important. This paper presents a preliminary review of service integration across sectors in Europe. Examples of service integration between social services, health, employment and/or education were studied. A further aim of the study was to improve conceptual clarity regarding service integration across sectors, using Minkman’s Developmental Model for Integrated Care (DMIC) as an analytical framework.
Methods
The study methods comprised a literature review (34 articles) and a survey of practice examples across Europe (44 practices). This paper is based on a more comprehensive study published in 2016.
Results
The study demonstrates that although the focus of integration across sectors is often on social services and health care, other arrangements are also frequently in place. The review shows that integration may be either tailored to a particular target group or designed for communities in general. Although systems to monitor and evaluate social service integration are often present, they are not yet fully developed. The study also highlights the importance of good leadership and organizational support in integrated service delivery.
Discussion
The study shows that the DMIC can work as a conceptual framework for the analysis of service integration across sectors. However, as this is an exploratory study, further in-depth case studies are required to deepen our understanding of the processes involved in service integration across sectors.
Recently social work in the Netherlands underwent two major changes. Specialized agencies were replaced by one-stop shops (district teams) and the welfare state was replaced by a ‘participation society’, in which vulnerable groups have to rely on their social network rather than resort to professional care. The first change is termed ‘de-specialization’; the second ‘basic de-professionalization’. The research question in this article is: how do Dutch social workers experience and evaluate these two developments? Qualitative interviews with 29 experienced social workers show that most of them endorse de-specialization, as this type of aid is deemed better for clients with complex problems. Moreover, many social workers like to take on new tasks. Basic de- professionalization is met with more reserve. Social workers observe that many clients do not have a suitable network and need professional help. In addition, they feel that their profession is being degraded as lay people and volunteers take over (part of) their work. However, they feel unable to resist this development, because resistance might get them sacked. Some social workers even enhance basic de-professionalization because of their willingness to continue working as (retired) volunteers. Social workers and theorists need to address and counter the move towards basic de-professionalization.
At the centre of the undeniably contentious debates about climate change lies the question of authority: Which voices will be heard and, thus, who will influence policy, activism, and scientific inquiry? Following high-profile errors found in the Fourth Assessment Report of the Intergovernmental Panel on Climate Change (IPCC), the Dutch Parliament sought to achieve ‘balance’ in these debates by bringing together climate scientists and skeptics for a set of online discussions. Using both communication and dialectical theorizing, we explore the organizing of authority around climate change in the Netherlands. We locate dialectical tensions and discursive positions of diverse actors in the debate, examining the communication practices by which actors sought to resolve tensions as part of three authoritative moves: bridging, (de)coupling, and resisting. The combination of these authoritative moves failed to engage with – and therefore could not resolve – the sources of the underlying dialectical tensions. We build on these insights to suggest contributions to the climate change debate and theory on authority in organization studies.
Purpose
Differences in professional values, organisational interests and access to resources are key issues to be addressed when integrating services. They are widely seen by service planners and commissioners to be matters of governance. However, they also inform critical debates in political science. In essence they revolve around the question of distribution, or (how to decide) who gets what. The purpose of this paper is to re-frame the subject of inter-organisational governance in integration by conceptualising it through the lens of three prominent politico-theoretical approaches: the liberal, the authoritarian and the radical-utopian.
Design/methodology/approach
A discussion paper that proceeds by utilising political science terms of reference and applying it to a public management problem.
Findings
All three theories provide particular insights into the way in which service planners and commissioners may think about the inescapable plurality of values and interests in integration programmes. Where the liberal perspective places particular emphasis on the purpose and utility of organisational autonomy and self-direction, the authoritarian model highlights the need to produce results within tight timescales. It also accords with the manner in which integration policy is normally implemented, top down. The radical-utopian model is built on the least realistic assumptions but offers researchers a useful framework to assess the rationale and effectiveness of value-based policy in integration programmes wherever robust inter-organisational structures fail to materialise.
Originality/value
Whilst there has been significant research on how to conceptualise integration programmes, scholars have usually championed a public management approach. The potential insights of political thought have not been explored until now. The paper demonstrates that the wider conceptual framework of political theory has significant purchase in the field of integration studies and can help us understand the benefits and limitations of an interdisciplinary approach.
When studying individual attempts to foster citizen engagement, scholars have pointed to the coexistence of competing rationales. Thus far, however, current literature barely elaborates on the socio-political processes through which employees of professional organizations deal with such disparate considerations. To address this gap, this article builds on an ethnographic study, conducted in the Netherlands between 2013 and 2016, of a professional care organization's attempts to engage local citizens in one of its elderly care homes. To investigate how citizen engagement is ‘done’ in the context of daily organizing, we followed employees as they gradually created and demarcated the scope for such engagement by approaching citizens as either strategic partners (pursuing ‘democratic’ rationales) or as operational volunteers (pursuing ‘instrumental’ rationales). In order to deal with such potentially incongruent orientations, we found that employees used discursive strategies to influence the balance that was struck between competing rationales; either through depoliticization—i.e., the downplaying of incongruities and the framing of disparate considerations as being complementary within the pursuit of a shared, overarching goal—or through politicization, i.e., the active challenging of how their colleagues prioritized one consideration over another. By showing how the successful conveyance of such (de)politicized accounts helped employees either defend or redraw the boundaries of what citizen engagement was (not) about, we contribute to extant theorization by (1) developing a processual approach to studying citizen engagement that (2) is sensitive to organizational politics.
The concept of co-production suggests a collaborative production of public welfare services, across boundaries of participant categories, for example professionals, service users, peer-workers and volunteers. While co-production has been embraced in most European countries, the way in which it is translated into everyday practice remains understudied. Drawing on ethnographic data from Danish community mental health services, we attempt to fill this gap by critically investigating how participants interact in an organisational set-up with blurred boundaries between participant categories. In particular, we clarify under what circumstances the blurred boundaries emerge as believable. Theoretically, we combine Lamont and Molnár's (2002) distinction between symbolic boundaries and social boundaries with Goffman's (1974) microanalysis of “principles of convincingness”. The article presents three findings: (1) co-production is employed as a symbolic resource for blurring social boundaries; (2) the believability of blurred boundaries is worked up through participants’ access to resources of validation, knowledge and authority; and (3) incongruence between symbolic and social boundaries institutionalises practices where participants merely act ‘as if’ boundaries are blurred. Clarification of the principles of convincingness contributes to a general discussion of how co-production frames the everyday negotiation of symbolic and social boundaries in public welfare services.
Purpose
The purpose of this paper is to outline the current thinking on co-production in health and social care, examine the challenges in implementing genuine co-production and argue for a pragmatic version of co-production that may assist programme managers in deciding which type of co-production is most suitable for which programme.
Design/methodology/approach
A discussion paper based on the professional and academic knowledge and insights of the authors. A focus group interview schedule was used to guide discussions between authors.
Findings
The authors argue for a pragmatic approach to co-production within integrated care programmes. The authors set out the basic parameters of such an approach containing procedural rather than substantive standards for co-production activities leaving sufficient room for specific manifestations of the practice in particular contexts.
Practical implications
The authors put forward a pragmatic model of co-production that defines the essential elements of a process for ensuring services are designed to meet with the needs of patients yet allowing the process itself to be adapted to different circumstances.
Originality/value
The paper summarises the discussion on co-production in relation to integration programmes. It formulates a pragmatic model of co-production that may assist programme managers in establishing good practice co-production frameworks when designing or implementing integrated health and social care services.
Patient and public involvement in health research and care has been repeatedly theorised using the metaphor of spaces, knowledge spaces and participatory citizenship spaces. Drawing on data from a three year qualitative study of people involved in health research with organisations across England, this article explores where these spaces fit in a wider social, political and historical landscape. It outlines a theme recurring frequently in the study data: a unified public/patient/service-user perspective in opposition to a professional/clinical/academic view. This is discussed in relation to Habermas's division between the lifeworld and system. Patient and public involvement is mapped as spaces between these spheres, therefore between the social norms pertaining to them. In this way, involvement spaces are seen as liminal, in-between or threshold spaces; this concept provides us with new insights on both the opportunities and the conflicts that are integral in the ambiguous, complex interactions which take place in these spaces.