Ewen Speed

Varieties of co-production in public services: time banks in a UK health policy context

Time banking is a third-sector initiative that enacts principles of co-production and offers a model with which to understand how users can become actively involved with professionals and other stakeholders in the delivery of public services. This article explores possible lines of tension between principles that underpin time banking practices and principles informing the health policy field in the United Kingdom. We develop a framework rooted in the logics approach to critical policy analysis with which to track shifts in conceptions of co-production at three nodes situated along the full length of the public service chain: (1) service provision and distribution; (2) service delivery; and (3) service governance. Our analysis reveals discrepancies in the way co-production principles can be defined, interpreted, and linked to broader notions of social justice: recognition-based interpretations with a transformative accent, and choice-based interpretations with an additive accent. We conclude that the health care regime, if understood as a ‘regime of choice’, will invariably prove to be a rather inhospitable environment for time banks, whose co-production principles are much more in tune with what we call a ‘regime of recognition’.

The Rise of Post-truth Populism in Pluralist Liberal Democracies: Challenges for Health Policy

Recent years have witnessed the rise of populism and populist leaders, movements and policies in many pluralist liberal democracies, with Brexit and the election of Trump the two most recent high profile examples of this backlash against established political elites and the institutions that support them. This new populism is underpinned by a post-truth politics which is using social media as a mouthpiece for ‘fake news’ and ‘alternative facts’ with the intention of inciting fear and hatred of ‘the other’ and thereby helping to justify discriminatory health policies for marginalised groups. In this article, we explore what is meant by populism and highlight some of the challenges for health and health policy posed by the new wave of post-truth populism.

The Health and Social Care Act for England 2012: the extension of `new professionalism’

The 2012 Health and Social Care Act, introduced by the coalition government, has been seen as fundamentally changing the form and content of publicly funded health care provision in England. The legislation was hugely controversial and widely criticized. Much of this criticism pointed to the ways in which the reforms undermined the funding of the National Health Service, and challenged the founding principle of free universal provision. In this commentary we take issue with the argument that the Act represented a radical break with the past and instead suggest that it was an extension of the previous Labour government’s neo-liberal reforms of the public sector. In particular, the Act invoked the principles of ‘new professionalism’ to undermine professional dominance, and attract private providers into statutory health care at the expense of public providers. In turn, this extension of new professionalism may encourage public distrust in the medical profession and absolve the state of much of its statutory health care obligation.

Discourses of Acceptance and Resistance: Speaking Out about Psychiatry

This chapter considers the different ways that are available to people to talk about mental health, mental illness and psychiatry in general. This may seem like a strange point of departure, and it certainly begs the question – ‘but surely people are able to talk about these issues in whichever way they choose’? I would argue that this is not the case. It is more accurate to say that a range of possible discourses exist that enable people to construct and imbue meaning into talk about mental health, mental illness, psychiatry or anything else for that matter. For example, phrases such as ‘nutter’, ‘schizo’, or ‘psycho’ draw from negative, stigma laden discourses of mental health, whereas ‘service user’ or ‘consumer’ are attempts to move towards more neutral characterizations of people who are using mental health services.

“Because You’re Worth It”: A Discourse Analysis of the Gendered Rhetoric of the ADHD Woman

Drawing on the traditions of discursive psychology and critical discourse analysis this study examined the presentation of attention deficit hyperactivity disorder (ADHD) in women in a sample of the most commonly identified online YouTube videos on this topic. The video material selected represented a combination of first-person testimonies from the “sufferer” and the sharing of “expertise” by “professionals.” Analysis involved the identification of common rhetorical devices and evaluation of the role of these devices in conveying various key meanings or themes. The categories generated by this method told a story of the construction of an “ADHD product” presented to women by other women, and unproblematically positioned within the biomedical discourse. Stimulant medication was endorsed for its ability to improve performance at work and in the domestic sphere. Women sufferers in the videos appear as “active consumers” promoting the ADHD diagnosis for its ability to enable them to fulfil the “superwoman” ideal. The medicalisation of underperformance witnessed in the videos is discussed in relation to literature on modern-day “discourses of femininity.”

Logics of marginalisation in health and social care reform: Integration, choice, and provider-blind provision

The period 2010–2013 was a time of far-reaching structural reforms of the National Health Service in England. Of particular interest in this paper is the way in which radical critiques of the reform process were marginalised by pragmatic concerns about how to maintain the market-competition thrust of the reforms while avoiding potential fragmentation. We draw on the Essex school of political discourse theory and develop a ‘nodal’ analytical framework to argue that widespread and repeated appeals to a narrative of choice-based integrated care served to take the fragmentation ‘sting’ out of radical critiques of the pro-competition reform process. This served to marginalise alternative visions of health and social care, and to pre-empt the contestation of a key norm in the provision of health care that is closely associated with the notions of ‘any willing provider’ and ‘any qualified provider’: provider-blind provision.

A note on the utility of austerity

Austerity hangs like a global spectre over health and welfare spending and provision. It is the new orthodoxy, an accepted popular ‘fact’ that we are all living in an ‘age of austerity’ (Farnsworth...

Discourses of consumption or consumed by discourse? A consideration of what “consumer” means to the service user

Background: Consumers and consumerism in a healthcare context are often read as evidence of creeping privatization and marketization. This paper considers discourses of consumption, in a mental health context, from data collected in the Republic of Ireland. Drawing on typifications of western welfare regimes, it will consider processes of commodification and consumption. Aims: The purpose of this paper is to explore the political connotations of the consumer discourse and to focus attention on the implications of utilizing discourse(s) of consumption for service users. Method: Data were generated through interviews with ten mental health service users who were members of mental health social movement organizations. This was analysed using a discourse-analytic technique. The analysis considers consumer discourse(s) and delimits the utility of this way of talking about being a service user. Results: The impacts and inferences of using a consumer discourse are identified. Under some conditions it can be a positive event for the healthcare consumer, but the discourse tends to favour the healthcare professional and/or the state, in that it implicitly reasserts the primacy of the medical model. Conclusion: The consumer discourse is a complex construct that speaks to and for both the state and the service user. However, use of this discourse carries political and therapeutic connotations for the service user. The political connotations relate to the consumer discourse as a feature of a state sanctioned re-positioning of healthcare provision within a more explicitly market based context. The therapeutic connotations relate to a lack of genuine alternative explanatory systems to that of the medical model and an often implicit championing of medical discourses as evidenced in the consumer discourse. Declaration of interest: This research was in part funded by a scholarship from the Irish Research Council for Humanities and Social Sciences (IRCHSS).

Irish Mental Health Social Movements: A Consideration of Movement Habitus

There has been a lack of any concerted mental health service users‘ movement within the Republic of Ireland. Mental health service users’ movements elsewhere have a marked orientation towards strategies of empowerment and the provision of peer advocacy and support for mental health service users. Two potential user habituses (drawn from the literature) are expounded and discussed, in a context of transformations they have effected in the mental health field. Through an analysis of Department of Health and Children literature and literature offered by mental health service user groups (such as Schizophrenia Ireland and AWARE) service user habitus in Ireland are delineated and explored. A comparison between the habitus drawn from international literature and the Irish literature illustrates that the dominant Irish mental health social movement habitus is a consumer habitus. This analysis demonstrates that Irish governmental psychiatric policy is driven by a consumer model that in turn is adopted by mental health social movement organisations, resulting in a dominant consumer habitus.

Beware Zombies and Unicorns: Toward Critical Patient and Public Involvement in Health Research in a Neoliberal Context

Patient and Public Involvement (PPI) in UK National Health Service (NHS) research has become an imperative in policy and practice. However, lack of clarity on what PPI is (or might be) has given rise to a poorly monitored, complex field of activity, variously framed by the expectations of policy makers, funders, host organisations, researchers, health professionals, individual recruits, volunteers, activists and third sector organisations. The normative shift towards PPI has taken place within a neoliberal policy context, the implications of which needs to be explicitly considered, particularly after the Brexit referendum which has left policy makers and researchers wondering how to better appeal to a distrustful public subjected to ‘post-truth’ and ‘dog whistle’ politics. This commentary examines the prospects for a more critical approach to PPI which addresses context, is evidence-informed and mindful of persistent inequalities in health outcomes, at a time when models of PPI in NHS health research tend to be conceptually vague, derived from limited clinical and managerial settings, and centred on a construction of the abstract, rational, compliant and self-managing patient or lay-person.