The institutional logics perspective

In their seminal article on institutional logics, ‘Bringing Society Back In’, Friedland and Alford (Reference Friedland, Alford, Powell and DiMaggio1991), identified the central institutions of modern western societies to be: capitalist markets, the bureaucratic state, democracy, the nuclear family and the Christian religion. They emphasised that each of these most important institutional orders has a central logic, a set of material practices and symbolic constructions which constitute its organising principles.

Institutional logics shape individual preferences and organisational interests as well as the repertoire of behaviours by which these may be attained. Institutional logics provide agents with socially constructed systems of classifications that constitute categories of social actors, organisational forms and organisational agendas (Thornton and Ocasio, Reference Thornton, Ocasio, Greenwood, Oliver, Suddaby and Sahlin2008). The existence of institutionalized elements of organisational structure enables social actors to organise along prescribed lines and makes organisations easier to create (Meyer and Rowan, Reference Meyer and Rowan1977).

Institutional logics are not permanent and static but historically and contextually conditioned: a) they are symbolically grounded, organisationally structured, politically defended, and technically and materially constrained and hence have specific historical limits; b) they are basic features and available to organisations and individuals to elaborate; c) the existence of multiple and potentially contradictory logics for individuals and organisations to draw on opens up spaces for confrontation and challenging of established practices and symbols (Friedland and Alford, Reference Friedland, Alford, Powell and DiMaggio1991).

Because society is constituted through multiple institutional logics, the major institutions are interdependent and yet also contradictory. Some of the most important struggles between groups, organisations and classes are over the appropriate relationships between institutions, the particular institutional logic by which different activities should be regulated, and which categories of persons they apply to (op. cit.).

The concept of hybridity illuminates how many organisations and organisational fields are permeated with several different and even contradictory institutional logics. Different logics may compete and eventually lead to the suppression of one logic and the dominance of another, or they may coexist in the form of stalemate, tension or equilibrium, and give organisations a hybrid character (Battilana and Lee, Reference Battilana and Lee2014; Reay and Hinings, Reference Reay and Hinings2009; Seo and Creed, Reference Seo and Creed2002; Van Gestel and Hillebrand, Reference Van Gestel and Hillebrand2011). Social enterprises can combine organisational forms from the logics of both business and charity. Likewise, organisational structures may be developed to allow the logics of medical professionalism and business-like health care to co-exist in collaborative, rather than only in conflicting, ways.

The argument in this article is that the concept of institutional logic can be applied fruitfully to enhance the understanding of not only whole organisations or organisational fields, but even of the various models that organisations utilize to organise their relationships to the environment (such as citizens and civil society). Applied to citizen involvement in health and social care, an institutional logic perspective points to the frameworks available to policy-makers and participants. When policies of citizen involvement are enacted, they have to be operationalized. Operationalizing involvement policies means giving citizen involvement organisational form, purpose and tasks, and linking it to the organisational structures and processes of health and social care organisations. Institutional logics offer templates that explicitly or implicitly guide operationalization of involvement policies. Institutional logics provide the cultural materials through which organisational forms are constructed. They provide prescriptions for involvement practices: for organisational forms; for tasks, assignments or entitlements given to positions, posts or bodies through which involvement is enacted and also for the perception of the relevant citizens involved, and the competencies requested of them. Because different institutional logics are available to draw on when involvement is operationalized, models of involvement could be embedded in different logics that may co-exist or compete, and thus models could become hybrids containing elements from more than one model.

Aim

The aim is to explicate key dimensions in the construction of citizen involvement through a presentation of some significant models in health and social care and the institutional logics on which these rest, and thereby to demonstrate significant differences in how involvement is operationalised.

The models are presented as ideal types, i.e. deliberate simplifications have been made in order to afford comparative analysis. Within an institutional logic approach, ideal types is a method of interpretive analysis for understanding the meaning with which actors invest their actions (Thornton and Ocasio, Reference Thornton, Ocasio, Greenwood, Oliver, Suddaby and Sahlin2008). As a theoretical tool to facilitate intelligible comparisons, ideal types are particularly suited to the aim of understanding variation in models of citizen involvement.

Analysis

The analysis is a synthesis of existing studies not unlike a process of inductively building theories from case studies (Eisenhardt, Reference Eisenhardt1989; Eisenhardt and Graebner, Reference Eisenhardt and Graebner2007), although the synthesis here is built on existing studies rather than new empirical research. In such theory building, selecting cases is based on theoretical sampling. Cases are selected because they are particularly illuminating; for example, because they could be examples of polar types likely to extend the emergent theory. Analysis means both within-case analysis (with existing studies already performed by others) and searching for cross-case patterns to identify categories or dimensions, and then looking for within-group similarities coupled with intergroup differences. Shaping of theoretical constructs (hypotheses, concepts, ideas) is a two-part process of a) refining the definition of the construct (here, the distinguishing dimensions of citizen involvement) and b) building evidence which measures the construct in each case (here, investigating whether the dimensions could be identified in all cases).

Due to the existing plethora of forms of citizen involvement, it would be impossible to cover the full variety within the space of one article. Instead, three contrasting models of involvement have been purposely selected to emphasise variation. The selection is based on the author's empirical research from Norway and a literature search to inform the analyses through findings from other studies, and thereby to compare and contrast forms of involvement from different national contexts. The analysis draws on reported studies from other European countries, mainly the UK. The UK is appropriate because it offers a rich collection of research material due to decades of various involvement policies.

Involvement of spokespersons from user organisations

The prevailing model of citizen involvement in health and social care in Norway is in the form of consultation through standing advisory bodies, termed ‘user councils’. In the regional health authorities, hospitals and in the labour and welfare administration, user councils are entitled to be involved in discussions in relation to the planning, provision and evaluation of services (Alm Andreassen, Reference Alm Andreassen2008). Often the councils are supplemented with ad-hoc forms of consultative forums involving larger numbers of service users in relation to specific matters on the decision-makers’ agenda.

The citizens involved are the ‘users’, those directly affected by service provision, through associations who organise and speak for citizens with long-term and complex conditions – people with chronic illnesses, disabilities or mental health problems, substance addicts, the elderly, and the economically disadvantaged. The organisations nominate their spokespersons, and public services can select council participants with the aim of achieving a representative cross-section of user groups. Involvement is grounded in a tradition of democracy where citizens elect those who are to speak for them – who, for their part, act on behalf of and are held accountable to their constituencies.

Besides intimate acquaintance with the situation of the relevant user group, important competencies expected of the participants include doing a proper job as spokespersons (Alm Andreassen et al., Reference Alm Andreassen, Breit and Legard2014). The organisations provide training programmes through which the participants are taught what it means to be ‘representatives’.

While organisations of health and social care users exist in many European countries, and many of them state that influencing policy is an important task, there are variations between countries as regards the extent to which the organisations are engaged in policy processes (Anker and Halvorsen, Reference Anker, Halvorsen, Hvinden and Johansson2007; Baggott and Jones, Reference Baggott and Jones2014; Opedal et al., Reference Opedal, Rommetvedt and Vrangbæk2012; Van De Bovenkamp et al., Reference Van De Bovenkamp, Trappenburg and Grit2010). The strong position of groups with long-term and complex conditions in Norwegian involvement policy could be understood in the light of active campaigning by disability organisations and their federation, in which organisations of persons with chronic illnesses and mental health problems are incorporated (Alm Andreassen, Reference Alm Andreassen2008).

This model of citizen involvement bears the hallmark of the logic of democracy, which can be explained by its embedding in the Nordic model of the state–civil society relationship, with the following key features (Alapuro and Stenius, Reference Alapuro and Stenius2010; Salamon, Reference Salamon2004; Wijkström and Zimmer, Reference Wijkström and Zimmer2011):

• • a vibrant civil society with a large number of voluntary organisations, with a high volume of membership, active participation, donations and voluntary work;

• • an expressive-dominant civil society sector where the organisations are not primarily service providers but vehicles for the expression of political, social and cultural interests and mechanisms of interest mediation from private lives to public policy;

• • widespread support of democratic governance and representation, underpinned by requirements for receiving public funding, and developed organisational models with internal democratic structures and boards elected by the members;

• • a particularly close relationship between state and civil society in the form of integrated participation or participatory corporatism, through which various societal interests have been involved in policy-making based on experiential knowledge of the issues under consideration; and

• • a transformation of traditional participatory corporatism, as features of ‘deliberative neo-corporatism’ involving networks, partnerships and deliberative forums are replacing centralised and hierarchical forms of representation (Enjolras, Reference Enjolras, Bozzini and Enjolras2012).

The advisory bodies and ad-hoc forums of service user involvement offer public spaces where a range of civil society organisations are brought in, including small and marginalized minorities, and where an abundance of interests, identities, voices and experiences can be expressed and debated. Such advisory bodies are placed in an in-between position, of being part of the decision-making processes of the public sector service organisations and partly autonomous bodies composed of members of voluntary organisations of civil society (Alm Andreassen, Reference Alm Andreassen, Waldahl and Enjolras2009b). This in-between position gives the councils a hybrid nature. User councils become both carriers of interests (as in the Nordic model of the state–civil society relationship) and, at the same time, providers of knowledge intended to be utilised by those in charge of health service deliverables, as the councils have to answer to managerial agendas.

Involvement of generalised publics of lay people

The Norwegian model of service users as the relevant citizens to be involved, and their role as representatives of those directly concerned, differs from models in other European countries where it is considered that the relevant citizens to be involved are the ‘public’. In health technology assessment, for instance, while those directly affected by a given health condition or technology are involved, such as individual patients and service users and their representatives (e.g. a disabled people's group or the Cancer Society), these publics are supplemented with publics deemed to represent a societal or lay perspective (Gauvin et al., Reference Gauvin, Abelson, Giacomini, Eyles and Lavis2010).

Forms of involvement where invited or self-selected individuals represent the public, understood as ordinary, true, or ‘unhyphenated’ citizens, have been more prominent in the UK, for instance in citizen juries or the Citizens Council of the National Institute of Clinical Excellence, as a way of keeping government and public services in touch with public values (Davies et al., Reference Davies, Barnett and Wetherell2006; Harrison and Mort, Reference Harrison and Mort1998; Martin, Reference Martin2008a).

The citizens involved are selected to represent the community as a whole, rather than to represent the interests of particular user groups (the ‘hyphenated’ citizens). Involvement procedures are guided by some conception of the ‘general public’. The citizens may be self-selected through open invitations or advertisements, or they may be systematically but randomly selected from the electoral registers, for example, then matched to fit a community profile and balanced to take account of characteristics such as gender, ethnicity, socio-economic status or age. The citizens involved are to reflect the community from which they are drawn.

These ordinary citizens are invited to serve only for a limited period of time to avoid professionalization of citizens. The aim is to ensure that the involved citizens are ‘new’ to the issues, and to prevent them from becoming too familiar with the services. The citizens are to be ‘genuine’ members of the public (Davies et al., Reference Davies, Barnett and Wetherell2006; Harrison and Mort, Reference Harrison and Mort1998).

There are hybrid aspects connected with this model of involvement, too, as the request for ordinariness is modified in that the citizens involved are expected to be knowledgeable about health care and able to devote a substantial amount of time to participation (Learmonth et al., Reference Learmonth, Martin and Warwick2009). The perception of the citizen is someone who knows and makes known his or her constituency, by being typical of the local population but also making efforts to better understand its views (Martin, Reference Martin2008a).

This hybridity in requirements for citizens to qualify leads to ambiguity: they have to be ‘ordinary’ to represent the community effectively, but, if they are ordinary, they cannot effectively represent the community. If they have knowledge, experience of providing or using services, and an understanding of the health needs of the community, and are capable of giving considered and informed opinions, the citizens are no longer ordinary but, rather, professional.

Such models, where ordinary citizens and members of the general public are involved, must be placed within a version of the logic of democracy which is different from the Nordic model of the state–civil society relationship. The mediating position of civil society organisations, which is so prominent in citizen involvement in Norway, is here replaced with a model that seems to operate with a direct link between the citizens and the state. A service-dominant civil society sector (Salamon, Reference Salamon2004), with a higher share of paid staff, might be part of the explanation: civil society organisations are themselves service providers.

Involvement of users as co-workers

User-employment is a model of citizen involvement in which citizens are involved as co-workers, co-carers, or co-researchers. The model appears to have spread from the US, and is found in Australia, New Zealand, the Netherlands, Canada, the UK and, more recently, also in Scandinavian countries.

Various terms are applied, such as ‘consumer-providers’, ‘consumer employees’, ‘lived experience workers’, ‘consumer consultants’, ‘peer counsellors’, ‘peer support workers’ and ‘peer-providers’. Personal experience as service users and having health conditions, mental health problems, disability or social problems is the important qualification in this model, too, but the form of involvement differs from consultative models in that service users are engaged by service-providing organisations, sometimes as voluntary workers, but most often in paid jobs.

As many of the terms indicate, peer employees are people with lived experience who are employed to support others who face similar challenges (Repper and Carter, Reference Repper and Carter2011). They are hired into designated positions with the task of performing peer-delivered interventions (Walker and Bryant, Reference Walker and Bryant2013). Consumer providers in mental health care, for instance, are those with serious mental illness who are further along in recovery and can draw upon their experience to provide services to others with similar mental health problems (Chinman et al., Reference Chinman, Young, Hassell and Davidson2006). User-employees work not only with peer support in health services but also in posts where the task is explicitly to communicate user perspectives to service providers or researchers, or to organise user involvement (Austin and Johannessen, Reference Austin and Johannessen2015).

An example from Norway is a collaborative research and development programme in social services where service users were employed on several occasions in part-time positions as project workers, as co-workers, co-researchers and, in some cases, as project managers (Austin and Johannessen, Reference Austin and Johannessen2015). Involvement of users as co-workers, instead of via consultative bodies, was founded on an idea of rebalancing the power relationship, acknowledging users as subjects rather than objects of research or professional help, and creating equality by ‘doing the same things’ (Eide, Reference Eide2015). Some of the citizens involved were associated with user groups or organisations. Nonetheless, most often they were not considered spokespersons of user organisations; rather, they were selected individuals personifying a ‘generalized service user’ (Alm Andreassen, Reference Alm Andreassen2015; Gjernes and Bliksvær, Reference Gjernes and Bliksvær2011).

Involvement through user-employment is not only a means of enhancing the responsiveness, quality and effectiveness of health and social care services through a source of service user perspectives, or a democratic right of citizens to influence services of great importance to their living conditions. In several cases, an equally important objective is the impact of involvement on the involved citizens themselves – their personal development, recovery and vocational rehabilitation. Thereby involvement as user-employment attains aspects of hybridity.

In the social service research and development programme much weight was placed on strengthening the citizens involved, on relieving them of feelings of guilt and shame produced by their status as social welfare recipients, and on building their self-confidence (Natland and Celik, Reference Natland and Celik2015). More formally, education to convert user experience into a professional qualification is organised as vocational rehabilitation. In the UK, for instance, a User Employment Programme in a mental health trust was established in 1995, as a ‘supported employment’ project aimed at helping people who have had mental health problems to gain and maintain employment within mental health services (Perkins et al., Reference Perkins, Rinaldi and Hardisty2010). A similar programme was tried out in Denmark from 2000 until 2007, founded on an ‘Individual Placement and Support’ programme for health and social care professionals at risk of being excluded from the labour market due to mental illness (Andersen, Reference Andersen2010). In Norway in 2006, a one-year education programme, undertaken by a vocational rehabilitation enterprise, was designed to educate ‘workers with user experience’ from a target group of individuals with mental health problems (Biong et al., Reference Biong, Fugletveit and Lofthus2012).

The ideal-type organisational form of user-employment is a job; the citizens involved are not spokespersons of user organisations from which they are elected, or members of the general public selected to represent ordinary citizens. Rather, they are employees or co-workers, hired by the services in which they work. Representativeness is of minor importance and, if made relevant, it is conceptualised more as typicality. Their qualifications become more important than their representativeness – the fact that they have knowledge and skills that are of use to the employers, i.e. the health and social care organisations. User-employment means establishing the experiential knowledge of service users as a qualification for paid work; in many cases as a sufficient qualification, in others as an essential supplement to a professional education. User-employment involves an employment process where meritocratic criteria for the best suited are taken into consideration.

In addition, citizen involvement through user-employment sometimes achieves a hybrid character. With its element of social policy, user-employment is not only a form of employment in which one important outcome is better services, but also a measure of vocational rehabilitation in which another important outcome is the recovery of the user-employees.