Understanding Democratic Governance: an inductive analysis of collective co-production in the NHS in England

This thesis explores the role of collective co-production in facilitating democratic governance in the National Health Service (NHS) in England. Democratic governance offers citizens a role in constructing their communities and institutions. It is a model of governance that is contingent on equality of decision-making between different citizens. However, in the NHS this form of administration has been atypical. Over the past 30 years NHS governance has been based on neo-liberal ethics and latterly institutionalised networks. These models have been imposed through compliance processes that strengthen managerialism and reduce the capacity of the service user.

Recently, a number of contemporary governance scholars have critiqued the notion that governance is simply imposed on institutions. Decentred theorists argue that organisations are inherently complex and cannot be understood through ideal models. Instead, they propose that governance is produced through the actions and beliefs of those who operate within institutions. Crucially for this thesis, this approach means that democratic governance can be generated by staff members, patients and other stakeholder communities.

In this thesis I study one route through which individuals organise and participate in democratic governance in the NHS. This is ‘collective co-production’: a form of decision-making that enables communities to work together and produce outcomes. To do this I have created an inductive framework that examines how the implementation of collective co-production is influenced by exogenous, institutional and departmental traditions; and which studies how actors participate within collective co-production and engage in equal decision-making.