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Attribution License (Prefigurative social movements are characterised by the insurrectional challenge to established values and structures that activists bring when they enact alternative realities. Activists performing within this paradigm create new spaces for change, practice, dialogue and distributed leadership (Maeckelbergh, 2012). This paper aims to investigate the potential to mobilise communities of healthcare providers within the National Health System (NHS) in the United Kingdom, looking at what drives them to participate and engage in change activities. We use this case study as a lens through which to elucidate the relationship between the drive to mobilise, and the process of enactment within prefigurative movements.
Drawing on a broader research study, this paper explores the emergence of the NHS Change Day (NHSCD) movement. It focuses concretely on the efforts of its activists to create a frontline mass movement aimed at mobilising collective action for the improvement of the NHS. NHSCD is a frontline led grassroots’ movement of activists, which has been emerging since 2013 (Hilton & Lawrence-Pietroni, 2013). The movement calls for both staff and patients to engage dialogically in the practice of improvements, aiming to show that small, individual actions can have a large impact:
NHS Change Day is a grassroots movement that’s about harnessing the collective energy, creativity and ideas of thousands of people to improve the care and wellbeing of people who use health and care services, their families and staff. Over the past two years thousands of people made pledges to change things. This year we want to inspire people to take action. Anyone can get involved, whether they work in or alongside the NHS or are a patient or member of the public.
The NHS has had, since its inception, a strong and formative social and political influence on the development of a modern national identity in the UK, and is viewed by many as inextricable from an understanding of what it is to be British. As the fifth largest organisation, and the largest healthcare system in the world, the NHS plays a key role in shaping both health and social care in the UK. The NHS is viewed by the British public as a social movement with a pioneering philosophy – one which makes a global contribution, conceptualizing the moral right to access free healthcare.
Yet, the NHS as we know it is under siege, facing political, economic, and cultural pressures, which challenge the founding vision of unlimited healthcare available for all. These pressures include restrictive budgets and shifting demographic structures, as well as encompassing concerns regarding the cost of treatment for an aging population. These issues challenge the dream of unlimited healthcare available for all. In addition, the NHS has faced a series of morale-reducing investigations into performance failures, including the Francis Report (Francis, 2013), which articulated both systemic and cultural failings regarding patient neglect on an organisational scale.
Policy makers have addressed these problems in the most part through the implementation of top-down local and national organisational and development change programmes, including The Health and Social Care Act (2012). Yet, the success of these initiatives has been the subject of public and critical debate.
In this context, NHS Change Day has been emerging since 2013. While this social movement was initiated in the English NHS, it has recently started to reach a global audience, with similar initiatives emerging in Australia, Northern Ireland, Canada, the Netherlands, Finland, the USA, Scotland, Wales, New Zealand, Jordan, and India.
As a prefigurative social movement, NHSCD spans the length and breadth of England. The movement’s call to action emphasises enactment and collaborative thinking under the slogan ‘Do Something Better Together’. The movement’s activism is rooted in, and emphasises the agency of frontline staff, as well as being open to public participation (Hilton & Lawrence-Pietroni, 2013; NHS Change Day, 2016; NHS England, 2014; NHS Improving Quality, 2013; Steen, 2014). Critical to our research on prefigurative social movements linked to large formal organizations, NHSCD emphasises the importance of nourishing small-scale, experimental, bottom-up changes, rather than large, planned, top-down change programmes; the movement encourages NHS stakeholders to make voluntary public commitments on an official website, to “make a difference”: an achievable change in their practice. It is through these individual actions of the NHS staff and public that the movement aims to reveal that grassroots actions can lead to large-scale improvements (Bevan, Roland, Lynton, Jones, & McCrea, 2013; Hilton & Lawrence-Pietroni, 2013). As such, NHSCD has developed a distributive network of leaders, most notably the ‘Hubbies’, from all levels of the hierarchy within the NHS. The movement’s volunteers fulfil particular roles, and there is no correlation between their influence within the movement and their seniority within the NHS. The movement’s activists volunteer their time to the movement through organising events, sharing communication, and collaborating on a national scale (Jones, 2014; Rutter, 2014).
In common with other contemporary prefigurative movements which challenge the established, hierarchical means of communication by utilising social media platforms, much of the Change Day movement’s communication is mediated and channelled through digital interfaces, including an official website of the movement. Moreover, just as Change Day ‘occupies’ specific places – online platforms through which participants voice opinions, record actions, and co-construct the movement’s dialogue – it also ‘occupies’ a day within the NHS calendar. The movement celebrates its cause and activities through an annual national campaign, enabling participants to have the opportunity to focus upon, and experiment with change initiatives that they might not otherwise have attempted.
In an article published in BBC News Health, the small-scale changes performed by movement participants were described:
This year, there have been pledges from everyone from NHS managers and chief executives, to nurses, doctors and healthcare assistants around the country. Pledges range from the simple, such as making sure a child's teddy bear is right next to them when they wake up in recovery, to the innovative, such as helping terminally ill children understand and relate to the cycle of life by growing and nurturing seeds on the ward.
Drawing upon an overall, ongoing, longitudinal and in-depth ethnographic study of the movement almost from its origins, this paper is based on the analysis of 23 in-depth interviews of the movement’s activists and participants.
In this paper, we examine the motivations for becoming involved in collective action as participants in the NHSCD movement. It is through this investigation that we aim to illuminate the complexity of the dynamics between the motivating factors driving people to activism, and the actual meaning they assign to their experience of participation in a prefigurative movement. In particular, we focus on the meaning assigned to the experience of the enactment of change in a prefigurative movement.
We analyse our findings in light of recent developments in the understanding of group identity processes in the mobilisation of collective action, and highlight the role of enactment in these dynamics. This exploration of the role of enactment in the dynamics of motivation and participation aims to provide a deeper understanding of the mechanisms of collective action inherent in prefigurative movements, and thus, to contribute towards the understanding of the processes driving change through prefigurative movements.
The paper is structured as follows: the following section outlines our theoretical framework regarding prefigurative social movements as challenging and presenting an alternative to top-down planned change. We proceed with a section delineating the fieldwork process and methodology applied in approaching the case study, and the analysis of collected data performed for the purposes of this paper. This is followed by a section that outlines the wider research context: the NHS, its core ethos, and significance to the UK’s national identity, as well as its wider organisational and political environment and challenges. A further section lays out findings regarding activists’ narratives, describing their processes of becoming NHSCD participants. We then analyse our findings in discussing the interplay between enactment, identity and motivation. We conclude this paper by arguing that motivation and enactment are mutually constituted processes.
Prefiguration: Challenging Planned Top-Down Change
The term ‘prefigurative culture’, coined by Margaret Mead (1970), refers to cultures of collective, multigenerational learning – cultures in which adults learn simultaneously from ancestors, peers and children (Mead, 1970, p. 51). Karl Boggs (1977) was the first to situate the term ‘prefigurative’ in a political context: “By ‘prefigurative’ I mean the embodiment, within the ongoing political practice, of a movement, of those forms of social relations, decision-making, culture and human experience that are the ultimate goal” (Boggs, 1977, p. 100). This concept has since developed to encompass various politically oriented, day-to-day activities (Yates, 2015). Prefigurative social movements are characterised by the insurrectional challenge to established values and structures through the activist-led enactment of alternative realities. This approach, therefore, emphasises the need for movements to align their ideology with their actions (Leach, 2013). By doing so, it is argued that prefigurative movements bring forward to the present their goals for the future (Yates, 2015). This performance of alternative political realities through enactment is argued to present a strategy for the transformation of the distribution of power (Maeckelbergh, 2011). Activists performing within this paradigm create new spaces for change, practice, dialogue, and distributed or horizontal leadership (Maeckelbergh, 2012).
Prefigurative movements challenge the way in which change is traditionally conceptualised as a linear, structured process, which can be strategically pre-planned and designed. According to such views, change interventions can set predetermined goals (Morgan, 2006). Change is often understood to be a dramatic process, involving the destruction of one configuration and its replacement with another (Demers, 2007; Galbraith, 2000). This understanding of change encourages the development of intervention models to guide, monitor and evaluate the implementation of change programmes (Senior & Swailes, 2010). Drawing on mainstream economic and management literature, such interventions aim to generate a shift from a ‘present condition’ to a more ‘desirable future’, often envisioned by small groups of external or senior people within the system (Beer & Nohria, 2000; Burnes, 2013; Carnall, 2007). This top-down view of change undermines the importance of social interaction and human agency, regularly failing to address the complexity and diversity of societal and environmental contexts in which change processes are implemented, and often, therefore, confronting resistance (Garcia-Lorenzo, 2008; Howarth et al., 2013).
In the context of the NHS, the effectiveness and resistance to top-down, large-scale restructuring programmes of change are constantly debated in healthcare management and improvement literature. Dominant change modules are attacked for being influenced by management theories. Such theories are critiqued for making over-simplified assumptions regarding the correlation between elements within the healthcare system, and consequently advocating for change programmes which ignore fundamental aspects of the organisational life (Plsek & Wilson, 2001). Moreover, healthcare environments such as hospitals, are delineated as extremely dynamic, interactive settings, which are difficult to evaluate according to performance models (Shiell, Hawe, & Gold, 2008). Other authors discuss the shifting standards and values by which the British public expects the NHS to adhere. They argue that a current health service must alter its focus from implementing change and improvements, to developing the ability to adapt so that it is constantly responsive to changing demands (Fraser & Greenhalgh, 2001). Top-down approaches of programmes focusing, for example, on “inspection and performance management” resulted in a lack of engagement of clinical staff with what many felt to be “yet another misconceived attempt by politicians to extend their control over frontline care” (Degeling, Maxwell, Iedema, & Hunter, 2004, p. 2).
Conversely, prefigurative initiatives invite us to trust the process of change, emphasising improvisation, and the importance of the journey involved in the change processes, and in collective action. Viewing improvisation as emerging from the tension between innovation and continuity enables goal setting to be flexible, and develop organically, rather than being stated from the outset (Cornish, Montenegro, van Reisen, Zaka, & Sevitt, 2014; Nolas, 2014). Viewing change as a continuous process rather than a periodic event, which happens incrementally rather than radically, gives a clearer vision of how it is through the agency of human actors that change is accomplished (Garcia-Lorenzo, 2010, 2007; Miller & Friesen, 1982; Tsoukas & Chia, 2002; Weick & Quinn, 1999).
Yet, the need to clarify how engagement and participation happens is key to understanding collective action. Indeed, social movement theory has, over the past few decades, been investigating various approaches to the study of the dynamics of mobilisation (Benford & Snow, 2000; della Porta & Diani, 2006; Snow & Benford, 1988).
Early studies in the field, popular in the 1950’s and 1960’s, attributed the emergence of protests to spontaneous and unexpected crowd responses to strain upon the social structure (Smelser, 1998). These studies tended to associate participation in collective action with negative connotations, often viewing social movements as posing a threat to democratic political systems (Eyerman & Jamison, 1991). The motivation to participate in collective action by joining social movements has been further attacked, most dominantly in the 1970s, by the proponents of ‘instrumental rationality’, arguing that it would not be rational for people to join in collective action when they could by-stand (or ‘free ride’) and still enjoy the results of others’ efforts. Olson’s (1971) ‘free rider’ paradox thus further stresses the question of how the mobilisation and maintenance of collective action occur (Opp, 2009; Mueller, 1992).
The perception of social movements has, however, altered significantly with the emergence of the counterculture movements of the 1960’s and 1970’s, the civil rights movement, and the ‘new social movements’. These movements were perceived as driving positive social change, and as fundamental to the democratic freedom of speech and expression (Scott & Marshall, 2009). These new types of movements also presented new theoretical questions and new opportunities for research, highlighting the importance of group identity, as well as the need to move beyond the logic of strategic or instrumental rationality in conceptualising the mobilisation of collective action (Cohen, 1985). Gamson (1992), for example, criticised Olson’s theory as “an individual utilitarian model”, which fails to address issues of group identity, claiming that “when people bind their fate to the fate of a group, they feel personally threatened when the group is threatened. Solidarity and collective identity operate to blur the distinction between individual and group interest, undermining the premises on which such utilitarian models operate” (p. 57). Klandermans (2004) further claims that even though participation in collective action requires, on the one hand, the investment of both time and effort, as well as often putting participants in risk, it answers, on the other hand, participants’ psychological need “to change their circumstances […] to act as members of their group, or […] to give meaning to their world and express their views and feelings” (p. 361).
In reviewing early and recent conceptualisations of collective identity, Hunt and Benford (2004), trace the interest in the concept to the works of Marx and Weber, discussing the dominant contribution to the understanding of collective identity made by social psychologists such as Mead, Berger, Luchmann, Giddens, Moscovici and others, and elaborating upon the development of the concept in the study of social movements, highlighting the dynamic, multi-layered and multifaceted nature of collective identity:
Collective identity is conceptualized as individuals’ identifications of, identifications with, and attachments to some collectivity in cognitive, emotional, and moral terms. Rooted in and shaped by particular sociocultural contexts, collective identities are produced and reproduced in ongoing interactions between allies, oppositional forces, and audiences who can be real or imagined.
(Hunt & Benford, 2004, p. 450)
The study of identity processes within social movements thus aims to elucidate the manner in which a ‘collectivity’ is formed, and sustained. It further explores the process of identification through which group members become associated with a collective, and make sense of their participation in it (Melucci, 1996, p. 69).
Van Zomeren, Postmes, & Spears (2008) state that the three key subjective drivers shown to predict collective action in quantitative research are the collective sense of injustice, identity, and efficacy – three socio-psychological factors, which they argue should be considered in one integrated model rather than separately. The authors suggest the Integrative Social Identity Model of Collective Action (SIMCA), which argues for the centrality of identity in mobilisation, both as a direct and indirect prediction of collective action. The SIMCA model contends that social identity “underlies injustice because it provides the basis for the group-based experience of injustice” and also “underlines efficacy because a stronger sense of identity empowers relatively powerless individuals” (van Zomeren et al., 2008, p. 511). Another key recent contribution to the field is the Encapsulation Model of Social Identity in Collective Action (EMSICA) developed by Thomas, McGarty, and Mavor (2009a). The model further nuances the dynamic relationship of group membership, claiming that “perceptions of injustice and group efficacy provide the basis for the emergence of social identity and become captured in social identity” (Thomas, Mavor, & McGarty, 2012, p. 3). Thomas et al. (2009a) contend that “understanding the ways that people give meaning to their identities, in context, is what truly underpins the study of social change” (p. 205). The interest taken by contemporary scholarship in social movements, therefore, considers the underlying processes shaping actors’ perceptions of their interests and identities, and possibilities for change (Campbell, 2005).
Fieldwork and Methods
This paper stems from a wider, ongoing PhD research project. Field research adopted a triangulation of three distinct qualitative methods of data collection. In-depth longitudinal ethnographic research, beginning in July 2012, and encompassing three consecutive NHS Change Days, in 2013, 2014 and 2015, involved field ethnography, in which first-hand data were collected through travelling the length and breadth of England, capturing the nationwide phenomenon of NHSCD in acute detail. Field ethnography included more than 200 hours of participant observations, discussions, and the collection of field documentation, such as pamphlets, leaflets, and email correspondence. As a phenomenon, a substantial part of NHSCD is conducted online, via official websites; thus, more than 400 hours of digital ethnographic data were collected in real time. Furthermore, a media review of 389 articles surveyed local, national and trade print publications. This variety of data collected has been vital to the understanding of the dynamics of the movement, and has informed the development of this paper.
Specifically, the findings presented in this paper are based upon data from 23 in-depth interviews, conducted with a range of purposely-sampled stakeholders, including the movement’s founders, leaders, and participants. The corpus of interviews encapsulates perspectives from a range of stakeholders within the NHS, representing a spectrum of professions, levels of seniority, and geographical locations, designed to portray both horizontal and vertical processes. The interview process used a semi-structured guide, designed to collect rich narrative data from the perspective of activists, which was developed on the basis of preliminary insights obtained from participant field data. Throughout the process of interviewing, the guide was interpreted flexibly, based on the interaction during the interview. Care was taken to ensure that no leading questions were asked; questions were asked in an open-ended manner.
A thematic analysis was utilised in order to code the data, organising basic themes into 11 categories, which were used to develop 4 global themes: contextual motivations to participate in NHSCD; collective agency as motivation – “do something better together”; the power of bottom-up change as motivation; and enactment as motivation.
The Wider Research Context: The NHS
The NHS was founded in 1948 with the aspiration of making the best medical advice and treatment freely available to the entire British population. The NHS was the first comprehensive health system in the Western world based on national provision of services rather than on insurance principles (Delamothe, 2008a, 2008b). The NHS plays a central part in the life-course of British citizens: “From the cradle to the grave, citizens are promised healthcare, delivered according to need, free at the point of delivery” (Ballatt & Campling, 2011, p. 1). In this sense, the NHS has the capacity to galvanise nationalist sentiment, as is exemplified by its frequent treatment in political discourse, in the news, in British television, and in iconic symbolic events such as the 2012 Olympic Opening Ceremony (Abbasi, 2012; Ballatt & Campling, 2011).
The NHS is the largest healthcare system in the world, as well as one of the five largest workforces today, including the US Department of Defence, McDonalds, Walmart, and the Chinese People’s Liberation Army. The NHS employs an estimated 1.6 million people, with 1.3 million of whom work for NHS England. Today, NHS England provides health and social care services to a population of 54 million people, of whom 1 million patients are estimated to access the NHS’s health and social care services every 36 hours (Alexander, 2012; NHS choices, 2015).
The NHS, however, has had to face the increasing challenges, imposed by budget constraints, of delivering its vision of free adequate healthcare for all (Delamothe, 2008c). The recent years of global recession (Appleby, 2012; Stuckler, Basu, & McKee, 2010) have aggravated political questions about what proportion of gross domestic product (GDP) should be spent on healthcare, as well as the issue of how these costs should be levied, whether through taxation, fee charges to patients, or insurance policies (Delamothe, 2008d). This has made the NHS a constant and critical topic in current political debates (Mason & Morris, 2014).
Funding concerns have become inseparably associated with patient autonomy, and the extent to which patients rather than experts should have the right to determine their own treatment (Delamothe, 2008d). Moreover, the NHS is challenged with improving service responsiveness to patient demand, whilst investing in health promotion and prevention (Crisp, 2011; Bevan, 2012). These challenges are amplified by the growing healthcare needs of an expanding elderly population, including treatments for long-term conditions and dementia (Boyd, Burnes, Clark, & Nelson, 2013). There is debate about the system’s preparedness for continued universal healthcare in the context of these challenges (Godlee, 2013; Select Committee on Public Service and Demographic Change, 2013). The conflicting demands in which the NHS is required to constantly improve the quality of patient healthcare whilst reducing its costs is aggravated by the need to maintain currency with increasing technological innovations (Bevan et al., 2013).
In addition to funding problems, healthcare scandals, from the murders of Harold Shipmani, to the recent abuse at Winterbourne Viewii, have sent shockwaves throughout the NHS, undermining public faith in the ability of staff to deliver consistent, high quality services (Delamothe, 2008e; Mohammed, Cheng, Rouse, & Marshall, 2001; O’Dowd, 2012). The media furore triggered by high-profile scandals undermines public opinion of the NHS, dents the morale of frontline staff, and forces NHS employees through retroactive programmes of change, designed to tackle systemic problems (Hilton & Lawrence-Pietroni, 2013).
Negligent surgical practices at Bristol Royal Infirmary, leading to excess paediatric mortality, for example, were attributed to groups of influential clinicians reinforcing poor-quality care. Subsequently, the critique of the absence of managerial structures resonated NHS-wide, triggering policy change (Kennedy, 2001; Mannion, Davies, & Marshall, 2005; Mannion et al., 2010; Stevens, 2004). The high-profile nature of the Mid-Staffordshire NHS Foundation Trust Public Inquiry into revelations of malpractice at Stafford Hospital highlighted poor quality care, patient neglect and cultural failings on an organisational scale. The report highlighted the tension between the staff needing to focus on patient care and pressure in terms of delivering government targets (Francis, 2013).
In order to address the onslaught of issues faced by the NHS, organisational development programmes have been introduced locally and nationally. A quasi-market system has been developed where different subcontractors compete for contracts, in which ‘payment’ is determined ‘by results’. NHS Foundation Trusts have been established, resulting in service redesign throughout NHS organizations, and increased private sector commissioning (Freeman & Peck, 2010; Hyde, 2010). In 2013, the NHS embarked upon its most recent structural change: The Health and Social Care Act (2012). This restructuring involves a move to clinically led commissioning, increased patient involvement through independent consumer champion organisations, and a complete reconfiguration of health service provision. These changes have been described in the British Medical Journal as “the largest set of changes the NHS in England has seen since its formation” (Edwards, 2013, p. 2090).
Findings: Enacting Activism, Becoming a Participant in the NHSCD Movement
Contextual Motivations to Participate in NHSCD
Anxiety Regarding the Future of the NHS
Anxiety about the future of the NHS, and a sense of disempowerment resulting from contextual pressures, were described by NHSCD participants as motivators compelling them to take on personal responsibility for improvements. Participants articulated the emotional importance of finding ways to respond effectively to challenges with positivity and meaningfulness.
Anxieties expressed focused upon the gradual disestablishment and privatisation of services. The fears voiced orientated around implications of budget constraints undermining the core NHS values, and the ability to provide integrated care:
I hope that the NHS doesn’t get broken up, it feels like we’re heading towards piecemeal privatisation of the NHS where industry takes over the easy parts of the NHS – easy services, easy operations, things like that.
(An NHS doctor)
NHSCD participants worried about whether the NHS could survive the dramatic slashes predicted. Furthermore, there was a sense of anticipation, resulting from the understanding that pressure exerted on the current system would alter what the healthcare system represented in the UK, not just what it was able to deliver.
[…] we’re not going to survive in the NHS […] we have to make savings every year and they’ve done all the salami slicing, they’ve done all the quick wins, but now they need a whole new change to deliver savings and to deliver care effectively and that’s what NHS Change Day can help deliver.
(An NHS Graduate Management Trainee)
NHSCD participants emphasised the day-to-day insecurity created by the constant restructuring programmes including the recent Health and Social Care Act. They described external political pressures which they felt were shaping the NHS, and how the uncertainty associated with having to navigate unseen obstacles was becoming a daily reality on the frontline of healthcare provision in the UK.
[…] the Health and Social Care Act is a massive change: having to battle with reducing finances and increasing demand […] I think we’re talking a bit more crystal ball here and I think it depends a bit on what the politicians do over the next few years. We’ve seen a major reorganisation of the NHS, to a scale that we’ve never seen before and it’s going to take a good ten years before we understand what that reorganisation is going to look like in terms of the NHS.
(An NHS Graduate Management Trainee)
Participants described how this sense of anxiety and the ensuing anger provoked by what they described as the constant onslaught of top-down organisational changes, was a key motivator, inspiring them to participate in the Change Day movement.
My personal motivation was really because I think I was so negative about the Health and Social Care Bill that came out around the time we set up the first Change Day... and this real frustration that all this top-down change and reorganisation was being done to us […] We didn’t want a lot of this change to be forced on us. I think it was almost a reaction to that... that actually we’ve got to take charge, and we’ve got to take an ownership of what is within our gift to control – so, the things we can change.
(An NHS General Practitioner)
In addition to top-down pressure to cope with repeated structural changes and budget cuts, NHSCD participants described the demoralising impact of media critiques of frontline professionalism, and, in particular, of the Francis report.
The Francis Report, and a Sense of Identity Crisis
NHSCD participants described how the movement’s positive ethos, celebrating the everyday efforts of the NHS staff, felt like a necessary antidote to frequent media criticism, highlighting poor performance within the NHS. Constant criticism was described as hurtful to highly motivated, conscientious staff:
I think NHS Change Day is important because you have a lot of negativity in the NHS, in the media at least. A lot of the media stories are about negative elements – long hospital waiting times, long accident and emergency waiting times, the scandals that happen with patient care, the budget. You never hear the positive things that the nurses do, that the frontline staff do, that people do to try and make the NHS what it is.
(An NHSIQ Improvement Leader)
NHS frontline staff prided themselves, especially under the pressure of budget cuts, on working at full capacity: the public criticisms levied against the NHS were felt undermine their sense of vocation as NHS staff.
I also think that because of our loss of confidence, because of the constant attacks and the pressure – as we’ve seen with the Francis report – people buckle and I think Change Day just helps them inject some enthusiasm and inject some positivity in amongst that pressure and helps people refocus on what are the important things rather than just seeing the NHS as a job.
(An NHS doctor)
Participants described how they viewed the relationship between Change Day, and the NHS staff reaction to the Francis report. They explained how they felt that the opportunity to participate within, as well as identify with the Change Day movement was crucial to their capacity to assert, through changes in their practice, the fact that they were vocationally driven and collectively unified.
People say Francis is one sign of a lot of poison in the NHS. I don't know if I believe that, I haven't experienced it in my organisations, but Francis shows why people need to have the confidence in their colleagues to remain inspiring […] without Change Day, Francis is just individuals trying to respond in all these haphazard ways, and Change Day gives people something to hold onto. […] and there are 100,000 people doing that, that shows more respect and care for the people – those families that made the effort to campaign in Francis, I think, than anything else that we can do.
(An NHS manager)
Participants described how the feeling of being attacked motivated participation in Change Day: frontline staff were keen to reassert a sense of positive collective identity.
Collective Agency as Motivation – “Do Something Better Together”
Collective Belief: “Together We Can Make a Change”
NHSCD participants described how the ethos of NHSCD reinforced the self-belief of its members, challenging the traditionally hierarchical working culture of the NHS, which tended towards passivity.
I think that there has been a history of top-down, authoritarian management in the NHS and now we have realised that we need networks, we need influences, and we need to believe in ourselves, and that’s what NHSCD does, it helps us to believe that we can make that change, and we don’t have to wait for that directive.
(An NHS Graduate Management Trainee)
Participants described how their actions and initiatives were validated through the collective passion and power within the NHSCD movement, composed of like-minded, dynamic individuals who had responded with positivity and vision to the movement’s call for action.
I suppose it’s often the people, the passion, of making the difference to the NHS. When a group of people come together who have got this great idea of making significant change in the NHS that’s quite interesting to me, and so I’m naturally interested in engaging with people who are interested in making large-scale change and involved in change per se.
(An NHS Researcher)
Participants described how the opportunity to engage in, and to act collectively within the Change Day movement was key to the ways in which they connected with their peers and other activists.
The more reassuring thing, I found, is that I was not on my own. My problems were the other people’s problems, and the fact that we shared the problems and we found a solution together, that’s what I found very powerful about Change Day.
(An NHS Nurse)
This sense of togetherness liberated those who felt pigeonholed by the system; participants described how their capacity to enact change grew as their network expanded.
Having a Voice: “Each One of Us Counts”
Change Day participants described the sense of revelation that the incremental impact of multiple small changes could produce a cultural shift, impacting the ability of the NHS to deliver its vision.
[…] a very small change and repeated by a lot of people, can make a big impact. That made me think that instead of complaining that I was unhappy to work and everything, […] maybe, if I change something, I can make something better […] And if all my colleagues do the same and repeat it several times, I think, we can achieve something in the end. Because what can I lose? It cannot get any worse. The only thing is it can get better. And it got a lot better.
(An NHS Nurse)
Individuals explained that this paradigm shift was fundamental to their sense of being valued, and key to their sense of purpose within the movement: NHSCD enabled participants to celebrate and share their expertise, testing their individual capacity to enact positive change:
I’d done lots of different roles and now what I wanted to do was to bring all of that experience to bear onto something, that I could really make a difference.
(An NHS IQ Improvement Leader)
Participants described how NHSCD enabled individuals to both have a voice, and be heard. They revealed how staff often felt constricted within the NHS, to the point that they had to ask permission to make a change: NHSCD gave them the impetus to take action.
I think the biggest thing that it’s had – and you can recognise this nationally – is, like I say, the breaking down of the barriers for people to say, actually, if I’ve got an idea I can raise it... I do feel empowered to do that, I do feel okay to speak up about things.
(An NHS HR Manager)
Participants particularly stressed that they felt that belonging to the movement provided them with the opportunity to break down the rigid hierarchies within the NHS and to assert the importance and power of individual voices in collectively shaping the future of the NHS.
What I like about Change Day is that anyone from any background can have an input […] You can have your say and people will listen to you. And it’s that combination of there’s no hierarchy or anything. It’s just say what you need to say and you will make a difference.
(An NHS Graduate Management Trainee)
Being a Role Model
The Change Day movement grew rapidly and organically: participants, inspired by the actions of others, lent their voices to the cause. Those in positions of responsibility acknowledged their potential to act as role models, and as catalysts for the movement’s expansion. They affirmed however, that involvement in NHSCD was driven by deep, personal beliefs in the movement’s power and ideology, rather than from a sense of obligation.
Equally, as part of my role as head of department, I think within that role itself, it’s important to set a standard, to try and get other people involved, and the only way of getting other people involved is to do it yourself. But that’s not the main reason I did it. The main reason is because I believe in it, but as a leader, you can’t expect other people to do it if you’re not interested yourself.
(An NHS Frontline Manager)
The Power of Frontline and Bottom-Up Change as Motivation
“The Frontline Has the Answers”
NHSCD was believed to engage disconnected realms of the NHS in vital dialogue, ensuring that the expertise of frontline workers was used to shape relevant policy decisions:
I think we need to find a different way of finding the balance between what we can do and the resources we have. I don’t think that the senior managers always have the answer, sometimes they do but not always, and I think that there are a lot of people at the frontline who do know the answer and could help.
(An NHS Doctor)
NHSCD was understood as an important opportunity, not just for the frontline to have a voice, but also for strategic decision makers to join and support the movement, and to affirm that they were listening.
Some specialties we’re just starting to work with for the first time to actually try and engage with people and say, okay, no, we’re serious here, we genuinely mean we want your views, we genuinely mean we will try things that you’re suggesting, because every organisation has a history and some areas of this organisation have been quite top-down dictatorial and the staff don’t believe you when you say that they can contribute.
(An NHS Improvement Leader)
Frontline Communicating and Inspiring Each Other
Much of the impetus behind NHSCD came from the frontline: participants described how they felt empowered by enacting and envisioning change. The sense of empowerment generated through prefiguring change was associated with the feeling that celebrating positive stories within the workforce was a considerable cultural shift.
So for me, this is really positive, to hear some of the good stories that were happening on the wards, and the good-news stories about what we’d done, how we’d do […] how the teams were pledging to make that happen.
(An NHS HR Manager)
Participants discussed the positive momentum of NHSCD: each progressive change inspired a vision of future potential.
Enactment as Motivation
Change Starts From Within
Participants described how NHSCD’s profound and philosophical notion of change stimulated action, which resonated at a deep personal level, motivating their commitment to the movement. Through enacting changes focusing on patient care and wellbeing, individuals reconnected with a fundamental sense of their vocational identity:
I quite like the idea of pledging because it’s really a promise to yourself, that’s really what it is, and when you think about the motivation for change, that if you’re able to use your own motivation for change, then it’s much more likely that it’s going to happen, and I think that that’s what this notion is all about: what’s important to you?
(NHS IQ Improvement Leader)
Participants described the sense of freedom generated from making their own, independent, elective decisions to join NHSCD.
It was something different. It didn’t tell me that I needed to do it. It wasn’t saying that you must do it. […] It didn’t tell me what I had to do. Basically, I can do anything I wanted.
(An NHS Nurse)
Participants, exercising their agency to align with the movement’s philosophy and momentum, described the change enacted through joining the movement as ceremonial, marking a step taken to match their working style with their values as healthcare practitioners.
The Enactment of Small-Scale Changes
Participants noted how the movement’s celebration of incremental changes motivated their personal engagement with NHSCD. From an organisational perspective, the meaning assigned to small-scale, individual, self-determined improvements resonates with Karl Weick’s notion of the ‘enactment’ of shared reality, which emphasises the unconscious, proactive role played in creating perceptions of the world we live in (Weick, 2001). Furthermore, the emphasis that the movement puts upon feasible change initiatives resonates with Weick’s concept of ‘small wins’, which he defines as resulting from the breakdown of larger problems, making the steps needed to address them seem more manageable (Weick, 1984). The efforts which participants made, however small, were figured as part of a wider, cultural shift:
I think on an individual level people are making small changes, I think when lots of people make the same change then that becomes a big change. I also think that there’s something else – I think there’s something bigger than that that’s changing, and I think this is changing culture.
(An NHS Doctor)
For some participants, the value which NHSCD placed on their individual capacity to enact change, effected an emotional transformation:
What Change Day did for me is it made me realise that I have the power and I have control of what I do and what I want to do in my life. And Change Day gave me my passion for my work back that I lost before, because I thought that I could not influence anything, I could not change anything.
(An NHS Nurse)
The notion that the ability to pledge individual action was a ‘gift’ was repeated by interviewees, suggesting that the system of pledging was key to participants feeling that the Change Day movement enabled them to reclaim their power, sense of initiative, and autonomy within the NHS.
[…] the majority of changes happen to you. They’re enforced changes, they happen to you, not with you […] yes, you get a certain amount of involvement, but ultimately, depending on your role within that, it’s taken away from you, whereas the pledge is personal and it’s within your gift to take it as far as you possibly can.
(An NHS Porter)
NHSCD, a National Campaign
Participants in NHSCD described how their involvement in the movement determined their ability to envision a brighter future for the NHS. The mind shift, which participation in Change Day necessitated, was in itself felt to be the tangible change, which could influence the future direction of the NHS:
We need to create an environment for professionals to develop […] We need to create the environment for them to realise that throughout their training […] what they put in can be amplified in terms of what they get out. And if we can start from an early stage then perhaps, just perhaps, when they get into a position where they have a bigger influence over the bigger picture they’re not that cynical person, they are an enabler.
(An NHS Doctor)
Participants described the utopian potential of this shift, exploring the importance of endowing individuals with personal responsibility.
Every day should be Change Day in the way that every day is a school day. We should be coming in to try and make things better every single day. I don’t think that anyone in the NHS comes to work because they want to do a bad job. You should be coming to work with the idea that there is no point getting annoyed with things, you should be thinking about how you can make things better.
(An NHS IQ Improvement Leader)
For some, the power of NHSCD lay in the number of participants mobilised by the movement. The potential for large-scale change, in the light of this, was described as unprecedented. NHSCD was felt to mark a sea-change from fragmentation to unity.
To think about being part of something that’s being delivered on a national level, that’s quite exciting for me; large-scale change, seeing 350,000 to 400,000 people make a pledge [...] In terms of numbers, it’s quite significant.
(An NHS Researcher)
One of the movement’s key activists described how he felt that the Change Day movement illuminated the national significance of the NHS as a social movement facilitating and inspiring a culture of socialised medicine.
It’s the love of the NHS. It’s the love of the job. It’s the love of caring for people. It’s the love of socialised medicine. For me, it’s slightly political as well, with a small ‘p’, because it’s saying the NHS is a social movement, and NHS Change Day is a social movement within the NHS.
(An NHS Doctor)
There was the sense that Change Day was creating a different NHS where, when it came to engaging with government decision-making and drives which would impact healthcare policy, frontline workers would have power and influence.
Discussion: Prefiguration as the Interplay Between Enactment, Identity, and Mobilisation
This paper has considered what motivates people to participate as activists in the NHSCD social movement. The narratives of participants suggest a cyclical relationship between the processes of motivation and participation. Narratives illustrate that the experience of participation in NHSCD, and the motivation to participate, are co-constructed. The exploration of the tension between individual motivation and collective action, illuminates the difficulty in creating a chronological explanation to address the relationship between motivation and collective action. From an organisational perspective, this finding resonates with the dynamic of the action-structure paradox described by Poole and Van de Ven (1989), shedding light on the difficulties associated with the implementation of top-down organisational change.
NHSCD activists articulated how participation in the movement enabled them to address the sense of disempowerment triggered by the contextual financial and organisational challenges that they faced. The strong “sense of ownership of the NHS among both public and NHS workers” (Shapiro & Smith, 2003), as described in the context section above, is key to the reading of our findings. The understanding that the existence of the NHS, built upon the principal of access to, and support of, its services, is inextricable from the modern concept of British citizenship, contextualises the interpretation of this study. The role, and expectations, of NHS frontline employees as compassionate care providers is key to the positive identification of NHS staff, both as individuals and as a workforce (Dutton, Dukerich, & Harquail, 1994; Tajfel & Turner, 1979). This wider contextual role of the NHS and its staff sheds light on the anxiety described by participants regarding the NHS’s future, as well as on the sense of identity crisis caused by external criticism of frontline staff, associated in particular with the commissioning, findings of, and political reaction to the Francis report. In this respect, the described daily pressures to perform, combined with the constraints from budgetary restrictions to time pressure experienced by frontline staff, amount to a perceived restricted agency which is emphasised by the perceived onslaught of frequent top-down organisational changes. The relevance of these findings can be elucidated with the aid of both the Integrative Social Identity Model of Collective Action (SIMCA; van Zomeren et al., 2008) and the Encapsulation Model of Social Identity in Action (EMSICA; Thomas et al., 2009a).
The SIMCA model suggests that “social identity is central to collective action because it directly motivates collective action and simultaneously bridges the injustice and efficacy explanations of collective action” (van Zomeren et al., 2008, p. 505). Our findings resonate with SIMCA’s understanding of the pivotal role of “social identification” in collective action (e.g., participants’ identification with NHS and with their vocation) as galvanising the effects of participants’ motivation to join positive collective action, contributing to “improve the care and well-being of those who use the NHS” (NHS Improving Quality, 2016). The emotions of anxiety and frustration, however, are also described by participants to “precede and precipitate” the group formation of the NHSCD movement (Thomas et al., 2012, p. 3).
Jasper (1997) argues that the development of motivations is complex, determined through the individuals’ experience of the world, as well as through their moral code. The ethos of Change Day, celebrating the core ideologies of the NHS, was key to motivating participation in the movement. Actions taken in the name of the movement resonated with core shared beliefs regarding the NHS, its staff, and its role in society. “The content” of the NHSCD’s movement identity was shaped “through an inductive process of norm-generation, debate and consensualisation about what that group membership means” (Thomas & McGarty, 2009, p. 129); for example, the belief that the frontline, holding the expertise, and values at the heart of the NHS, both could and should be in a position to direct change. NHSCD provided frontline workers with the opportunity to reprioritise their values over and above a sense of being driven by targets.
Our findings further suggest that the experience of involvement in the NHSCD movement enabled participants to regain a strong sense of their vocation and to celebrate their collective identity. Particularly, our findings reveal that the experience of activating personal agency within the constraints of the wider NHS system was meaningful in motivating people to action. These findings tessellate with the EMSICA model, which claims that “it is social identification that mediates the effects of affective reaction to injustice and efficacy on commitment to action” (Thomas et al., 2009a, p. 205). In the case of our findings, it is the experience of enactment within a supportive group setting that participants describe to be fundamental to the containment of their anxiety and to the sense that they lack agency, stressing the mediating function of enactment in enabling the translation of anxiety into pro-change beliefs (Thomas & McGarty, 2009, p. 129), enabling meaningful positive collective action; e.g., “Doing Something Better Together” (Hilton & Lawrence-Pietroni, 2013). Our findings further suggest that it is through the process of enactment that the identification of participants with the NHSCD movement occurs. It is through this process of identification as activists in the movement that the positive group identity of NHS staff is strengthened. In particular, this process encapsulates the belief that “change is possible” (Thomas & McGarty, 2009, p. 129) – a belief that is fundamental to participants’ claims of regaining their sense of individual agency and group efficacy.
Our findings further tessellate with Thomas et al.’s (2009a) normative alignment model in which they consider “action, emotion, and efficacy elements as content of the identity”. These content elements, they claim, are “complementary aspects of identity meaning”, and thus, they argue that “change in one part of the normative framework of the identity would also produce shift in the whole identity meaning” (p. 207). Our findings reveal the key role of enactment in the construction and shaping of shared group beliefs in respect of participants’ individual agency and collective efficacy. In particular, participants articulated their beliefs regarding group efficacy as a motivating factor, giving meaning to their individual agency, and inspiring their collective action. In this context, participants found especially meaningful the belief that as participants in a large group, they could have an increased individual as well as collective impact. Significantly, the sense of both feeling empowered to voice personal opinions and being listened to, as well as acting as role models within the group, was expressed.
Activists described how their sense of personal agency was strengthened through an increasing belief in their group efficacy. A sense of empowerment was formed through their collective non-hierarchical enactment of small-scale, individual improvements. The fact that such practices involved individuals from a wide spectrum of the NHS hierarchy and from a range of professional backgrounds, all enacting personal improvements in an atmosphere of equality, was often described as a motivating factor. This experience of collaborative enactment tessellates with other ethnographic descriptions of prefigurative movements (Cornish et al., 2014; Maeckelbergh, 2011, 2012; Moskovitz, 2012). Western’s (2014) analysis regarding the enactment of leadership in prefigurative movements for example, states: “Leaders or followers are interchangeable and both participate autonomously to co-create the enactment of leadership” (p. 7). The movement’s own, non-hierarchical structure led activists to experience the mobilising potential in devolution, with the contingent feeling of togetherness, liberating individuals from the sense that their actions were constrained by the system. This resulted in the dialogical construction of the ‘Hubbies’ network, which relied both on the expansion and coordination of the existing network, and on the generation of new networks. Consequently, frontline staff felt impelled to initiate change rather than wait for managerial intervention. Similarly, participants were motivated by a sense of collective passion and potential, as they experienced how their actions and voices were validated through their membership of an ever-expanding, dynamic, and like-minded network.
Our findings further reveal the process of enactment to be value based. Participants describe how this resonated with their experience at an existential level, associating a sense of emotional transformation with their involvement in the movement, describing feelings of liberation and empowerment. Ganz (2010) discusses how emotions are crucial in motivating people to join social movements. He splits emotions into two categories: those that motivate participation in collective action, such as urgency, anger, hope, and solidarity, and those that prevent participation in collective action, such as inertia, apathy, fear, isolation, and self-doubt (p. 535). Participation within the NHSCD movement had wide-scale implications: through affirming their potential to enact small-scale change, participants acknowledged their capacity to match their working style with their values as health-care practitioners. In particular, feelings of compassion and empathy for patients’ needs were repeatedly expressed as motivating emotions for collective action (Thomas, McGarty, & Mavor, 2009b).
In describing how their individual agency was galvanised through their participation in a collective and national initiative, Thomas et al. (2012) state that “EMSICA proposes that emotions and efficacy can themselves initiate a shared emergent understanding of “who we are” as group members, where the resultant group membership is premised in a shared understanding of emotional reactions” (p. 3). Participants shared their understanding of the interplay between the individual and collective experience, stressing the profound impact on their sense of efficacy, in taking part in a national campaign.
Ultimately, in this paper, we show how individuals are driven to voluntarily participate in prefiguring change in the NHS through the daily enactment of self-initiated activities. These findings tessellate with the developing notion in the literature that identification with a social movement is a performed phenomenon. Johnston (2009) states, for example, that movement activists “make their unique contribution to the collective definition of identity through their actions, and also contribute their own unique perspective on strategy, goals, and behaviors. These different perspectives on courses of action are important sources of innovation, experimentation, and opposition” (p. 10). Eyerman and Jamison (1998) further refer to the role of enactment in social movements on a collective level, discussing how social movements reconstitute both politics and culture. They emphasise the lasting impact which social movements can have on cultural memory, long after the movements themselves no longer play an active role in directly affecting political change.
Conclusion
The findings in this paper illustrate how the NHSCD movement embodies the key characteristics of a prefigurative movement. Enactment and collaborative thinking drive the movement; its activism is rooted in the grassroots agency of frontline staff, emphasising the importance of nourishing small-scale, experimental, bottom-up changes rather than large, planned, top-down change programmes.
There are as many different reasons why NHSCD exists, as there are individuals who have participated in it. As presented in the results above, participants in the movement emphasise different aspects of the experience of participation as meaningful to them, and as their driving force in activism. Our findings show that motivation, although inspired by strong emotions preceding group formation, is not purely an individual, intrinsic endeavour, which exists prior to the enactment and engagement associated with the NHSCD movement. Even when exploring the contextual factors motivating their activism, participants constantly emphasised their belief that enactment within the setting of NHSCD presented them with an emotionally satisfying solution for their sense of disempowerment.
The Change Day movement aims to bring about change and improve day-to-day practices and experiences for NHS staff and patients; however, the manner in which change is delivered holds a greater significance for participants than just as a means to an end. We illustrate the dynamic and circular interplay between motivation and participation in collective action, and the key role played by enactment in the process through which the participants identify themselves with the movement, and the movement’s collective identity is crystallised. We argue that it is through enactment that the process of participation, as well as the movement’s ideology and vision, is shaped. We argue that the notion of change as promoted by the movement was perceived as philosophical, inspiring participants with a deep sense of hope. Participation in the movement, we argue, resonated with contextual, preexisting senses of anxiety and strong emotions related to a positive and value based sense of vocational identity. It is through the enactment, we contend, that the encapsulation and translation of these emotions into a sense of efficacy and pro-change beliefs was facilitated. The sense of collective energy generated through the movement was vital, especially as, in celebrating the power of small-scale, incremental changes, participants were able to envision the grander impact of enactment, and a brighter future for the NHS.
The participants described experiences of the process through which change was delivered; their associated sense of their ownership of change through enactment was viewed by participants as empowering, and thus viewed as a goal in its own right. In this sense, it becomes impossible to separate the improvement goals that change is aiming to achieve from the manner in which change is being delivered. It is, therefore, impossible to separate motivation from enactment and vice versa, to separate enactment from motivation: they are completely interwoven processes, which inform each other over time.