What do shifting societal trends towards a sharing economy mean for the NHS? Understanding New Power (Heimans & Timms, December 2014) sets out a framework to conceptualise shifts in power which are enabled by digital technologies in contemporary society:
Old power works like a currency. It is held by few. Once gained, it is jealously guarded, and the powerful have a substantial store of it to spend. It is closed, inaccessible, and leader-driven. It downloads, and it captures.
New power operates differently, like a current. It is made by many. It is open, participatory, and peer-driven. It uploads, and it distributes. Like water or electricity, it’s most forceful when it surges. The goal with new power is not to hoard it but to channel it.
The authors conceptualise a participation scale from consumption to co-owning, from old power models exemplified by Britannica to new power models such as Wikipedia. You can find out more about their framework in a fascinating Ted Talk given by Heiman here:
Despite this being a contemporary framework, informed and enabled by digital technologies, it resonates with Shirley Arnstein’s Ladder of Participation which was published all the way back in 1969 and remains common currency in the field of NHS patient participation. Arnstein conceptualised an eight rung ladder of participation in decision making from manipulation and tokenism at the bottom to citizen control at the top. Heiman and Timm’s framework is like Arstein’s ladder, with the rocket fuel of technology as an enabler of new power possibilities for those of us who have access to the digital tools and literacy to take advantage of them.
Is new power evenly distributed?
Is new power evenly distributed? Despite the hype, digital literacy remains a salient concern in our society. According to 2015 Ofcom figures 93% of UK adults own a mobile phone and 66% own a smartphone. 80% of UK adults have (mobile and fixed) broadband access and 72% of online adults access social networking sites. However, according to Go ON UK 23% of adults in the UK lack basic digital skills and the charity’s heatmap indicators demonstrate the interrelationship between social factors such as age, education, income and health and digital literacy. The 2013 Cultures of the Internet Report illustrates that Internet users are still mostly likely to be young, educated and wealthy, with disabled people less likely to access the Internet (p. 22). Are the tools of new power available to the people who might most benefit from challenging dominant viewpoints held by the beneficiaries of old power? Or is new power predominantly available to the privileged few? Whilst the digital tools of production are cheaper and more available than ever before, the extent to which they are harnessed remains inequitable. This must be a part of the picture for those of use interested in new power models and values.
What does new power mean for the NHS?
What does the emergence of new power values and models mean for an institution like the National Health Service – a bastion of old power with its centralised management and professional hierarchies? Whilst the NHS might appear a monolith from a distance, it is not only made up of multiple separate organisations but also over 1.6 million staff who themselves will have diverse attitudes towards new and old power values. Are the affordances of digital technologies making a significant impact in the NHS and are staff willing and able to leverage them in a work context?
My experience this week gives a clue towards the current state of affairs for new power in the NHS. I gave a lecture to students on a healthcare innovation module on an MSc in leadership and management. The subject of my session was digital innovation and I took the opportunity to try out Heiman and Timm’s new power / old power framework with the group. Despite all participants having access to the Internet, a tiny proportion had access to a smart phone at work and still less were able to access online social networks via their employer’s broadband. All of the group were tasked with an NHS innovation project but few, if any, had considered the possibility of new power style participatory approaches such crowdsourcing . My point is not to malign those students, but rather to reflect on how far apart the new power rhetoric and the old power reality actually are for the majority of staff in the NHS. The enabling tools are largely absent and the culture often not sufficiently aligned. One student reported how their organisation had set up an intranet based crowdsourcing platform for staff, only for contributors to be castigated when they challenged the views of management – new power tools in an old power context. All of the students remained untouched by established peer-led social movements such as the Twitter based wecommunities within healthcare.
New power prickling the NHS
Despite the fact it is unevenly distributed, the NHS is most definitely being prickled by new power values and significant numbers of its employees are proponents and participants in a sharing economy. NHS institutions are recognising they need to have a presence in online social networks and are leveraging them for activities such as public health campaigns. NHS England is creating elasticity in its old power status by experimenting with increasing accountability and participation through NHS Citizen and The Edge – old power reaching out to the new. Increasing numbers of NHS staff are taking to online social networks to learn, share, collaborate and participate and there are plentiful public communities which provide spaces for them to do so. All of these networks are inside out – old power stretching out to new power. But there is also outside in – new power endeavouring to speak to old power and hold it to account This is exemplified by Patient Opinion, Justice for LB campaign and tweet chats such as #BPDChat . Junior doctors are part of old power institutions but as a professional group have leveraged new power online collaboration to campaign against proposed government changes to their contract #juniordoctors. The dynamics of old and new power are characterised by flux and fluidity.
Whilst the conceptualisation of new power and old power is compelling, Arnstein’s ladder of participation shows that the tension between closed and open is nothing new to the NHS and other public bodies. New power may well increasingly have the upper hand with digital technologies on its side, which make it increasingly difficult for old power institutions to retain a closed, leader driven, broadcast focused orientation. However, the potential for new power value and models to benefit people who are most disadvantaged is limited by the social and digital exclusion experienced by a significant minority of UK citizens.