Analysing boundaries of health and social care in policy and media reform narratives

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  • 1 Vrije Universiteit Amsterdam, , the Netherlands
  • | 2 Vrije Universiteit Amsterdam and Vilans, Centre of Expertise for Long-term Care, , the Netherlands
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Collaboration has become an imperative of many new healthcare policies; however, little attention has been paid to how system-level narratives in both policy documents and the media create boundaries that shape implementation processes. By using boundary work as a theoretical lens, this article critically analyses the discourse found in both policy documents and the media surrounding the 2015 Dutch LTC reform. This discourse analysis contributes, first, by revealing two separate narratives – one epic, one tragic – which we argue represent different rhetorical styles used to (de-)legitimise symbolic boundaries. Second, we contribute by unravelling boundary work in both the social and symbolic dimensions to show how the design of the 2015 reform led to a tension-ridden position for local actors: symbolic boundaries demanded integration, while social boundaries imposed differentiation. These findings have implications for literature on boundary work as well as for policy design and its local implementation.

Abstract

Collaboration has become an imperative of many new healthcare policies; however, little attention has been paid to how system-level narratives in both policy documents and the media create boundaries that shape implementation processes. By using boundary work as a theoretical lens, this article critically analyses the discourse found in both policy documents and the media surrounding the 2015 Dutch LTC reform. This discourse analysis contributes, first, by revealing two separate narratives – one epic, one tragic – which we argue represent different rhetorical styles used to (de-)legitimise symbolic boundaries. Second, we contribute by unravelling boundary work in both the social and symbolic dimensions to show how the design of the 2015 reform led to a tension-ridden position for local actors: symbolic boundaries demanded integration, while social boundaries imposed differentiation. These findings have implications for literature on boundary work as well as for policy design and its local implementation.

Introduction

Collaborations in healthcare are often closely examined by scholars who study boundary work (for example, Chreim et al, 2013; Meier, 2015). These scholars tend to focus on actors who cross or defend professional boundaries in their everyday work, revealing, for example, how local actors open, close, or negotiate boundaries in order to organise their cross-boundary interactions (Chreim et al, 2013), how technological innovation may prompt the (re-)construction of boundaries (Lindberg et al, 2017), or how hospital professionals may alternate between dissolving and maintaining boundaries to care for patients (Meier, 2015). However, with this emphasis on ‘zooming in’ on actors involved in collaboration, goes a lack of ‘zooming out’ on how societal actors external to the immediate collaboration influence the definition of boundaries across the healthcare system, for example, in the case of central policymakers. Moreover, the effect of the wider public debate – both on the legitimacy of externally proposed boundaries and on the subsequent implementation of policies encouraging collaboration – has gone understudied.

Processes of collaboration are not designed and implemented in a vacuum: these reforms unfold in a wider context, which may entail conflicting perspectives and debates. As citizens tend to read about politics in the media rather than witnessing them first-hand, the media plays an important role in citizens’ understandings of governmental actions (Hjarvard, 2008; Klijn and Korthagen, 2018) – for example, in regard to healthcare reforms. As a ‘mediating’ party between the government and the public, the media shapes how both governmental actors, including their intentions and actions, and collaborative measures are implemented and perceived in society (Klijn and Koppenjan, 2012). As such, it is important to not only study the narratives of the central policymakers who impose measures on locally collaborating actors – measures which, in terms of organisational theory, can indeed be seen as boundaries – but also to study the narrative shared in the media. Both of these narratives influence the legitimacy of the imposed boundaries, while also informing collaborating actors’ assumptions about one another. In order to further our understanding of the dynamics influencing the definition of boundaries between local actors, we have developed the following research question: How does the boundary work of system-level actors shape the playing field in which local stakeholders collaborate in order to implement policy reform?

Many actors and dynamics play a role in the social dynamics surrounding local boundary work, it is therefore important to be explicit about what part of this context we focus on (Meier and Dopson, 2021). We studied the discourse around the 2015 Dutch long-term care (LTC) reform as found both in policy documents developed by the central government, and in national and regional Dutch newspapers from 2014 and 2015. By decentralising the responsibilities formerly organised under the Exceptional Medical Expenses Act, the LTC reform shifted the provision of care that had previously been organised on a national level to municipalities, healthcare insurers and care offices. Jointly, these stakeholders were expected to transform the health, social and long-term care sectors. Translated into terms of boundaries, the design of the reform implied a redefinition of boundaries within the healthcare system, and accordingly, a redefinition of the playing field in which actors were supposed to establish collaboration: the central government attempted to both erase old and create new boundaries between actors. Using the concept of ‘boundary work’ as a lens to guide our analysis, we specifically studied two aspects: (1) how the reform was discursively constructed by the central government (in policy documents) and the media (in newspapers); and (2) how the objectives and involved stakeholders were represented in each narrative. As such, this article sheds light on how system-level actors, such as the central government and media, attempt to impose, dissolve, or question precisely the same boundaries with which local actors are obliged to contend. Before moving on to our methodology and findings, we will first explain how this zooming out on the boundary work of system-level actors increases our understanding of collaboration between local actors – an imperative that is often made central to current healthcare policies.

Local boundary work to organise everyday interaction

Boundary work refers to the practices in which actors engage in order to define and organise their interactions across boundaries (Gieryn, 1983; Langley et al, 2019). The term ‘boundary work’ was first coined by Gieryn (1983), who showed how actors discursively attempt to protect the demarcation between science and non-science. Boundary work studies tend to focus on actors who cross and/or protect the boundaries they encounter in their everyday work, for instance: between healthcare professionals in the field of mental health (Chreim et al, 2013), between nurses and doctors (Liberati, 2017; Lindberg et al, 2017), or between a wider variety of professionals and managers in a hospital (Meier, 2015). This growing body of literature depicts healthcare professionals’ intricate, everyday boundary work as they care for patients. However, although these studies highlight the importance of contextualisation and actors’ situated positionings, the broader dynamics which inform organisational actors’ boundary work often remains unseen. Given the impact of the consequences of central actors’ boundary work on the space available for local actors (Glimmerveen et al, 2019; Langley et al, 2019), this lack of attention to the bigger picture is problematic. As Glimmerveen et al, (2019) show, the top-down dissolving or drawing of boundaries by managers can either create or remove space for negotiation by local actors. When studying processes of boundary work, it is therefore important to not only zoom in on the everyday interactions between collaborating actors, but also to zoom out on the actors who attempt to impose or remove boundaries from the outside – that is, on the configuring actors.

Central boundary work to shape the boundaries between local actors

Although collaborating actors are conspicuously involved in the (re-)construction of the boundaries they encounter in their everyday work (Abbott, 1995; Apesoa-Varano, 2013), they do not act in isolation. By moving from the collaborating actors themselves to the actors who attempt to influence these actors’ boundaries from the outside, we enter the territory of ‘configurational boundary work’ (Langley et al, 2019) – also defined as the process of ‘designing boundaries to orient configurations of differentiation and integration among groups’ (p. 707). This strand of literature tends to focus on the manipulation of boundaries on an organisational level, that is, how managers or directors attempt to rearrange boundaries to facilitate interaction between other organisational actors (for example, Mørk et al, 2012; Bucher and Langley, 2016; Oldenhof et al, 2016; Lunkka et al, 2021). However, it also carries the potential to elucidate how the discursive practices of actors external to the collaborating organisations, most notably those of central policymakers, enable or constrain the implementation of local collaboration. This would be insightful given the increasing pervasiveness of central governments looking to outline the interactional setup across the complete healthcare system.

Indeed, the prevalence of boundaries and their subsequent organisational consequences are often externally triggered, especially by shifts in political thinking and governmental policies (for example, Llewellyn, 1998; Martin et al, 2009; Bucher et al, 2016; Oldenhof et al, 2016; Sanders and Harrison, 2008). The discursive configurational boundary work of central governments frequently shapes the space available for collaboration by attempting either to ‘arrange’ boundaries between actors through policy measures and mechanisms, or to ‘buffer’ these boundaries through the creation of dedicated experimental spaces (Langley et al, 2019). A central government’s legislation, funding and communication can all be seen as policy instruments used to shape the boundaries of the playing field for local collaborating actors.

In order to explore the intricate dynamics that accompany boundary demarcation and cooperation in institutional arrangements, policy scholars explore the discursive struggles that emerge in such processes (for example, Hoppe et al, 2013; Boswell, 2018; Metze, 2017). Boswell (2018) shows that understanding reforms as a performance of demarcation provides room for understanding the unexpected ways in which reforms can unfold: an organisation’s size and status at the start may not equal more autonomy in the final set-up of the field. Instead, the narratives of key actors can play an important part in the (de-)legitimisation of boundaries. In building these narratives, actors deploy discursive resources to draw and contest boundaries. These discursive resources include referring to incidents, counter expertise and contextual differences (Metze, 2017), or attributing different meanings to concepts such as autonomy and control (Korinek and Veit, 2015). Taken together, this reveals how discursive boundary work can be used to provide or remove legitimacy for boundary demarcations outlined in policy (Metze, 2008). It shows conceptualising policy and media narratives as boundary work is a promising approach to increase our understanding of the dynamics that accompany policy reforms.

To further our thinking of what configurational boundary work entails, it is important to differentiate between policy instruments that affect social versus symbolic boundaries. Analytically distinguishing between boundary work’s social and symbolic dimensions (see also, Lamont and Molnar, 2002) also elucidates how boundaries can be perceived both as constructed by actors in interaction, and as taking on a constraining character, making boundaries appear to be ‘out there’ or experienced as something to be crossed. Social boundaries represent concrete boundaries that are ‘manifested in unequal access to or distribution of resources’ (Lamont and Molnar, 2002: 168). Social boundaries represent stable and identifiable patterns of inclusion or exclusion, or they can be policy-driven boundaries that function to divide people into groups with specific resources (Lamont and Molnar, 2002). As such, they can be experienced to be ‘out there’ and observable; for example, in: who is allowed to take part in negotiations? Or who is allowed to make financial decisions? A central government can use policy instruments, such as legislation and funding, to attempt to direct specific interactions or resource allocations among stakeholders. By so doing, these instruments then help influence and define the social boundaries between local actors.

Symbolic boundaries are somewhat elusive, but not less important, and represent the ‘conceptual distinctions’ actors make in their efforts to categorise and ‘separate people into groups’ (Lamont and Molnar, 2002). This is reflected in, for example, the ideas actors have about ‘who’ their collaborative partners are: are positive qualities attributed to them? Are they considered an ally? Or are they evaluated negatively and considered a rival? Actors create these conceptual distinctions by drawing lines through which they create ‘islands of meaning’ which structure our world (Zerubavel, 1991: 5, 116). Actors categorise people using labels based on others’ (perceived) characteristics, traditions or experiences. In everyday communication, actors use these labels and frames to evaluate and understand the legitimacy of boundaries and give (competing) meanings to them. These meanings are ambiguous, flexible, and rooted in actors’ experiences, culture and background. As such, actors do not only make demarcations as individuals, but as ‘members of society’ for whom certain social boundaries become normalised and expected (Zerubavel, 1991: 77, 80). Symbolic boundaries then represent the different narratives that actors create to (de-)legitimise boundaries. These symbolic boundaries are influenced by communication – another policy instrument – as it serves to influence the meanings actors attribute to themselves, their partners, and perceived social problems.

The media: a missing piece of the boundary work puzzle

Discussions of boundary work tend to neglect the active role of the media in the configuration of boundaries. When included at all, the role of the media is generally mentioned as contextual information or treated only in passing (for example, Zietsma and Lawrence, 2010; Grodal, 2018). Media discourse is virtually never taken as an analytical point of departure, let alone as an active influence on the definition of boundaries. Given the widely acknowledged impact of media narratives on the development of policy initiatives (Hallam, 2002; Hayes et al, 2007; Wolfe, 2012; Korthagen and Klijn, 2014; Klijn and Korthagen, 2018), this lack of scholarly attention for the effect of the media on symbolic boundaries is surprising. Policy studies teach us that the media is responsible for ‘framing the public debate’ and, as such, that ‘they’ possess the power to not only (re-)shape the actual policy issues, but also to create, erase and affect the public’s support of policy proposals and their implementation (Klijn and Korthagen, 2018). In other words: media can deploy symbolic boundary work to contest social boundaries proposed or implemented by the central government. Because media coverage effectively ‘mediates’ the public’s consumption of politics, the message intended by the government is inevitably filtered through an intercepting actor. This means that the media plays an increasingly significant role in how governmental processes and actions are framed and understood by the wider public (Hjarvard, 2008; Klijn and Koppenjan, 2012; Klijn and Korthagen, 2018) and collaborating actors themselves. After all, these actors are citizens that use media too.

Existing research already shows concrete effects of the media on collaborative efforts: ‘mediatisation’ may complicate actors’ abilities to work within networks, which are often essential to implementation of collaboration (Korthagen and Klijn, 2014; Klijn and Korthagen, 2018). For instance, media coverage may either delimit the range of possible policy options or make the already fragile relationship between partners even more precarious (Korthagen and Klijn, 2014; Klijn and Korthagen, 2018). The media’s discursive framing can influence how collaborating actors perceive, for example, the problem of rising healthcare expenditures, and the feasibility of using collaborative and localised healthcare as a possible solution. Translated into terms of boundary work, both the central government and the media can be seen as participating in configurational boundary work when they attempt to discursively frame others’ perceptions, for example, of the actors involved in a reform and its underlying problems (Creed et al, 2002; Langley et al, 2019).

In order to better understand how the playing field for collaboration is shaped, as well as who plays a part in shaping the boundaries between collaborating actors, we believe that researchers must therefore take a step back. Doing so allows not only the analysis of how collaborating actors themselves respond to policy issues and proposals, but also the study of how boundaries between collaborating actors are configured – that is, how they are presented in policy documents and news coverage – by both the government and the media.

Methodology

Critical discourse analysis (CDA) emphasises and investigates the persuasive elements of discourse, as well as how certain power relations are (re-)produced through text (Fairclough and Wodak, 1997). Using this method to analyse and contextualise the text of policy documents and news articles can reveal wider social dynamics that play a part in societal changes such as reforms. Wodak’s approach to CDA is sensitive to the discursive dynamics of inclusion and exclusion (Angermuller et al, 2014), and is therefore particularly useful for studying the discursive definition of boundaries. In our study, we employed CDA to trace how discourse around the 2015 reform was constructed and to shed light on the tensions between different (groups of) people in the healthcare system.

Because of our focus on the roles of both the central government and the media in shaping boundaries in the healthcare system, our data comprised two categories: policy documents and newspaper articles. To analyse the policy of the 2015 Dutch LTC reform, we examined four main policy documents. Two of these were from the Dutch Ministry of Health, Welfare, and Sport (van Rijn, 2014b; 2014a), which included descriptions of the reform and its implications for a range of stakeholders, for example, municipalities, healthcare insurers and providers. The other two documents were from the Dutch Ministry of Interior Affairs (Plasterk, 2013b; 2013a), which specifically addressed the decentralisation of LTC tasks to municipalities. We also analysed media narratives of the reform. It is important to note that, although in the past media was pillarised, over the years Dutch media has become relatively independent. In fact, the Netherlands ranked second (RSF, 2014) and fourth (RSF, 2015) out of 180 countries in the World Press Freedom index at the time of our data collection. We selected newspaper articles for our analysis, viewing these articles as ‘graspable’ representations of the media discourse: they had been read and trusted by a broad audience, and would provide us with both background information and a reliable view of the media framing at the time since they could not be changed or adjusted post publication. To collect these articles, we twice searched LexisNexis Academic – a leading news database with over 150,000 sources – using the criteria ‘newspaper’ and ‘full text’. Our first search used the terms ‘hervorming’ (reform) and ‘zorg’ (care) to find newspaper articles that covered the LTC reform (1,369 hits). Our second search used the term ‘decentralisatie’ (decentralisation) as this feature was often used to describe the part of the reform that was implemented in the social sector (893 hits). We then filtered the results based on year (2014–2015), specific newspapers, and relevance (for example, we excluded duplications and results that included unrelated uses of the word decentralisation). We chose to focus on three different newspapers that together cover a broad audience: two national – De Telegraaf, the largest Dutch newspaper which is tabloid-like in its reporting (N=36: 6 Decentralisation, 30 Reform), and NRC Handelsblad, a newspaper of record (N=39: 10 Decentralisation, 29 Reform) – and one regional – BN/De Stem, from the area in which ethnographic research was conducted as a wider part of this study (N=24: 11 Decentralisation, 13 Reform). This led to a total of 99 newspaper articles.

Analysis. Our textual analysis consisted of two steps: an entry-level, thematic examination, through which we mapped the contents, and an in-depth analysis, in which we explored the argumentation behind and the representation of actors in the discourse. In this article, we are reporting on our findings of the in-depth analysis. In order to (re-)construct the argumentative discourse, we searched for so-called ‘topoi’, that is, the arguments that are used to justify a certain evaluation of a concept. These are not always made explicit in a text and must often be excavated by the researcher. Constructing a scheme of the textual topoi sheds light on how different attributes of a change such as the LTC reform are evaluated, justified or argued – in turn, revealing how the concept of reform was shaped and constructed in the articles. In order to identify the topoi underlying the text, we adopted an abductive approach (Timmermans and Tavory, 2012): we started with a list of ‘typical’ topoi described in the literature (Reisigl and Wodak, 2001) but were open to changes, which meant adjusting and adding the topoi that emerged throughout our analysis. By moving back and forth between the data, we found the most common argumentative themes in all three newspapers to be: (1) (dis)advantages, (2) finances and (3) reality. In correlation with these themes and for clarity purposes, we also classified the arguments according to the following topics: (1) policy intentions, (2) resources and (3) anticipated results.

By next juxtaposing the discursive arguments we found in the media with those of policy documents, we were able to identify two contrasting narratives – one ‘epic’ (policy) and one ‘tragic’ (media). The epic tale narrated by the central government was abstract and system-oriented, whereas the tragic tale told by the media was more concrete and detailed regarding its impact on various specific actors within that same system – for example, it questioned whether the design of the reform would actually lead to the envisioned abstract goals. Due to the complexity of the latter, we chose to designate more of our attention in the presentation of the data to the media’s tragic tale.

Next, we zoomed in on the representations of actors in both tales. We analysed the: (a) attributions, that is, which actors were placed in the foreground and which in the background; (b) role allocations, that is, which actors were described as active and seen as the drivers of change versus which were portrayed as passive and perceived as undergoing the changes; and (c) characterisations, that is, how were the actors labelled or, in other words, who was the hero and who was the villain of each narrative? Altogether, these analyses provided insight into how the central government and the media not only discursively constructed and imposed symbolic boundaries as part of the LTC reform, but also subsequently positioned its key actors across the healthcare system.

Findings

Our analysis revealed two contrasting narratives surrounding the LTC reform. One was the government’s epic tale, which focused on saving the healthcare system from disaster while, in the process, making it more efficient, contemporary and ‘better’. The second, narrated by the media, was a tragedy centred on how the LTC reform would eventually lead to the demise of the care system. To organise our investigation, we structured and juxtaposed the narrative arguments we found according to their (1) policy intentions, (2) implications for resources and (3) anticipated results (see Table 1).

Table 1:

LTC reform in policy versus media

Policy’s epic taleMedia’s tragic tale
Policy intentions
  • Saving the healthcare system

  • Vital improvement of the LTC system

  • Destroying the LTC system

  • Irresponsible and illogical objectives

Implications for resources
  • Realistic and more efficient LTC system

  • Effectively reigning in costs

  • Unrealistic budget cuts

  • Shifting costs within the system

Anticipated results
  • A modernised LTC system

  • More suited to contemporary care needs and goals, such as living at home and self-reliance

  • Out of touch with reality

  • Abandonment of care recipients and their providers

Policy documents: an epic tale

Presenting positive arguments in terms of intentions, resources and anticipated results, we found policy documents to reveal an epic narrative. The plot centred on overcoming the disaster of an inaccessible healthcare system due to ever-increasing expenses. After years of exponentially rising governmental spending on healthcare, the presiding cabinet’s intention was to reform the healthcare system in order to make it more sustainable and accessible to everyone. Efficiency was touted as one of the main advantages of the reform: the same quality of care would presumably be delivered at a lower price. This would be realised by shifting the organisation of tasks to municipalities, who, by definition, are in closer proximity to citizens and therefore presumably better able to efficiently connect the provision of long-term care with other domains, such as employment. Furthermore, this decentralising of responsibilities would allow for the so-called ‘bridging’ of different domains and, consequently, for the creation of seamless care and support plans tailored to the needs of the individual. Citizens would be expected to take ‘more responsibility’ for their own health and support, but the reformed care system ‘should always be available to help them’ (Plasterk, 2013b). Municipalities, in turn, would be responsible for more care-provision tasks and would also be expected to organise these tasks differently to before (Plasterk, 2013b). As a result, the reform would not only make the healthcare system more efficient, it would also improve the system as a whole by placing citizens ‘centre stage’ and by allowing for more contemporary solutions to societal needs, for example, the provision of care at home (van Rijn, 2014a).

Newspapers: a tragic tale

The media, in contrast, presented a tale of tragedy. The plot focused on how the LTC reform would lead to the eventual demise of the healthcare system. While the ‘topoi’ we found were similar to those in policy documents, their substantiations were quite the opposite: ‘efficiency’ became ‘unrealistic budget cuts’, ‘decentralisation’ became ‘deflecting responsibilities to local actors’, and ‘self-reliance’ became ‘the abandonment of citizens’. Although the different newspapers we included have different audiences, and accordingly, their tone of voice differed, they substantiated the ‘topoi’ in a similar way. Given that the meaning that is attributed in these narratives is our main focus here, we do not further differentiate between newspapers in this section. To invigorate their narrative, newspapers drew on individual anecdotes of how the reform would affect the lives of specific actors, most often citizens. We will now go over these topoi one by one.

First, the media was sceptical of the central government’s intentions behind the LTC reform. Instead of an epic tale, the media proposed the exact opposite narrative, which they substantiated with a range of harrowing images and spectacles to invigorate their depiction of tragedy. The reform was most commonly described as a degradation of the care system (for example, Telegraaf 140211, 140715, 150927, 151214; NRC 140918, 150218; BN/DeStem 140418). In the eyes of the media, the LTC reform would lead to poorer quality care at a higher price to citizens (Telegraaf 140211). Towards the end of 2014, a news story about the state secretary’s mother made the deterioration of the care system personal: the subpar conditions in her care facility were framed as being exemplary of the degradation for which her own son was responsible (Telegraaf 141107; NRC 150124). The media also framed the reform as being irresponsible (for example, Telegraaf 140711, 140313, 140709; NRC 140521, 141115). This was often mentioned regarding the rushed time frame in which the reform was expected to be accomplished (NRC 14022; Telegraaf 140305, 140705). For example, articles were written about calls for postponement by a wide variety of stakeholders in the field, including healthcare insurers (Telegraaf 140314, 140917), the Court of Audit (NRC 140521), and the Council of State (Telegraaf 140709). Likewise, a variety of articles claimed that stakeholders were given insufficient time to both prepare (Telegraaf 140412, 140917; NRC 150604, 150926; BN/DeStem 140424, 140508), and to clear up any uncertainties and tackle potential problems of the reform’s design (NRC 140521, 150430; Telegraaf 150430). A third way the media challenged the government’s intentions was by framing the reform as illogical (Telegraaf 140418, 140522, 150111, 140410; NRC 140425, 150124, 141115). In doing so, the media was effectively questioning the true intentions behind the reform; asking, for example, ‘if all “they” want is higher quality care, then how do they explain the accompanying budget cuts’ (NRC 140206; Telegraaf 140709)? Also, would the reform really improve efficiency given the increased bureaucratic demands, such as additional rules and legislation (NRC 140925, 150218, 150325)?

Second, the media narrative around the reform’s implications for resources was completely opposite to that of the government. The media widely framed the task of organising care within the planned budget as being ‘impossible’ (for example, Telegraaf 140313, 140314, 140415; BN/DeStem 140315; NRC 140118, 151229). Articles reported on actors’ concerns about the accompanying budget cuts (for example, NRC 140118; BN/DeStem 140315) given that municipalities were now tasked with arranging the same amount of care with a quarter less budget (NRC 151230). Such concerns included that funding changes would reduce the control of central government (NRC 140521) and that local actors were not ready to deal with budgeting care tasks (Telegraaf 140522). Because of the House of Representatives’ concerns surrounding the budget cuts (Telegraaf 140407; NRC 140419), the central government was said to have ‘reluctantly given in’ at times by making more resources available for the reform (NRC 140118, 140426, 140922; Telegraaf 140130, 150520; BN/DeStem 140424). In the media, the reasoning behind the budget cuts was questioned and framed as illogical: direct costs might decrease, but costs elsewhere would increase (Telegraaf 140410, 140701, 150430). For instance, citizens’ insurance and employers’ healthcare premiums would likely increase (NRC 140822), and municipalities may be ‘forced’ to become more creative (BN/DeStem 140117) – for example, by decreasing the funds available for other municipal responsibilities in order to increase their budget for care provision (BN/DeStem 140425).

A third argumentative theme employed by the media was that of emphasising the potentially undesirable results: decentralisation was presented as wishful thinking, something that works in policy dreams, but not necessarily in the unruly local reality (NRC 151230). In this way, the media argued the reform would produce other results than those suggested by the central government’s policy narrative. Citizens, many articles stressed, would suffer from the reform (for example, NRC 140118, 141027, 150124; Telegraaf 140314, 140917; BN/DeStem 140117), for instance, due to long waiting lists (NRC 151229), municipalities being inept at understanding citizens’ care problems (NRC 140926), and the burden of the reform’s complex, bureaucratic requirements on citizens (NRC 150325). Newspapers also drew on citizens’ individual experiences to illustrate potential, more-widespread problems, for instance: an 80-year-old’s struggles with endless bureaucratic requirements and an unclear financial system (NRC 150325), a chronically ill patient’s efforts to adapt to his changing living conditions (NRC 140206), and a citizen’s visit to the ER caused by a stressful intake with the municipality (Telegraaf 140709). Moreover, the media also highlighted the troubles of, for example, care providers, who were purportedly facing grave uncertainties regarding their future contracts and responsibilities (Telegraaf 140415; NRC 150218).

Framing the key stakeholders

The LTC reform dictated a huge change, not only in terms of the re-distribution of responsibilities and funds, but also in the relationships between stakeholders. The tales described earlier have already alluded to certain actor positionings within the system. Because of our emphasis on boundaries, we will first discuss the design of the reform in terms of its boundaries – as a starting point. After that, we will move on to how the various actors were represented in both tales, that is, their roles, positionings and attributes (see Table 2). In other words: which symbolic boundaries were communicated through policy documents and the media?

Table 2:

Actor representation and positionings in policy versus media

Policy discourseMedia discourse
Central governmentBackgrounded; active role; described positivelyForegrounded; active role; described negatively
MunicipalitiesForegrounded; passive role; described positivelyForegrounded; passive role; described negatively
Healthcare/LTC insurersBackgrounded; passive role; described positivelyBackgrounded; passive role; described positively
CitizensForegrounded; active role; described positivelyForegrounded; passive role; described positively

Policy documents: designing social and symbolic boundaries

The legislative framework of the LTC reform arranged for a division of care responsibilities among three main actors. Municipalities, operating under the Social Support Act, were made responsible for social care. Healthcare insurers became responsible for district nurses under the Healthcare Insurance Act. So-called regional ‘care offices’ – healthcare insurers’ designated LTC departments – became responsible for the remaining long-term care tasks under the Long-term Care Act. The Dutch Ministry of Health, Welfare, and Sport remained responsible for the system as a whole. Concretely, the LTC reform implied a clear division of stakeholders by assigning distinct responsibilities, legal frameworks and funding streams (van Rijn, 2014b). By implementing these firm social boundaries, the central government effectively separated the different actors within the system.

Simultaneously, however, the central government was also focused on uniting these different stakeholders in their communication: the reform was intended to reduce fragmentation, and to allow for an integrated approach to care and social support (van Rijn, 2014a). According to the government, citizens should not be burdened by the complexities of the new funding streams that accompanied the reform’s implementation. This policy ideal required collaboration between the new funding partners: municipalities, healthcare insurers and the regional care offices would be expected to work together closely. In order to sufficiently integrate, the central government required these actors to paradoxically cross the very same boundaries which they were responsible for implementing.

We will now zoom in further on the designated key stakeholders involved in the organisation of localised healthcare, discussing the healthcare insurers and regional care offices as one (in practice, the former often also represented the latter). Given their responsibility to provide an integral set of solutions to citizens in need of social care (Plasterk, 2013b; 2013a), policy documents foregrounded the role of municipalities. Municipalities, the reform prescribed, should arrange this care in new and different ways, for example, by preventing citizens from needing care in the first place (Plasterk, 2013a). Interestingly, municipalities were often depicted as being passive participants in this process. For instance, in 2013, the minister in charge of the reform concluded that, although some municipalities were already preparing for their new role, others had yet to begin (Plasterk, 2013a). Also, in policy papers, municipalities were generally construed as being dependent on larger organisations, such as healthcare insurers (van Rijn, 2014b; 2014a), in order to complete their tasks. A symbolic boundary was thus drawn around municipalities and insurers, who were expected to jointly prevent citizens from falling between the cracks of different acts (van Rijn, 2014a). To be good partners to the healthcare insurers, municipalities were also asked to develop inter-municipal collaborations (Plasterk, 2013b). All of these occurrences were based on doubts around the competency of municipalities, whose capabilities were labelled as not always being sufficiently operative.

In contrast, policy documents often overlooked the expected roles and capabilities of both healthcare insurers and the central government. As such, these stakeholders were effectively backgrounded in the epic policy narrative. Made out to be passive participants, insurers were merely described as being the recipients of additional responsibilities and as an important partner for municipalities (van Rijn, 2014b; 2014a). As such, healthcare insurers were labelled positively, and presented as being capable and knowledgeable actors within the healthcare system. Although also in the background, the central government itself was described as an active participant, positioned as the driver behind the reform and responsible for facilitating its implementation. Nonetheless, policy documents also alluded to the government’s foreseeable struggle in terms of its own responsibility for the functioning of the system as a whole: the need to balance between, on the one hand, creating sufficiently flexible policy for municipalities and, on the other, central frameworks to guarantee citizens’ care (Plasterk, 2013b).

Importantly, citizens themselves were also seen as key stakeholders. Although not captured within the social boundaries imposed by the government’s legislational framework, policy documents implied that citizens would be seen as active participants by stipulating that one of the reform’s core goals was to help citizens become more self-reliant (van Rijn, 2014a). ‘Transformed’ from passive recipients into active, participating stakeholders, citizens were thus foregrounded in policy. In addition to being primarily responsible for their own health and wellbeing, they were also asked to access services only when their needs could no longer be met by themselves or their environment (Plasterk, 2013a). As such, citizens were labelled positively and their capabilities as self-reliant actors were rarely questioned.

Stakeholders in the media: questioning the boundaries’ design

In addition to questioning the design of the boundaries imposed by the central government, the media narrative challenged the legitimacy of actors being placed in the foreground versus the background, of their allocated responsibilities and capabilities, and of them being depicted as active drivers versus passive recipients of change. Like policy documents, the media also presented the central government as being the active driver behind the reform (NRC 149424, 141108, 150926; Telegraaf 140130, 140423, 2407055; BN/DeStem 140424). Particular attention was given to the state secretary (Telegraaf 140709; BN/DeStem 140424), whose reform ambitions were described as being ‘unyielding’ (Telegraaf 140116, 140305). Interestingly, the media characterised the role of the House of Representatives as passive, purporting that they had become less influential due to the changes implied by the reform (NRC 140521; Telegraaf 140522). The media thus differentiated between, on the one hand, the state secretary and the cabinet, and, on the other hand, the house of representatives. But both were described depreciatively.

Municipalities were also foregrounded by the media. With regard to questions about their capabilities, municipalities were generally described as being unequipped and overburdened (NRC 141027, 140926, 151229, 151230; Telegraaf 140522). Descriptions of their role differed. Initially, they were described as having a passive role, forced to undergo the reform (BN/DeStem 140116; Telegraaf 140917) and be loyal to the central government (NRC 140118; Telegraaf 140305). Over time, however, municipalities were increasingly portrayed as active stakeholders. Attention was increasingly drawn to their own responsibilities and influence (NRC 150604, 151230; BN/DeStem 141001, 140418), particularly in terms of aldermen – for example, how they actually wanted more responsibilities (with the accompanying resources) (NRC 140118), but also how they often missed deadlines and were unprepared for the decentralisation (NRC 140221, Telegraaf 140522, 140917).

Healthcare insurers were kept in the background and rarely mentioned in the media, save the rare comparison to a previous reform in which healthcare insurers had also been central (NRC 151230). Incidentally, insurers’ critiques of the LTC reform were often quoted (Telegraaf 140314, 140917). The media treated insurers as an authority in the healthcare field, taking their opinions on the envisioned reform seriously and using them to strengthen their own arguments around the degradation of the LTC system.

Like municipalities, citizens were foregrounded by the media, and differentiations were made between citizens who were dependent on the care system and those who were not. Often zooming in on those dependent on the care system, the media would depict them as passive actors suffering from the (potential) changes caused by the reform (BN/DeStem 140117, 140518; NRC 140118, 141008; Telegraaf 140415). Unlike in policy documents, care-dependent citizens were framed as being at risk, rather than as winners. As such, these care-dependent citizens were presented as being the inevitable victims of the reformed system.

Although the media narrative did not zoom in on cross-boundary collaborations between actors per se, it can affect these actors’ perceptions as they embark on new partnerships, given that their perceptions too, can be influenced by media narratives that reinforced the perception of healthcare insurers as ‘knowledgeable’, or depicted municipal actors as being both ‘unequipped’ to meet the demands of their new tasks and in need of help from other actors. As such, the media narrative effectively drew symbolic boundaries between (groups of) actors, which then contributed to a sense of unreciprocated dependence between partners.

Discussion

Although an increasing body of literature on boundary work continues to illuminate the complexities of working across boundaries, the actors who attempt to impose or dissolve boundaries from outside an organisation tend to remain out of sight. As we have shown here, system-level actors such as the central government and the media do inevitably influence the symbolic and social boundaries that exist between local actors through their use of ‘configurational boundary work’ – that is, their attempts to design integration and differentiation between groups of actors. Our analysis of policy documents and media articles has thus led to two main findings: (1) the media may challenge an epic tale as proposed by the central government by juxtaposing it with their own tragic tale, in which the same themes are evaluated but with a completely opposite lens; and (2) when the design of social boundaries (which impose differentiation) is opposite to that of symbolic boundaries (which demand integration), local actors are placed in tension-ridden positionings. These findings contribute to the literature in three ways.

First, although the emphasis of literature on boundary work tends to zoom in on actors who attempt to cross or defend local boundaries (for example, Allen, 1997; Meier, 2015; Liberati et al, 2016; Lindberg et al, 2017), we have instead zoomed out to show how central actors outside of these collaborations act, as such, shedding light on both central attempts to influence boundaries between local actors, and on the analysis of the design of policies that encourage collaboration. By juxtaposing their ‘epic’ and ‘tragic’ tales, we also zoomed in on how the central government and the media shape symbolic boundaries; that is, how they inform actors’ perceptions of themselves, their partners, and the challenges they face. Our findings show that their narratives do not change the concrete content of the change, but the symbolic meaning actors attribute to it (see also Zerubavel, 1991). Through their use of ‘epic’ and ‘tragic’ narratives, both policymakers and the media are responsible for shaping the boundaries imposed on collaborating actors, but in systematically different ways. In our study, the central government’s epic tale was ‘postalgic’ (Ybema, 2004), that is, they promised a golden future to create support for the reform at large. The central government communicated their intentions in general terms of systems and abstract groups. No questions were posed about the legitimacy of these newly imposed boundaries. Citizens, for instance, were assumed to be just as organised and responsible for their health as formal parties, and the stretching of boundaries around what constitutes the municipal domain was deemed unproblematic. In contrast, the media narrative was more dramatic and precise, as tragic tales tend to be. It questioned the legitimacy of the central government’s re-design of boundaries across the healthcare system. By focusing on anecdotal evidence of how the reform had an impact on different actors within the healthcare system, their tragic tale worked to undermine the abstract terms and ideas of the central government. In more general terms, this epic-tragic interplay can be conceptualised as a constant tension (Baxter and Montgomery, 1996; Poole and Van de Ven, 2004), meaning epic and tragic tales each evoke the other. Actors in favour of change, tell an epic tale in order to create support. Actors who are the subject of this change may contest or resist reforms by telling tragic tales to create support of why implementing the change is impossible or will not lead to its intended effects.

It should be noted that media outlets have a wider range of rhetorical tools at their disposal and are free to challenge, question or draw on problematic cases as they see fit. This gives the media more ‘power to influence’ in their communication, allowing them to more heavily affect the perceptions of actors – and, as such, to affect the shape of symbolic boundaries. Social boundaries, however, cannot be formed directly by the media. Likewise, the repercussions of miscommunication also differ: while consequences for individual media channels are relatively small – they may lose some readers or need to print a rectification – a central government stands to be held legally or financially responsible. Future research into the impacts on local stakeholder behaviour may want to explore this in more detail.

Second, and building on the previous point, our study draws attention to the importance of differentiating between boundary ‘types’, adding further nuance to the study of configurational boundary work (Langley et al, 2019). By separating symbolic and social boundaries, however, we have revealed the paradoxical expectations that central configuring actors sometimes place on collaborating actors in a system, that is, when their social boundaries enforce differentiation while their symbolic boundaries focus on integration. In our case study, the media questioned the legitimacy of these boundaries and the reform’s allocation of actor roles across the healthcare system. They also highlighted the shifting of responsibilities from the central government to local actors (including citizens), who, they argued, were unequipped to handle them. In both narratives, municipalities were placed at a disadvantage: they were presented as being ineffective and dependent on insurers, while the reverse was not suggested. Such tales informed actors’ perceptions, which then affected the dynamics of collaboration between unfamiliar partners. Although the media can be persuasive in shaping symbolic boundaries which may be used to contest social boundaries envisioned by policymakers, only the central government has the power to directly impose social boundaries between (groups of) actors, for instance, by changing legislation or funding streams. Therefore, while both configuring parties can influence boundaries, it is important to note that they are not able to do so in the same ways or with the same effects.

Third, and adding to the body of literature on the influence of media on governance (for example, Hjarvard, 2008; Klijn and Koppenjan, 2012; Klijn and Korthagen, 2018), we argue that, although the media may complicate governance processes, their narrative also functions to identify policy bottlenecks. Rather than starting with the envisioned result of a reform, as is often done in policy documents, the media appear more apt to emphasise its implications for citizens, as well as the capabilities, positions and interests of each individual actor. Through our analysis of media and policy discourse, we have identified some of the tensions that may arise between central and decentral actors, and when simultaneously encouraging both integration and differentiation. Such tensions can affect the establishment of partnerships in the healthcare system (van Duijn et al, 2021). Our findings therefore highlight the benefits of considering both policy and media discourse when attempting to understand the boundary work of local actors, and when developing policies to stimulate (healthcare) collaboration.

Limitations and future research

The (re-)configuration of boundaries is a process, dependent on local actors as well as central configuring actors. The term ‘configuring actors’ can refer to the government and the media, but also to other parties not included in our analysis here, for example, national policy agencies and global institutions. Future research could explore the interplay of a wider variety of configuring actors, and how this affects the shape of local boundary work and its dynamics. Future research could also build on our findings by further investigating the interplay between ‘configurational forces’ that work top-down versus bottom-up. While the attention of this article has been explicitly skewed towards the actions of central actors, future research may want to delve deeper into the interplay between local actors’ versus central actors’ boundary work. At last, in the Netherlands, media is relatively independent, narratives will be different in countries where media and politics are more interwoven. Future research could explore how these discursive struggles play out where media are more closely related to central politics.

Conclusions

Collaboration has become a key interest in both policy and the literature on boundary work. Scholars are keen to unravel how local actors negotiate, defend and cross boundaries to create or obstruct interaction in their everyday work. Yet little attention has been paid to how the narratives of central actors also inform and shape the playing field for these collaborating actors. By analysing both the policy and the media discourse surrounding the 2015 Dutch LTC reform, this study arrived at two main findings: (1) the epic tale of a central government can be undermined by the tragic tale of the media, who may use their rhetorical leeway to question the legitimacy of (the design of) boundaries, role allocation and representations of actors; and (2) a reform’s paradoxical configurational boundary can both bring stakeholders together and keep them apart. With these contributions, this article adds further nuance to the study of configurational boundary work. Similarly, our findings stress the importance of considering both policy and media narratives in the study of configurational boundary work, and when developing policies designed to stimulate (healthcare) collaboration.

Funding

This work was supported by the Ministry of Health, Welfare, and Sport.

Acknowledgments

The authors are grateful to Sierk Ybema, Frans Kamsteeg, and the members of the Talma Institute for their insightful comments which helped develop this article’s argument. We also thank the two anonymous reviewers for their constructive feedback.

Conflict of interest

The authors declare that there is no conflict of interest.

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    • Search Google Scholar
    • Export Citation
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    • Export Citation
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    • Export Citation
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    • Search Google Scholar
    • Export Citation
  • Bucher, S.V and Langley, A. (2016) The interplay of reflective and experimental spaces in interrupting and reorienting routine dynamics, Organization Science, 27(3): 594613, doi: 10.1287/orsc.2015.1041.

    • Search Google Scholar
    • Export Citation
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    • Search Google Scholar
    • Export Citation
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    • Search Google Scholar
    • Export Citation
  • Fairclough, N. and Wodak, R. (1997) Critical discourse analysis, in T.A. van Dijk (ed) Discourse as Social Interaction, London: SAGE Publications, pp 25884.

    • Search Google Scholar
    • Export Citation
  • Gieryn, T.F. (1983) Boundary-work and the demarcation of science from non-science: strains and interests in professional ideologies of scientists, American Sociological Review, 48(6): 78195. doi: 10.2307/2095325

    • Search Google Scholar
    • Export Citation
  • Glimmerveen, L., Ybema, S. and Nies, H. (2019) Engaged yet excluded: the processual, dispersed, and political dynamics of boundary work, Human Relations, 73(11): 150436, doi: 10.1177/0018726719875494.

    • Search Google Scholar
    • Export Citation
  • Grodal, S. (2018) Field expansion and contraction: how communities shape social and symbolic boundaries, Administrative Science Quarterly, 63(4): 783818, doi: 10.1177/0001839217744555.

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  • 1 Vrije Universiteit Amsterdam, , the Netherlands
  • | 2 Vrije Universiteit Amsterdam and Vilans, Centre of Expertise for Long-term Care, , the Netherlands

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