Introduction
In the wake of calls for greater public accountability and ‘impactful’ research, governments and research funding agencies across the globe have shown a heightened interest in promoting collaborative modes of knowledge production (Phillips et al, Reference Phillips, Kristiansen, Vehviläinen and Gunnarsson2013; Walshe and Davies, Reference Walshe and Davies2013; Ersoy, Reference Ersoy2017). This drive to foster dialogue between ‘science and society’ is particularly pronounced in the United Kingdom’s health research field. In Best Research for Best Health (BRfBH) (DoH, 2006), the involvement of publics in the design, undertaking and management of research (what is often referred to as patient and public involvement or ‘PPI’Footnote 1) is placed at the heart of the UK’s government’s strategy to facilitate knowledge translation and ultimately ‘improve the health and wealth of the nation’. Crucially, the National Institute for Health Research (NIHR) (the funding body established to realise the vision set out in BRfBH) introduced a competitive system of funding which saw PPI become a condition of funding and an assessment criterion. In effect, PPI became a mandatory aspect of undertaking research and took on the traits of an ‘imperative’ policy (Ball et al., Reference Ball, Maguire, Braun and Hoskins2011: 612). These pivotal moments in the health research policy set the course for how NHS research funding is currently distributed and how PPI is promoted and enacted, and in many ways foreshadowed the elevation of ‘public involvement that came with the ‘impact agenda’ pushed by UK’s Research Councils (UKRC) and the Research Excellence Framework (REF) (Watermeyer and Lewis, Reference Watermeyer and Lewis2018).
In this paper we explore the role that PPI plays in ‘producing or ‘making up’ new ‘professional subjectivities’ (Ball, Reference Ball2000: 2). In doing so we show how researchers are called upon to perform ritualistic displays of PPI which have the effect of constructing researchers as effective and efficient knowledge workers and enterprising selves. We argue that this feeds into and extends the ways in which regimes of funding and performance accountability align the conduct of researchers with the logics of a global knowledge economy. We show, however, that these processes of governing are not straightforward, drawing attention to narratives of scepticism and alternative identifications in the health research field.
Governing researchers through PPI?
A recurrent theme in much of the literature on PPI and participatory research more broadly is a concern that power remains in the hands of researchers (Brett et al., Reference Brett, Staniszewska, Mockford, Herron-Marx, Hughes, Tysall and Suleman2014; Phillips et al., Reference Phillips, Kristiansen, Vehviläinen and Gunnarsson2013). Previous studies that have focused on researchers’ responses to PPI suggest that much of this has to do with the paternalistic attitudes of researchers and their reluctance to recognise the value of ‘lay’ knowledge (Thompson et al., Reference Thompson, Barber, Ward, Boote, Cooper, Armitage and Jones2009; Ward et al., Reference Ward, Thompson, Barber, Armitage, Boote, Cooper and Jones2010). While these studies point to how such acts of recalcitrance relate to the (re)production of professional identities and start to point the contextual factors that provide the conditions of their existence, they stop short of critically examining how such issues connect to the governance and subjectification of researchers. What is often left unexamined is (1) how PPI functions as an instrument of governance that constructs particular kinds of researcher subjects and (2) how researchers’ resistance towards PPI is bound up with a ‘struggle over subjectivity’ (Ball, Reference Ball2015) brought on by regimes of audit and performativity.
In our previous work we have shown how the increased embedding of PPI mechanisms in UK health research structures produces its own corresponding types of emotional experience (Komporozos-Athanasiou and Thompson, Reference Komporozos-Athanasiou and Thompson2015), hybrid forms of professional knowledge (Renedo et al., Reference Renedo, Komporozos-Athanasiou and Marston2018), spaces of participatory accountability (Komporozos-Athanasiou et al., Reference Komporozos-Athanasiou, Thompson and Fotaki2018a), and political rituals (Komporozos-Athanasiou et al., Reference Komporozos-Athanasiou, Fudge, Adams and McKevitt2018b). In this paper we aim to shed light on the role that PPI plays in governing researchers. We take our cue from anthropologists of policy and policy sociologists who have examined the spread of ‘audit culture’ and ‘performativity’ associated with the move towards neoliberal governance and the rise of New Public Management (NPM) (Shore and Wright, Reference Shore and Wright1999; Ball, Reference Ball2000). Inspired by Foucault’s notion of governmentality (Dean, Reference Dean1999; Rose Reference Rose, Barry, Osborne and Rose1996), such studies have been key probing how the imposition of quasi-market mechanisms and performance-management systems has enabled governments to ‘govern at distance’. In particular, they have brought into focus the ways in which such techniques of governance construct professionals as ‘enterprising subjects’ (Ball, Reference Ball2000:18) or ‘flexible selves’ – that is, ‘workers who do not need to be supervised but who ‘govern themselves’ through the exercise of introspection, calculation and judgement’ (Shore, Reference Shore2008, 284). As Shore (Reference Shore2008: 284, also see Peters, Reference Peters2011) suggests, to understand how such a neoliberal mode governance works it is important to recognise how it seeks ‘to act on and through the agency, interests, desires and motivations of individuals, encouraging them to see themselves as active subjects responsible for improving their own conduct’. Moreover, it’s important to understand how such a mode of governance works in conjunction with the imperatives of a ‘global knowledge economy’ characterized by fast capitalism and flexible specialization’ (Shore, Reference Shore2008: 283). The ideal subjects that emerge from policy constructions of the knowledge economy are ‘flexible’ and ‘enterprising’ workers who adapt to changing demands and continually invest in their own human capital.
Higher education has been a central focal point for many who have examined the rise of audit culture and performativity (Shore, Reference Shore2008, Ball, Reference Ball2012; Hyatt et al., Reference Hyatt, Shear and Wright2015). Here much has been written about the disciplining and controlling effects of technologies such as research assessment exercises, league tables and performance indicators such as publications and grant income. A key theme, which is particularly pertinent to our study, is how the spread of these technologies, coupled with reduced block funding, has helped to cultivate a ‘grants culture’ (Leathwood and Read, Reference Leathwood and Read2013) where researchers strive to prove their worth through the procurement of external research funds. Grant applications are thus a key site of performance measurement and competition, feeding into the ways which in researchers are ‘incited to become ever more striving, self-monitoring, entrepreneurial and productive’ (Leathwood and Read, Reference Leathwood and Read2013: 1164).
We argue that the insights of these studies shift attention towards the role that PPI plays in governing the conduct of researchers. In particular, they orientate us towards PPI’s connections with systems of audit and performativity, especially those associated with the ‘impact agenda’ (Knowles and Burrow, Reference Knowles and Burrows2014), and the different ways in which PPI enhances the visibility of researchers. What is of particular note here is how the demand to perform PPI not only puts researchers under the gaze of members of publics (who are assigned the role of helping researchers to do better quality and more relevant research), but also opens them up to new measures of value against which they can be judged and compared. We take up this line of inquiry and ask: how does such enhanced visibility affect the subjectivities of researchers?
To probe our main research question, we focus on how researchers experience and make sense of the PPI policy imperative. In this way ‘we attempt a ‘balancing act’ (Apple, Reference Apple and Grant1999: 61) that works across the dialectic tension between actor and subject’ (Ball et al. Reference Ball, Maguire, Braun and Hoskins2011: 611). That is to say, we analyse how the PPI policy imperative constructs particular types of researcher subjects and how the PPI policy imperative is ‘subject to complex processes of interpretation and translation’ (ibid: 611). What we are particularly concerned with is how the PPI policy imperative ‘trickles down’ (Ball et al. Reference Ball, Maguire, Braun and Hoskins2011: 620) into the practices of researchers, and the discourses inscribed into these practices. This focus on the ‘enactment’ of the PPI policy imperative shifts attention towards ‘[t]he jumbled, sometimes ambiguous, messy process that is experienced on the ground’ (Maguire et al., Reference Maguire, Braun and Ball2015: 485) and brings into focus the various contextual factors that mediate and inflect researchers’ understandings and acts of PPI.
Methods
In this paper we present findings from 20 in-depth, semi-structured interviews, lasting between 30 and 60 minutes, with London-based professional health researchers tasked to demonstrate PPI as part of their grant-seeking and research activities. Our sampling strategy combined purposive and convenience approaches: our interviewees were chosen to represent a wide range of clinical areas including: neurosurgery, transplant surgery, breast surgery, oncology, ophthalmology, paediatrics, palliative care, nursery, psychology, physiotherapy, public health, medical statistics, and health services research. Selected participants also reflect varying levels of seniority, and diverse experiences of involving patients in research projects, as well as in competing for research grants.
This variety in clinical expertise and seniority was designed to make our sample of interviewees more representative of the different methods of implementing PPI, and therefore to better capture associated challenges. Firstly, our own professional experience in the field allowed us to identify the nuances – pertaining to variability in the nature of different research projects – which are required to ‘apply PPI’. For instance, we took into account important distinctions between involving patients in the design of lab-based research, and involving participants in the development of qualitative and social scientific research. Such distinctions were important because they pointed to demands on researchers for different skills and sensitivities when approaching PPI: for instance, the complexities of ‘knowledge translation’ in different forms of research, or the types and depth of patient experiences that must be represented, and so on. Secondly, we were able to discern different sets of challenges faced by researchers not only according to their expertise, but also importantly in respect to their relative career stages and power positions within their respective institutions – which, as both extant literature and our own experience had confirmed, reflected variable levels of commitment to the PPI agenda’s aims.
The interviews were conducted by the first author, who at the time also worked as a research advisor at an NIHR funded organisation in a London University, tasked with offering specialist PPI advice to London-based health researchers applying for grants.
All three authors were involved in this organisation in different roles, which gave them a unique understanding of the challenges faced by researchers in the grant-seeking process as well as the nuances of implementing PPI in their projects. These roles made establishing contact with our study participants easier and allowed us unique access to research teams that had not previously been interviewed for this subject. We were thus able to interview, for instance, highly busy senior clinicians who made themselves available for interviews, as part of an ongoing relationship which had been established with our organisation. At the same time, our position in the organisation meant that we occupied a dual role; acting to some extent as gatekeepers for the research governance system which we also aimed to critically examine – a duality that, of course, presented us with some ethical challenges.
To address this impact of the dual role on our study we draw on the principles of self-reflexivity advocated in the rising current of auto-ethnographic studies (see, for example, Gilmore and Kenny, Reference Gilmore and Kenny2015). In addition to following standard research ethics process (providing detailed information sheets and consent forms ahead of the interview, offering participant anonymity, conducting the interviews at places of participants’ choice), when approaching our participants, we were open about our own experiences of the shifting system of research governance, and specifically about the challenges and tensions that we faced in our capacities as PPI advisors. In a sense, we were able to relate between our dual role as PPI advisers and researchers and our participants’ own dual roles as health professionals and researchers. This allowed us to establish trust and rapport with the participants, and to elicit reliable and authentic information from them.
In our analysis of the interview data, we used iterative thematic analysis (Hammersley and Atkinson, Reference Hammersley and Atkinson1995) to identify prominent themes. This level of analysis focused on two interrelated areas: (1) professionals’ experiences of the structural characteristics of the research infrastructure (e.g. rules, audit processes, performance targets) in which they were operating and competing for research income, and (2) participants’ strategies for navigating the research infrastructure.
Following others (e.g. Kirwan et al., Reference Kirwan, McDermont and Clarke2016) who have borrowed from the work of Wetherell (Wetherell, Reference Wetherell2013; Wetherell and Edley, Reference Wetherell and Edley1999), we also viewed the participants’ accounts as examples of ‘discursive practice’. This second level of analysis involved treating each interview as a whole and analysing the discursive repertoires participants used to make sense of the PPI policy imperative. Central to this was referring back to existing literature and other secondary resources such as policy documents and practice guidelines to identify the wider discourses of PPI, which the participants could draw on or resist to construct their accounts. We also referred back to the thematic analysis, examining how the discursive repertoires that participants utilised related to the various themes we identified. This multi-layered approach enabled us to examine how researchers interpreted and rearticulated the PPI policy imperative, as well as the contextual factors that mediated their interpretations. Moreover, it opened us up to the dynamic processes of subject formation. One implication of adopting this approach is that we focus on a few select accounts and at times present lengthy extracts. Presenting data in this way helps to bring into view the interpretive work of the participants and the complexities of subject formation.
The following section discusses the findings from our case studies in detail. Emerging themes were discussed and iteratively reviewed with the third author, whose distance from the primary data collection allowed better triangulation of findings.
Findings
The efficient and effective knowledge worker
Common across participants’ accounts was the perception that in recent years researchers have been summoned to enact PPI. Government research funding bodies appeared to play a key role in mobilising this incitement. Most participants, for instance, first became aware of the term ‘patient and public involvement’ or ‘PPI’ through developing research grant applications, revealing an awareness informed by funders’ guidance notes and/or advice from associated infrastructure bodies. Moreover, for many participants, the involvement of patients in their research has been prompted by the need to meet funders’ stipulations.
These pathways to involving patients might help explain why participants’ accounts tended to be framed by the ‘orthodox’ view of PPI being a means to enhance the appropriateness and relevance of research (Rose, Reference Rose2014: 151). They might also help to explain why participants often made direct references to government rationales when describing PPI. Julie, a non-clinical psychologist, was one researcher who made such direct references:
‘I think the why is political and the direction is definitely more and more service user involvement, more and more ‘PPI’, because I mean that seems quite clear from the steer that you get on the website… as I see it, you know, at the end of the day, all the money that we get for research is coming from the Government in one shape or form, … and, ultimately, you know, these are hard times and, you know, the Government is accountable to the public who elect the Government to say how they’re spending their money … and the idea that, … the Government is giving money to, sort of, little elite groups of researchers stuck in their offices in their ivory towers thinking up good ideas, which are great for the future of mankind but are not doing any benefit for us in the next few years, you know, is clearly not politically acceptable, so that’s the driver for it, in my view’.
The pervasiveness of the orthodox view of PPI and the explicit references to government rationales point a dominant representation of PPI that is imbued with a notion of accountability narrowly defined in terms of using public resources efficiently and effectively. It is this dominant representation that provides the discursive frames for researchers to understand what it means to involve patients and what it means to be a researcher. Thus, as an instrument of government, PPI can be seen to encourage researchers to act and think as an ‘efficient and effective knowledge worker’.
It would be wrong to suggest that all participants’ understanding and enactment of PPI policy can be explained in such narrow terms. Similarly, requirements and expectations of funders were not the sole factors driving participants’ PPI activities. Some spoke of motives that stem from personal experiences of being a patient. Others identified drivers emanating from their respective institutions and fields. In these participants’ accounts it’s possible to identify articulations of PPI that are not simply about being ‘economically accountable’. Brian, a dietician who specialises in HIV, offers a useful illustration:
‘….so I think involving patients in healthcare decisions in research, moving forward, I think it’s so important. … I’m a real convert to it, because of my experiences in designing this research and the great input that I’ve had so far. But also within HIV specifically, you know, my field …all the development of antiretrovirals came from the patients back in the bad old days of AIDS, you know, there were organisations like ACTUP and all of those guys who did amazing things. And they were faced with their own deaths, it was understandable. And so I think I’ve always had that in the back of my mind’.
In the extract above Brian references ACTUP – an activist group set up in the 1980s to pressure the US government and researchers to change their policies and practices and ultimately deliver better treatments. There are affinities between Julie’s and Brian’s articulation of PPI; they both share a concern with responding to the needs of patients and improving patient outcomes and being ‘accountable’. Yet there are important differences too. While Julie points to a government-driven technocratic notion of PPI, Brian intimates an understanding that takes its cue from ‘bottom up’ social movements, marked by sentiments of social justice and empowerment. It’s important to note, however, that Brian does not situate this prior understanding in direct opposition to the PPI policy imperative. Rather, as his remarks about already being a ‘convert’ indicate, he intimated how they resonate and feed into each other.
On one hand, the convergences and divergences evident in Julie’s and Brian’s understandings of PPI are indicative of how the PPI imperative animates and sediments ‘synapses’ (Clarke et al., Reference Clarke, Newman, Smith, Vidler and Westmarland2007: 29) between the neoliberal and managerial logics of cost-efficiency and effectiveness and the disaffections and demands of social movements and user groups. Moreover, they shift attention to how PPI functions as a technology of government that works with and through researchers’ desires to act ethically and responsibly.
On the other hand, the convergences and divergences reveal the multiple histories, orientations and motifs that feed into representations of PPI, and how this multiplicity opens up possibilities for different identifications to be made – identifications that enable researchers to understand themselves in terms that exceed the technocratic logics of efficiency and cost-effectiveness. It is important to consider here how researchers ‘make meanings with the discursive possibilities available to them’ (Ball et al., Reference Ball, Maguire, Braun and Hoskins2011: 612). As we can see from Brian’s account, his ability to articulate an understanding of PPI that gives voice to different logics and values needs to be understood in relation to his position in the field of HIV and the particular discursive repertoires that this affords him. By the same token, Julie’s narrower articulation of PPI needs to be viewed in relation to her pathway to involving patients in her work (she was one of the many researchers whose awareness and enactment of PPI grew out of writing grant applications). Such uneven spread in discursive repertoires, which was apparent across our sample of researchers, highlights the importance of recognising how various factors (such as institutional position, professional field, personal biography) shape researchers’ capacities to reinterpret the PPI policy imperative and to forge different identifications.
The enterprising knowledge worker
We now extend our analysis of the role PPI plays in governing the conduct of researchers by exploring how the cultivation of the ‘efficient and effective knowledge worker’ works in tandem with the production of enterprising subjects. In doing so, we bring PPI’s entanglement with regimes of audit and performativity into sharper focus.
The pressures brought on by the continuing monitoring of performance was a common theme across participants’ accounts, with many making reference to the constant need to ‘win research grants’ and to demonstrate ‘impact’. As Julie put it:
‘You know, the REF has just happened, you know, we’ve all had to do impact case studies. So it affects your day to day job. It does affect it a lot actually, so there’s a lot of insecurity. It affects it enormously in terms of everybody’s rushing to get on television and the radio in order to demonstrate the impact of their work. Personally, I think it undermines science completely because it’s a short-termist view and, as with everything, you know, there’s a balance in the middle which, you know, but I mean of course it does impact, it does make a difference to what you do and how you do it. I mean, I think some people can still go off and do their own thing, so it does depend on personality a little bit, but it also depends on stage of career, you know, if you’re older, closer to retirement, you know, probably doesn’t matter so much and you’re also more established so, you know, you can adhere to -, I mean, actually we had this conversation at our New Year party with colleagues, and there was myself and another junior colleague and a professor who’s recently got his professorship and, you know, complaining about, you know, well my colleague was sort of complaining more adamantly, more vehemently than I do about the integrity, the loss of integrity around research because of the need to tick the boxes that are required, so involving users being one of them, not that he thought that was a bad thing necessarily, but not being able to pursue the things that you believe in in the way that you believe is right because of the constraints around having to demonstrate impact, get high impact journals, yourself everywhere, all these things that you sort of have to do that he was feeling compromised his integrity as a scientist, you know, and I was saying to the professor ‘well look, you’ve been really successful’, and yet, because I know, ‘you don’t do any of that, you know, you don’t feel that way’ and actually his answer was ‘I don’t know!’, so it wasn’t very helpful. But I think in some extent it comes down to how susceptible you are to kind of external pressures generally, you know, and how secure or insecure you feel.’
We first want to draw attention to how Julie frames PPI as an additional demand imposed by regimes of audit and performativity. This can be seen in how PPI is referred to as another ‘tick box’. On one level, this signifies the trivialising of PPI; PPI is framed as an inevitable – perhaps even undesirable – activity which is merely performed to meet the requirements of funders. On another level, it points to how PPI adds to the assemblage of performances which researchers are judged and compared against. What is notable here are Julie’s remarks about the precarity of academic life and the concomitant pressures to comply with the demands of audit and performativity. This shifts attention to how PPI is not merely a perfunctory activity that can be ignored, but rather an activity that researchers need to perform in order to maintain and develop their career.
The role that PPI plays in expanding the arenas of academic competition and broadening the ‘academic portfolio’ was further apparent in the participants narratives of professional development. Some participants, for instance, framed PPI as a new knowledge area to acquire and a means to develop a broader range of skills and become ‘better’ researchers. Such sentiments are illustrative of how PPI is inscribed with the logic of continuous training associated with the notion of the ‘entrepreneurial self’ (Peters, Reference Peters2011: 27); to do PPI, in this sense, is to invest in one’s own human capital and become multi-skilled, flexible and marketable. PPI’s role in cultivating an entrepreneurial ethos can also be seen in the extension and entrenchment of habits of competition; here participants spoke about PPI becoming a means to gain the competitive edge over others when applying for research funding.
In this section so far, we have drawn attention to how PPI feeds into and augments the ways in which regimes of audit and performativity encourage researchers to think and act as enterprising subjects. Next, we explore in more detail the complexities and ambiguities that characterise processes of subjectification. However, it is worth further dwelling on the data we have discussed so far as a way to introduce and further contextualise these key themes.
What we particularly want to bring into focus here are the feelings of unease and scepticism evident in Julie’s account. Such feelings were widespread across our sample, often surfacing when participants spoke about needing to comply with funders’ requirements for PPI. In many ways the surfacing of these feelings bore the traits of the ‘disaffected consent’ (Clarke, Reference Clarke, Hyatt, Shear and Wright2015: 142) that has come to define how many academics respond to the spread of audit and performativity in academia. By shifting our attention to how PPI induces and compounds feelings of dissatisfaction and unease, we can detect traces of ‘sceptical subjects’ (Shore and Wright, Reference Shore, Wright, Shore, Wright and Pero2011: 18). For instance, in Julie’s remarks relating to the uncertainties of academic life and the loss of autonomy and integrity, as well as her earlier references to government rationales, we find a sceptical researcher who reflects upon PPI’s entanglements with regimes of audit and performativity and who questions the points of subjection that this entanglement generates.
What is also notable about Julie’s expressions of disaffection and scepticism are the distinctions she draws between herself and ‘older’, more established colleagues who she views as having more freedom to resist the demands of audit and performativity. This marking of collegial distinctions can be seen as an attempt to illuminate how ‘external pressures’ shape the actions of researchers (rather than simply their ‘personality’). It can also read as an identification with other junior researchers who also suffer from the effects of precarity. Either way, Julie’s comments point to the importance of considering how the forces of the PPI imperative touch researchers differently depending on their institutional position.
At the same time, it is important to note how the demands to perform PPI can easily cut across such professional divisions. ‘Established’ professors that we interviewed spoke about the pressures to be aware of and enact PPI. The fact that PPI is a policy imperative – and one that opens up new measure of value – means that it has to be on their radar.
This brings us onto our final point about the ambiguity surrounding the value ascribed to PPI. While all participants spoke about the growing importance that research funders and regulatory bodies place on PPI, many spoke about a mismatch between the rhetoric of PPI and the prevailing institutional structures, practices and epistemic cultures. Here participants expressed how funders’ promotion of PPI jars with and/or falls secondary to their emphasis of ‘sound science’. For some this was reflected in a mismatch between the rhetoric of PPI and the support available to help researchers facilitate it. These mixed signals point to the ambiguities and contradictions that arise from the co-existence of ‘old’ and ‘new’ modes of scientific governance (Irwin, Reference Irwin2006). The uncertainties that they stimulate also point to how regimes of audit and performativity take hold. The ever-changing and expanding assemblage of expectations and metrics leads to uncertainty about which performances are being summoned and judged – an uncertainty which means ‘that any and all comparisons have to be attended to’ (Ball, Reference Ball2000, 3).
Playing the game: PPI spectacles and impressing the funders’ ‘gaze’
We have seen so far how all participants showed signs of enacting PPI with funders in mind. Indeed, there is an overriding sense of participants choreographing their PPI to respond to and impress the funder’s gaze. Participants whose engagement with patient involvement preceded the recent policy/funder imperative intimated how their practices shifted and evolved to fit funders’ expectations. A common theme here was how researchers have been impelled to ‘build involvement’ into all stages of the research process. For many others their PPI seemed to be characterised by surface-level spectacles; enactments which are simply about doing what is sufficient to ‘play the game.’ For example, Stuart, a transplant surgeon, said:
‘I still think, like most of the parts of applying for a grant, it is just playing the game and saying the things that they want you to say. So I still think that a large part of it is that. And I think it’s possible to play that game without doing it properly. But actually if you’re doing it properly, I think it can be very valuable. And particularly in defining the research question, because clearly there’s not much point in doing a study to answer a question that patients aren’t really interested in’.
Stuart’s choice of words ‘playing the game’ was often used by participants to legitimise the plasticity and inauthenticity that can be seen to characterise enactments of PPI. The refrain functions to frame acts of dramaturgy as an inevitable– albeit perhaps regrettable – part of securing research funds; a necessary act to survive and be successful in the competitive world of academia. While Stuart’s comments may suggest a submissive or contingent compliance, his remarks about the value of involvement suggest a somewhat converse self-driven endorsement of involvement. Importantly, they also suggest a persistence of vocational element of the researchers’ professional role (du Gay, Reference du Gay2000) represented in their moral commitment to ‘do research properly’.
While the refrain ‘playing the game’ can be seen to offer a means to rationalise inauthenticity and plasticity, the ‘fabrication’ of PPI nevertheless appears to entail ‘costs to the self’ (Ball, Reference Ball2000: 7). As the palpable anxieties visible in Julie’s account suggest, much of this is to do with the integrity of researchers being undermined and the destabilisation of their professional identity. A number of relating and overlapping factors can be seen to be at play here: (1) the advancement of a market-based customer accountability which displaces a relationship of trust in which funders allowed researchers to exercise judgement and autonomy to deliver what is required; (2) the introduction of PPI as a mandatory feature of research funding proposals which again undermines the autonomy and judgement of researchers, as their enactment of PPI is imposed/prescribed rather than based on their own judgment and creative agency; (3) the inauthenticity and insincerity that derives from needing to play the game goes against conventional practices and established moral codes of conduct – consonant with the Weberian idea of beauty truth in ‘Science as a Vocation’ (Weber, Reference Weber, Lassman, Velody and Martins1988).
While the accounts of those who spoke of anxieties about their integrity contained traces of all these points, much of the concerns coalesced around points two and three. Indeed, the prescriptiveness of funders’ stipulations and expectations appeared to be the key source of much disquiet. Here participants proclaimed that the demands of funders are leading to fabrications and inappropriate practices because what is summoned and expected isn’t appropriate for all forms and aspects of research. In a similar vein, participants also expressed that what is demanded isn’t feasible given the time and resource constraints they face. Paul, a psychologist, was one participant in particular who articulated concerns about the stimulation of inappropriate PPI. While Paul expressed the importance and value of involving patients in research, he spoke of struggling with the perceived expectation of building such involvement into all stages of the research process. In particular, he intimated that involving patients during the design phase is often futile and artificial as scientific knowledge and conventions prevail. The extract below from the interview with Paul demonstrates how this struggle is bound up with questions of professional identity:
‘Generally I think it’s a good idea … I guess … what I struggle with continually is I can’t understand how, how involving service users and sort of the design of studies when it’s supposed to have taken me and my colleagues sort of ten, fifteen years, you know, doing a doctorate etc. to develop these skills. Yet we’re suddenly told, ‘That’s good, but actually just go for the service user who, you know, and ask them about designing your trial,’ and stuff, and how, you know, randomised control trial sort of context of how that would work – I’m not entirely clear, you know. And so that’s where I struggle with it’.
This account could simply be interpreted as being emblematic of researchers’ reluctance to relinquish power and the maintenance of professional paternalism; factors which are frequently identified as key barriers hindering the successful implementation of involvement (see, for example, Richards, Reference Richards2017; Brett et al., Reference Brett, Staniszewska, Mockford, Herron-Marx, Hughes, Tysall and Suleman2014; Thompson et al., Reference Thompson, Barber, Ward, Boote, Cooper, Armitage and Jones2009). However, viewed in light of the feelings of unease and disaffection expressed by Paul, the drawing of professional-lay boundaries can be seen as an attempt to deal with the destabilisation of professional identity and undermining of integrity that results from needing to ‘play the game’ and invest in plasticity. In this sense what could be defined as opposition to patient involvement is less reflective of ingrained attitudes or elitism, and more representative of a resistance to the regimes and demands of performativity and audit, which formal ‘PPI’ seems to embody and reproduce.
Discussion and conclusions
A first insight emerging from our study concerns the role that PPI policy plays in governing the conduct of researchers. We have drawn attention to the ways in which PPI feeds into and augments regimes of audit and performativity that are geared towards the cultivation of a workforce conducive to a global knowledge economy and the imperatives of neoliberalism (Shore, Reference Shore2008, Ball Reference Ball2000). We showed how this involves the installation of a mode of accountability defined in terms of cost-efficiency and effectiveness, and the imposition of new measures of value that encourage researchers to become more ‘enterprising’ and ‘flexible’. Like previous studies on audit and performativity, we pointed to how such processes of governing ‘act on and through’ (Shore, Reference Shore2008: 284) individuals’ own desires and motivations. What is particularly notable about PPI is how it speaks to a broader range of democratic principles and values than those commonly associated with audit technologies that have tended to be the focus of previous studies.
Technologies such as research assessment exercises bear a strong imprint of NPM and take on an explicit economic and managerial framing. However, the antecedents and motifs of PPI reflect an interest in promoting participatory democracy and give voice to notions of citizenship and social justice. From our interviews at least, the broader democratic principles and values that PPI animates tend to sit more comfortably with researchers. In this way PPI and its entanglements with regimes of audit and performativity can be seen to represent a more insidious technology of governance as it carries a greater potential to tap into and mobilise researchers’ desires to act ethically and civically.
However, such processes of governing are characterised by ambiguities and tensions. By virtue of its various roots and routes, PPI opens up a space for multiple identifications to be made – identifications that exceed the technocratic logics of cost-efficiency and effectiveness. Moreover, it is clear from the narratives of scepticism across our participants’ accounts that researchers reflect on and question the ways in which PPI works to construct them as objects of power. Importantly, by dwelling on these narratives of scepticism we unravelled a more complex picture of researchers’ resistance towards PPI than that which is commonly portrayed in existing literature (e.g. Richards, Reference Richards2017; Lehoux et al., Reference Lehoux, Daudelin and Abelson2012; Brett et al., Reference Brett, Staniszewska, Mockford, Herron-Marx, Hughes, Tysall and Suleman2014; Thompson et al., Reference Thompson, Barber, Ward, Boote, Cooper, Armitage and Jones2009). As we demonstrated, researchers’ scepticism can be more about PPI’s entanglements with regimes of audit and performativity than it is to an unwillingness to recognise the value of ‘lay’ knowledge. A key insight to emerge here is how the drawing of professional-lay boundaries may not simply reflect engrained paternalistic and elitist attitudes but rather reveal a more complex set of identifications and relations including an appeal to professional judgement and integrity and a resistance towards becoming more malleable.
A related implication is that emerging power distributions within the research systems of our study were not necessarily skewed in favour of professionals. By contrast, health researchers, much like patients, appeared to be imbricated in an evolving nexus of control and responsibility structures, which seek to reshape their professional roles and legitimacy. Hence it is important to note that the power dynamics described here within the ‘research system’ did not lead to a broader rebalancing of power between professionals and patients. In other words, we were able to attest an increasingly vulnerable position of professional researchers (especially so for those in less senior and more insecure positions), yet such vulnerability did not seem to translate into a corresponding empowered position for patients. Although this study did not aim to ascertain the impact of PPI implementation on patients’ positions (a topic that has been the focus of our previous work), it nonetheless suggested that, at least from the perspective of researchers, professionals and patients alike find themselves disempowered within the organisations they both inhabit.
Our study thus contributes to a growing body of important critical work (e.g. Newman et al., Reference Newman, Barnes, Sullivan and Knops2004; Boaz et al., Reference Boaz, Biri and McKevitt2016; Komporozos-Athanasiou et al., Reference Komporozos-Athanasiou, Renedo and McKevitt2019; Andreassen, Reference Andreassen2018), which seeks to unveil the limitations and failures of PPI implementation – what could be broadly described as ‘ticking the box’, or, more concerningly, as co-opting practices of PPI and undermining meaningful involvement. The novelty of our contribution in this paper is to suggest a link between the ritualised – yet ambivalent – enactment of PPI and a shifting professional subjectivity, which is at once more precarious and more adaptable to the new research systems.
