What is mutual about Public Service Mutuals?: critical realist study of mutualism within healthcare organisations in England

Former Cabinet Office Minister Francis Maude once made the ambitious claim that one million public sector workers would own and run the services they provide by 2015. It never happened, but there are still approximately 110 Public Service Mutuals (PSMs) in England. Yet whilst mutuality permeates the discourse of this policy, mutualism in PSMs, as both ethos and practice, is under-theorised and under-researched. This thesis addresses these gaps using a critical realist approach. Drawing on a review of literature on mutuality and co-operation, mutualism in PSMs is conceptualised as interrelated cultural and structural emergent properties, comprising mutual ideas, relations and practices. These are applied in an empirical research project to explore the mutual in PSMs. A large N survey of healthcare providers was followed by in-depth comparative case studies of an NHS Foundation Trust and two PSMs. Using a critical realist framework, mutual structures and generative mechanisms, together with agent (employee) interaction with them, were investigated. The findings revealed that organisational mutual practices of ownership, shared benefit, voice and transparency can cause the emergence of the mutual relations of trust, co-operation and reciprocity when allied to a common purpose. In turn, the causal powers of these mutual relations strengthen organisational mutual practices. However, this does not occur quickly or automatically and the corporate agency of managers and staff, coalescing around joint projects, is necessary for the mutual in Public Service Mutuals to emerge and thrive