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Local democracy has increasingly faced problems such as declining voter turnout and decreasing trust in political parties. Certain forms of participatory democracy have been introduced to address political disengagement. Often these efforts do not deliver the envisaged results, as they exacerbate existing inequalities by attracting only certain groups of citizens. This paper takes a close look at representation to find out if and how it can strengthen local democracy. Non-electoral representation, as manifested by representative claims based on non-electoral grounds, such as identity and expertise, made by local councillors, as well as non-elected individuals and organisations, might serve to mitigate democratic problems. We empirically study manifestations of electoral and non-electoral representation and their interactions. We conclude that non-electoral representation can strengthen local democracy, but its relationship with electoral representation can also be problematic. We make suggestions as to how these problems might be overcome in an effort to strengthen the local representative system.

Local democracy has increasingly faced problems such as declining voter turnout and decreasing trust in political parties. Certain forms of participatory democracy have been introduced to address political disengagement. Often these efforts do not deliver the envisaged results, as they exacerbate existing inequalities by attracting only certain groups of citizens. This paper takes a close look at representation to find out if and how it can strengthen local democracy. Non-electoral representation, as manifested by representative claims based on non-electoral grounds, such as identity and expertise, made by local councillors, as well as non-elected individuals and organisations, might serve to mitigate democratic problems. We empirically study manifestations of electoral and non-electoral representation and their interactions. We conclude that non-electoral representation can strengthen local democracy, but its relationship with electoral representation can also be problematic. We make suggestions as to how these problems might be overcome in an effort to strengthen the local representative system.

In many countries patient involvement is high on the healthcare policy agenda, which includes patient representation in collective decision-making. Patient organizations are generally considered to be important representatives of patients. Other actors also claim to represent patients in decision-making, such as politicians, healthcare professionals, and client advisory councils. In this paper we take a broad view of patient representation, examining all the actors claiming to represent patients in the Dutch debate on the decentralization of care. We conclude that variety in forms of representation could help do justice to the variety of patient preferences. In addition we conclude that in order to ensure the democratic quality of patient representation, actors making representative claims have to reflect on how their claims relate to each other and how they can ensure authorization and accountability in the representative relationship with those they claim to represent.

In many countries patient involvement is high on the healthcare policy agenda, which includes patient representation in collective decision-making. Patient organizations are generally considered to be important representatives of patients. Other actors also claim to represent patients in decision-making, such as politicians, healthcare professionals and client advisory councils. In this paper we take a broad view of patient representation, examining all the actors claiming to represent patients in the Dutch debate on the decentralization of care. We conclude that variety in forms of representation could help do justice to the variety of patient preferences. In addition we conclude that in order to ensure the democratic quality of patient representation, actors making representative claims have to reflect on how their claims relate to each other and how they can ensure authorization and accountability in the representative relationship with those they claim to represent.

Background Patient participation on both the individual and the collective level attracts broad attention from policy makers and researchers. Participation is expected to make decision making more democratic and increase the quality of decisions, but empirical evidence for this remains wanting. Objective To study why problems arise in participation practice and to think critically about the consequence for future participation practices. We contribute to this discussion by looking at patient participation in guideline development. Methods Dutch guidelines (n = 62) were analysed extended version of the AGREE instrument. In addition, semi-structured interviews were conducted with actors involved in guideline development (n = 25). Results The guidelines analysed generally scored low on the item of patient participation. The interviews provided us with important information on why this is the case. Although some respondents point out the added value of participation, many report on difficulties in the participation practice. Patient experiences sit uncomfortably with the EBM structure of guideline development. Moreover, patients who develop epistemic credibility needed to participate in evidence-based guideline development lose credibility as representatives for 'true' patients. Discussion and conclusions We conclude that other options may increase the quality of care for patients by paying attention to their (individual) experiences. It will mean that patients are not present at every decision-making table in health care, which may produce a more elegant version of democratic patienthood; a version that neither produces tokenistic practices of direct participation nor that denies patients the chance to contribute to matters where this may be truly meaningful.

Institutional arrangements used to steer public policies have increasingly become layered. Inspired by the literature on institutional layering and institutional work, this paper aims to make a contribution to our understanding of institutional layering. We do so by studying an interesting case of layering: the Dutch hospital sector. We focus on the actors responsible for the internal governance (Board of Directors and Supervisory Boards) and the external regulation (the Healthcare Inspectorate) of hospitals. In the paper, we explore the institutional work of these actors, more specifically how institutional work results from and is influenced by institutional layering and how this in turn influences the institutional makeup of both healthcare organizations and their institutional context. Our approach allowed us to see that layering changes the activities of actors in the public sector, can be used to strengthen one's position but also presents actors with new struggles, which they in turn can try to overcome by relating and using the institutionally layered context. Layering and institutional work are therefore in continuous interaction. Combining institutional layering with a focus on the lived experiences of actors and their institutional work makes it possible to move into the layered arrangement and better understand its consequences.

Patient organizations increasingly play an important role in health care decision-making in Western countries. The Netherlands is one of the countries where this trend has gone furthest. In the literature some problems are identified, such as instrumental use of patient organizations by care providers, health insurers and the pharmaceutical industry. To strengthen the position of patient organizations government funding is often recommended as a solution. In this paper we analyze the ties between Dutch government and Dutch patient organizations to learn more about the effects of such a relationship between government and this part of civil society. Our study is based on official government documents and existing empirical research on patient organizations. We found that government influence on patient organizations has become quite substantial with government influencing the organizational structure of patient organizations, the activities these organizations perform and even their ideology. Financing patient organizations offers the government an important means to hold them accountable. Although the ties between patient organizations and the government enable the former to play a role that can be valued as positive by both parties, we argue that they raise problems as well which warrant a discussion on how much government influence on civil society is acceptable.

In Dutch healthcare, new market mechanisms have been introduced on an experimental basis in an attempt to contain costs and improve quality. Informed by a constructivist approach, we demonstrate that such experiments are not neutral testing grounds. Drawing from semi-structured interviews and policy texts, we reconstruct an experiment on free pricing in dental care that turned into a critical example of market failure, influencing developments in other sectors. Our analysis, however, shows that (1) different market logics and (2) different experimental logics were reproduced simultaneously during the course of the experiment. We furthermore reveal how (3) evaluation and political life influenced which logics were reproduced and became taken as the lessons learned. We use these insights to discuss the role of evaluation in learning from policy experimentation and close with four questions that evaluators could ask to better understand what is learned from policy experiments, how, and why.

In Dutch healthcare, new market mechanisms have been introduced on an experimental basis in an attempt to contain costs and improve quality. Informed by a constructivist approach, we demonstrate that such experiments are not neutral testing grounds. Drawing from semi-structured interviews and policy texts, we reconstruct an experiment on free pricing in dental care that turned into a critical example of market failure, influencing developments in other sectors. Our analysis, however, shows that (1) different market logics and (2) different experimental logics were reproduced simultaneously during the course of the experiment. We furthermore reveal how (3) evaluation and political life influenced which logics were reproduced and became taken as the lessons learned. We use these insights to discuss the role of evaluation in learning from policy experimentation and close with four questions that evaluators could ask to better understand what is learned from policy experiments, how, and why.