Candidacy is best understood as a conceptual framework, model or construct that identifies distinct factors – spheres of experience – that influence the behaviour of individuals, service professionals and systems at all points on the access route to services. This is an emerging concept and is still being refined through academic research (see Mackenzie et al). In order to arrive at a working model, the following construct is used in this report. This adheres to the dynamic Dixon-woods model but tries to anticipate more recently suggested refinements, whilst also taking into account the need to develop a workable model that can be applied to the research methodology.
Candidacy can be considered from the following six dimensions:
- Identification – how people recognise themselves as needing a service “People may be highly sensitive to perceptions of their behaviour by professionals and others. Many help¬seeking studies show that people’s fear of identity threats influences their decisions to seek help for medical problems and their interaction with health services. Their need to protect their identity – as rational, non¬neurotic, non¬hypochrondriacal, responsible users of health services – may mean that they delay help¬seeking” Dixon Woods, 2006
- Navigation – awareness of the services on offer and the practicalities of accessing those services (including transport and physical accessibility)
- Permeability – the ease with which people can use services (Ie do people have to be referred? Is it a drop¬in service?)
- Presentation – the ability to self¬present, communicate and articulate the ‘need’ or issue; relates also to the ability to voice concerns about the standard of service if those needs are not met. This category also makes provision for political rationing, which covers the ability of individuals and groups to use political or other mechanisms to increase their access to services when competing demands and claims on a service mean more likelihood of the rationing of that service.
- Professional adjudication – professional perceptions that may disadvantage certain people. This refers to the construction of the individual as ‘deserving’ or ‘undeserving’ and involves moral and social judgements on the part of the “service professional”, or gatekeeper.
- Operating Conditions – Candidacy is subject to multiple levels of influence at the societal and macro levels, depending on the political, economic and environmental context at the time of presentation.
According to Mackenzie et al, Candidacy should be seen as a cyclical process, with different interactions embedded in their meso and macro contexts, rather than as a dynamic journey where each part of the process is contingent on another. Attention is drawn by Mackenzie et al to the multiplicity of layers of complexity inherent in some of these dimensions. Specifically:
- Multiple candidacies are possible for some individuals and these can be in conflict with each other.
- Hierarchical structures within services can dictate outcomes: “Some services operate within explicitly hierarchical systems that structure the decisions of individuals in iniquitous ways” Mackenzie et al, 2012
- Candidacy can be depressed or refuted at a political, institutional or professional level. Service provision can be structured in such a way that it entrenches iniquitous service access.
The report accounts for these refinements as they become relevant to the issues discussed in the Findings section below.