Strengthening citizenship: A healthcare improvement priority.

We propose that strengthening citizenship could help realise some of the substantial changes that are being called for in mainstream health policies. We highlight the way that current healthcare improvement agendas entail, and depend upon, large-scale and complex cultural change. But, we suggest, there is a severe limit to how far such cultural change can be engineered from above or through conventional quality improvement methods. In summary, we argue that supporting what we call 'civic culture' - a culture that encourages and -enables effective citizenship - may be a precondition for -bringing about policy aspirations and related improvements.