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Paid carers play an important role in helping older adults with care needs to remain living in their own homes. This paper examines changes in the home care field, specifically the emergence of self‐employed care entrepreneurs ('microentrepreneurs'). To do this, it employs Bourdieu's concepts of field, capital and habitus. Drawing on 105 semi‐structured interviews with stakeholders working in home care, the paper describes how the interaction of changes to field structures, and altered practices of care have challenged the taken‐for‐granted acceptance of traditional, transactional forms of care provision. This process has been highly dependent on local state actors, their ability to mobilise relevant forms of capital and the factors which shaped their habitus. It should be seen within the context of changes to local field structures and the hierarchical classification processes which underpin them. These changes threaten the distribution of capital in the home care field in ways that are beneficial to microentrepreneurs. Bourdieu might categorise these developments as 'partial revolutions', which do not challenge the fundamental axioms of the field. However, for care entrepreneurs, formerly employed as low‐paid home‐care workers, a revolution that is only partial may be better than none at all. [ABSTRACT FROM AUTHOR]

In the British NHS the principle of exceptionality involves assessing whether a patient is sufficiently different from the generality of patients to justify providing a treatment, such as an expensive cancer drug, not approved for routine funding. In England, individual requests for certain high‐cost treatments are considered by local panels that examine exceptionality alongside treatment efficacy and cost as the main criteria for funding. This was also the case in Wales until September 2017. Our paper draws on audio recordings of panel meetings and interviews in a Welsh Health Board to investigate how exceptionality was constructed in discussions. It focuses on the problematic combination of different decision criteria in meeting talk, particularly regarding the discourses associated with efficacy and exceptionality. Exceptionality is a fluid category that raised questions about the evidence‐based nature of panel decision making. In particular, the paper discusses the use of subgroup data from RCTs and the difficulty of deciding how small a subgroup of patients should be before it is deemed exceptional. Determining exceptionality has been an important mechanism for deciding that a minority of NHS patients can still receive high‐cost treatments not routinely provided for all. As a neglected rationing mechanism it warrants sociological examination. [ABSTRACT FROM AUTHOR]

This paper investigates the comprehensive compassionate care reform programme within the National Health Service (NHS) in England. Through a synoptic reading of policy documents, we show how 'compassion' is introduced as an overarching meta‐virtue designed to govern relationships and formal positions in health care. Invoking an 'ethics of office' perspective, mainly drawing on the thinking of Max Weber, we evaluate the promotion of compassion as a managerial technology and argue how seemingly humanistic and value‐based approaches to healthcare management might have unintended consequences for the quality of care and the conduct of health professionals that in some ways resemble and in some ways exceed those of the more traditional New Public Management measures, which the new compassion paradigm is expected to outdo. In the paper's final sections, we turn to the original work of the nursing icon Florence Nightingale to argue that compassion and other virtues should continuously be formulated and re‐formulated in relation to the role‐specific skills and duties of particular offices in the healthcare sector. [ABSTRACT FROM AUTHOR]

Professional autonomy has come under greater scrutiny due to managerialism, consumerism, information and communication technologies (ICT), and the changing composition of professions themselves. This scrutiny is often portrayed as a tension between professional and managerial logics. Recently, medical autonomy has increasingly been shaped in terms of transparency, where publication of clinical performance (via ICT) might be a more pervasive form of surveillance. Such transparency may have the potential for a more explicit managerial logic but is contested by clinicians. This paper applies notions of surveillance to public reporting of cardiac surgery, involving the online publication of mortality rates of named surgeons. It draws on qualitative data from a case‐study of cardiac surgeons in one hospital, incorporating interviews with health care managers and national policymakers in England. We examine how managerial logics are mediated by professional autonomy, generating patterns of enrolment, resistance and reactivity to public reporting. The managerial 'gaze' of public reporting is becoming widespread but the surgical specialty is accommodating it, leading to a re‐assertion of knowledge, based on professional definitions. The paper assesses whether this form of surveillance is challenging to or being assimilated by the medical profession, thereby recasting the profession itself. [ABSTRACT FROM AUTHOR]

This paper examines the impact of disruptions to the organisation and delivery of healthcare services and efforts to re‐order care through emotion management during the COVID‐19 pandemic in the UK. Framing care as an affective practice, studying healthcare workers' (HCWs) experiences enables better understanding of how interactions between staff, patients and families changed as a result of the pandemic. Using a rapid qualitative research methodology, we conducted interviews with frontline HCWs in two London hospitals during the peak of the first wave of the pandemic and sourced public accounts of HCWs' experiences of the pandemic from social media (YouTube and Twitter). We conducted framework analysis to identify key factors disrupting caring interactions. Fear of infection and the barriers of physical distancing acted to separate staff from patients and families, requiring new affective practices to repair connections. Witnessing suffering was distressing for staff, and providing a 'good death' for patients and communicating care to families was harder. In addition to caring for patients and families, HCWs cared for each other. Infection control measures were important for limiting the spread of COVID‐19 but disrupted connections that were integral to care, generating new work to re‐order interactions. [ABSTRACT FROM AUTHOR]

Professional accounts of emotional distress originate from within mainstream mental illness discourses and are underpinned by largely conjectural biomedical, brain‐based conceptions of disorder. Alternative, formulation‐based approaches remain delimited by cultural norms and linguistic resources. Service users frequently declare the most ordinary aspects of therapy the most helpful: listening, understanding, and respectfulness; these are not contingent upon the presence of a mental health professional. This paper describes ameliorations in states of emotional distress amongst volunteer trainee mechanics in a bicycle workshop, which has little overtly to do with mental health. Possible explanations for these ameliorations, or 'recoveries', are presented. In an enabling setting that offers the social and material resources conducive to particular ways of being, an applied actor‐network approach is introduced as a practical way to disentangle the concomitant complexities of bicycles and everyday life. This approach to analysing states of distress—introduced here as 'actor‐network therapy'—combines notions of enactment and enhandedness in the appreciation of 'engrenage' – the intriguing intricacy of locally generated, provisional realities. [ABSTRACT FROM AUTHOR]

Internationally, there has been substantial growth in temporary working, including in the medical profession where temporary doctors are known as locums. There is little research into the implications of temporary work in health care. In this paper, we draw upon theories concerning the sociology of the medical profession to examine the implications of locum working for the medical profession, healthcare organisations and patient safety. We focus particularly on the role of organisations in professional governance and the positioning of locums as peripheral to or outside the organisation, and the influence of intergroup relationships (in this case between permanent and locum doctors) on professional identity. Qualitative semi‐structured interviews were conducted between 2015 and 2017 in England with 79 participants including locum doctors, locum agency staff, and representatives of healthcare organisations who use locums. An abductive approach to analysis combined inductive coding with deductive, theory‐driven interpretation. Our findings suggest that locums were perceived to be inferior to permanently employed doctors in terms of quality, competency and safety and were often stigmatised, marginalised and excluded. The treatment of locums may have negative implications for collegiality, professional identity, group relations, team functioning and the way organisations deploy and treat locums may have important consequences for patient safety. [ABSTRACT FROM AUTHOR]

The social positioning and treatment of persons with dementia reflects dominant biomedical discourses of progressive and inevitable loss of insight, capacity, and personality. Proponents of person-centred care, by contrast, suggest that such loss can be mitigated within environments that preserve rather than undermine personhood. In formal organisational settings, person-centred approaches place particular responsibility on 'empowered' direct-care staff to translate these principles into practice. These staff provide the majority of hands-on care, but with limited training, recognition, or remuneration. Working within a Foucauldian understanding of power, this paper examines the complex ways that dementia care staff engage with their own 'dis/empowerment' in everyday practice. The findings, which are drawn from ethnographic studies of three National Health Service ( NHS) wards and one private care home in England, are presented as a narrative exploration of carers' general experience of powerlessness, their inversion of this marginalised subject positioning, and the related possibilities for action. The paper concludes with a discussion of how Foucault's understanding of power may help define and enhance efforts to empower direct-care staff to provide person-centred care in formal dementia care settings. [ABSTRACT FROM AUTHOR]

Smoking in high‐income countries is now concentrated in poor communities whose relatively high smoking prevalence is explained by greater uptake but above all by lower quit rates. Whilst a number of barriers to smoking cessation have been identified, this is the first paper to situate cessation itself as a classed and cultural practice. Drawing on ethnographic research carried out in a working‐class community in the North of England between 2012 and 2015, I theorise smoking cessation as a symbolic practice in relation to the affective experience of class and social mobility. I show that ambivalence about upward mobility as separation and loss translated into ambivalence about smoking cessation. The reason for this was that the social gradient in smoking operated dynamically at the level of the individual life course, i.e. smoking cessation followed upward mobility. A serious health problem was an appropriate reason to quit but older women continued to smoke despite serious health problems. This was linked to historical gender roles leading to women placing a low priority on their own health as well as the intergenerational reproduction of smoking through close affective links with smoking parents. [ABSTRACT FROM AUTHOR]

This paper is a direct response to Wilkinson's (1996) call for more research into housing insecurity and health. It explores the consequences of mortgage arrears for both the health of indebted home owners and their use of primary health care services. It is based on the results of a secondary analysis of the British Household Panel Survey. It demonstrates that the experience of mortgage indebtedness has an independent effect on the subjective well being of men and women, and that it increases the likelihood that men will visit their general practitioners. The paper draws upon the sociological notions of 'ontological security' and 'individualisation' to make sense of these empirical findings. It suggests that policies which have encouraged the growth of home ownership are premised on the idea of individual responsibility, a notion which underpins other spheres of contemporary welfare policies. Within this context, the consequences of mortgage indebtedness are likely to have profound psychosocial consequences for those who have direct experience of it. The spectre of mortgage debt may also contribute to the insecurity which has come to form a feature of our contemporary social and cultural life. [ABSTRACT FROM AUTHOR]

The National Institute for Health Research (NIHR) aims to improve national 'health and wealth' by providing infrastructural support to enable clinical research in National Health Service settings in England and Wales. Cognisant of the consequences of studies' failure to achieve required numbers of participants, it also actively campaigns to promote patient awareness of research, and willingness to participate in trials. In this paper, we analyse recent NIHR campaigns and policies designed to encourage patients to participate in clinical research to interrogate how they are implicated in the national bioeconomy. In doing so we expand the notion of 'clinical labour' to include the work of patient recruitment and highlight an emergent obligation on patients to contribute to research processes. Whereas once patient knowledge and experience may have been devalued, here we draw on the concept of 'assetisation' (Birch 2012) to explore the emergent relationship between healthcare system and patient as research participant. We consider how patients' contribution goes beyond the provision of standardised objects of valuation so that patients themselves may be perceived as assets to, not only recipients of, the national healthcare system. [ABSTRACT FROM AUTHOR]

In this paper, we examine how space is integral to the practices and politics of restructuring health and care systems and services and specifically how ideas of assemblage can help understand the remaking of a region. We illustrate our arguments by focusing on health and social care devolution in Greater Manchester, England. Emphasising the open‐ended political construction of the region, we consider the work of assembling different actors, organisations, policies and resources into a new territorial formation that provisionally holds together without becoming a fixed totality. We highlight how the governing of health and care is shaped through the interplay of local, regional and national actors and organisations coexisting, jostling and forging uneasy alliances. Our goal is to show that national agendas continued to be firmly embedded within the regional project, not least the politics of austerity. Yet through keeping the region together as if it was an integrated whole and by drawing upon new global policy networks, regional actors strategically reworked national agendas in attempts to leverage and compete for new resources and powers. We set out a research agenda that foregrounds how the political reorganisation of health and care is negotiated and contested across multiple spatial dimensions simultaneously. [ABSTRACT FROM AUTHOR]

Food insecurity in the UK is a pressing concern that is associated with poor health outcomes. Research to date has focused on the challenges for adults in providing food for families. However, there is little evidence showing how children and young people experience food insecurity, particularly outside of the home and school. This paper, drawing on 14 months of ethnography in a youth club in the North of England, explores how young people manage food insecurity. In this youth club, the circulation of takeaway food is part of an informal network where boys purchase, share and receive food. This practice allows the boys to participate meaningfully within their peer groups whilst also providing stable access to food. This peer practice, however, was not available to everyone. This was a gendered practice that for the girls held little benefit due to their concerns about eating and pressure to provide for others. Instead, some girls depend on romantic relationships for food provision that is equated with affection and care. The findings will be discussed through a 'materialities of care' perspective to explore the complex ways in which food as a practice of care is part of everyday routines embedded within local places. [ABSTRACT FROM AUTHOR]

Violence against doctors provides an illuminating context for studying medicalisation and its limits in the management of deviance. The paper examines the emergence of such violence as a policy issue in England, with particular reference to general practitioners (GPs) in the National Health Service. Recent guidance exhorts doctors to exercise ‘zero tolerance’ with respect to acts of violence. The emphasis is on risk management and protecting victims rather than on resolving the perpetrators’ problems. The paper argues that this policy frame is consistent with recent claims from criminologists that there is a new ‘turn’ in penal policy, away from rehabilitation and addressing the needs of individual offenders. However, responses of individual GPs, obtained through a postal questionnaire sent to c.1000 GPs and in–depth interviews with a sub–sample, suggest that doctors are not ‘zero tolerant’ in responding to attacks. But nor are they medical imperialists seeking to include all perpetrators within their professional jurisdiction. Rather, they exercise professional discretion about behaviours which often fall into a ‘grey area’ between ‘illness’ and ‘crime’, and about individuals who are not clearly categorisable as either ‘sick’ or ‘bad’. [ABSTRACT FROM AUTHOR]

This study reports research on the experiences of stroke survivors and their informal carers who are receiving stroke services in the community. As part of a qualitative evaluation of a Pilot Community Stroke Service in Nottingham, England, interviews were conducted with stroke survivors, their families and friends, alongside interviews with the managers and professionals providing the service. The findings from the interview data were compared across cases and with findings from analyses of documentary data such as clients' individual plans, and participant observational data, such as those of team meetings. Data analysis revealed that of the 57 survivors, 13 had suffered setbacks that were a direct consequence of their interactions with health and social care services and were system induced. This paper introduces and discusses the concept of the system induced setback by exploring the experiences of these 13 survivors. Implications for understanding the interplay of service provision and disease process are highlighted. [ABSTRACT FROM AUTHOR]

Given the difficulties of implementing 'top-down' quality improvements, health service leaders have turned to methods that empower clinicians to co-produce 'bottom-up' improvements. This has involved the adoption of strategies and activities associated with social movements, with clinicians encouraged to participate in collective action towards the shared goal of improvement. This paper examines the adoption of social movement methods by hospital managers as a strategy for implementing a quality improvement 'campaign'. Our case study suggests that, despite the claim of empowering clinicians to develop 'bottom-up' improvements, the use of social movement methods can be more narrowly concerned with engaging clinicians in pre-determined programmes of 'top-down' change. It finds a prominent role for 'hybrid' clinical leaders and other staff representatives in the mobilisation of the campaign, especially for enrolling clinicians in change activities. The work of these 'hybrids' suggests some degree of creative mediation between clinical and managerial interests, but more often alignment with the aspirations of management. The study raises questions about the translation of social movement's theories as a strategy for managing change and re-inventing professionalism. [ABSTRACT FROM AUTHOR]

The article analyses the decision-making process between doctors and parents of babies in neonatal intensive care. In particular, it focuses on cases in which the decision concerns the redirection of care from full intensive care to palliative care at the end of life. Thirty one families were recruited from a neonatal intensive care unit in England and their formal interactions with the doctor recorded. The conversations were transcribed and analysed using conversation analysis. Analysis focused on sequences in which decisions about the redirection of care were initiated and progressed. Two distinct communicative approaches to decision-making were used by doctors: 'making recommendations' and 'providing options'. Different trajectories for parental involvement in decision-making were afforded by each design, as well as differences in terms of the alignments, or conflicts, between doctors and parents. 'Making recommendations' led to misalignment and reduced opportunities for questions and collaboration; 'providing options' led to an aligned approach with opportunities for questions and fuller participation in the decision-making process. The findings are discussed in the context of clinical uncertainty, moral responsibility and the implications for medical communication training and guidance. A Virtual Abstract of this paper can be accessed at: [ABSTRACT FROM AUTHOR]

The pharmaceuticalisation of sleep is a contentious issue. Sleep medicines get a 'bad press' due to their potential for dependence and other side effects, including studies reporting increased mortality risks for long-term users. Yet relatively little qualitative social science research has been conducted into how people understand and negotiate their use/non-use of sleep medicines in the context of their everyday lives. This paper draws on focus group data collected in the UK to elicit collective views on and experiences of prescription hypnotics across different social contexts. Respondents, we show, drew on a range of moral repertoires which allowed them to present themselves and their relationships with hypnotics in different ways. Six distinct repertoires about hypnotic use are identified in this regard: the 'deserving' patient, the 'responsible' user, the 'compliant' patient, the 'addict', the 'sinful' user and the 'noble' non user. These users and non-users are constructed drawing on cross-cutting themes of addiction and control, ambivalence and reflexivity. Such issues are in turn discussed in relation to recent sociological debates on the pharmaceuticalisation/de-pharmaceuticalisation of everyday life and the consumption of medicines in the UK today. [ABSTRACT FROM AUTHOR]

Hypertension is a common condition which disproportionately affects African Caribbean people in England, yet this experience is rarely reported in the literature. Whilst a body of literature exists that explores chronic illness experience, little attention is paid to hypertension, nor to ethnicity as a mediating concept in chronic illness experience. This paper explores the meaning and consequences of hypertension for African Caribbean people residing in England. The study conducted was a qualitative study, informed by the ethnographic tradition. The study methods included the conduct of two focus group interviews (10 participants), 21 in-depth interviews and five vignette interviews. Thirty-six people in total participated in the study, both men and women, aged between 37 and 82 years (median age = 59.5 years) in two English cities. The sample was generated by contacting GP surgeries, community groups and associations and included economically active and retired people. The narrative accounts provided illuminate the personal biographies of the mid-life and older participants in the study, providing evidence as to how issues such as ethnicity, migration, cultural adaptation, racism and discrimination may impact upon the chronic illness experience. Participants’ understandings of their self-defined condition of high blood pressure differed greatly from medical conceptualisations of the condition of hypertension. The implications of the study are that in order to provide effective health and social care for individuals of African Caribbean origin with hypertension, care-providers require insight into how migration and cultural adaptation may create major disruption to an individual's life trajectory, to which the subsequent diagnoses of chronic illness are relative in terms of the individual's response and adaptation. [ABSTRACT FROM AUTHOR]

This paper addresses how London gay men use the internet to meet sexual partners, or for e-dating. Based on qualitative interviews conducted face-to-face or via the internet, this research develops an account of how information technologies mediate the negotiation of identity and risk in connection with sexual practice. E-dating itself is a bricolage, or heterogeneous DIY practice of internet-based-communication (IBC). A central aspect of IBC is 'filtering' in and out prospective e-dates based on the images and texts used to depict sexual identities. Interpretations and depictions of personal HIV risk management approaches in IBC are framed by the meanings of different identities, such as the stigma associated with being HIV positive. This paper argues for a sexualities perspective in a theory of network society. Further, HIV prevention in e-dating can potentially be addressed by considering the interplay of the HIV prevention imperatives associated with different HIV serostatus identities. There is a case for encouraging more explicit IBC about risk in e-dating and incorporating the expertise of e-daters in prevention activity. There is also a need to rethink traditional conceptions of risk management in HIV prevention to make space for the risk management bricolage of network society. [ABSTRACT FROM AUTHOR]

This paper draws on research exploring lay men's and community health professionals’ attitudes towards ‘masculinity’ and ‘preventative health care’ conducted in the northwest of England. It is specifically concerned with the findings from the men's narratives that relate to male embodiment and the relevance of this to health and wellbeing. Whilst there is a burgeoning interest in the ‘sociology of the body’ it is only relatively recently that debates about embodiment have been supported by empirical research. Empirical work on male embodiment remains minimal and even less work has been done in considering the links between masculinity, embodiment and health. A series of focus groups and interviews were conducted with men that captured narratives about the lived (male) body in everyday life and its relation to health. These data allowed for greater insight into Watson's (2000 ) previous empirical work on the ‘male body schema’. Current findings presented here suggest that male bodies need to be considered as both material and representational, and that these two modes are not distinct but continually interact, with each other and with men's conceptualisations of health, to influence health practices and wider social interactions that impact on health and wellbeing. [ABSTRACT FROM AUTHOR]

Abstract In many countries governments are recruiting the medical profession into a more active, transparent regulation of clinical practice. Consequently the medical profession adapts the ways it regulates itself and its relationship to health system managers changes. This paper uses empirical research in English Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) to assess the value of Courpasson's concept of soft bureaucracy as a conceptualisation of these changes. Clinical governance in PCGs and PCTs displays important parallels with governance in soft bureaucracies, but the concept of soft bureaucracy requires modification to make it more applicable to general practice. In English primary care, governance over rank-and-file doctors is exercised by local professional leaders rather than general managers, harnessing their colleagues’ perception of threats to professional autonomy and self-regulation rather than fears of competition as the means of ‘soft coercion’. [ABSTRACT FROM AUTHOR]

Clinical autonomy has long been seen as conceptually central to the analysis of the occupational status of the medical profession, though the implications for this of recent developments in health care managerialism have been disputed by theorists. In particular, the question has arisen as to whether ‘restratification’, that is, the active involvement of physicians in this process, should be construed as medical élites exerting control over the rank and file in order to protect the profession as a whole, or as an incursion from outside it. This paper uses interview data from 49 general medical practitioners in Northern England. It investigates their perceptions of how current government policies, and the new institutions and governance arrangements that they have created impact on physicians’ ability to set their own limits and to judge their own work. We found a clear acceptance by GPs of the need to discharge ‘bureaucratic accountability’, in particular to maintain records of their clinical decisions. This provides the possibility of external surveillance of medical work, and thus implies a clear reduction in autonomy over the content of medical work on the part of rank-and-file GPs, who may regret this situation but offer little resistance to it. Our findings illustrate a form of restratification; the most frequently reported immediate source of pressure to modify casenote recording was the Primary Care Group (PCG), an organisation constitutionally dominated by physicians acting in a managerial capacity. Nevertheless, the agendas of PCGs are largely driven by central government and our study thus provides further evidence of the intermediary or contingent (rather than independent) character of professional autonomy. [ABSTRACT FROM AUTHOR]

This paper is based on a 10-month participant observation study within an inpatient hospice in Southern England. I highlight the difficulties of using homogenous categories such as `the dying patient' and `the dying process' in exploring the marginalisation of patients within the physical space of contemporary hospices and similar institutions. In opposition to such categories, my findings indicate the importance of focusing upon the body of the patient, and the disease processes taking place within it and upon its surfaces, in understanding why some patients are now sequestered within hospices whereas others are not. I argue that a significant proportion of patients are admitted to hospices because of the way in which their disease spread and subsequent deterioration affects the boundedness of their bodies and undermines their identities as persons. I suggest that conceptualising a hospice as a `no place' - i. e. a space within which the taboo processes of bodily deformation and decay are sequestered - allows it to be understood as a central part of contemporary Western culture. Setting the disintegrating body apart from mainstream society, as hospices appear to do, enables certain ideas about `living', personhood and the hygienic, sanitised, bounded body to be symbolically enforced and maintained. [ABSTRACT FROM AUTHOR]

Using the implementation of the Griffiths Report as an example, this paper examines the way in which sociologists and others have examined the process of managing change within the NHS. Several studies of Griffiths have documented a number of unintended consequences of its implementation but it is argued that none of these have adequately theorised these unintended outcomes of the policy implementation process. It is suggested that the process-sociological approach of Norbert Elias, and in particular his game models, enable us better to understand the complex interweaving of planned and unplanned processes which is involved in all processes of managed change. [ABSTRACT FROM AUTHOR]

Healthcare staff are encouraged to use feedback from their patients to inform service and quality improvement. Receiving patient feedback via online channels is a relatively new phenomenon that has rarely been conceptualised. Further, the implications of a wide, varied and unknown(able) audience being able to view and interact with online patient feedback are yet to be understood. We applied a theoretical lens of dramaturgy to a large ethnographic dataset, collected across three NHS Trusts during 2019/2020. We found that organisations demonstrated varying levels of 'preparedness to perform' online, from invisibility through to engaging in public conversation with patients within a wider mission for transparency. Restrictive 'cast lists' of staff able to respond to patients was the hallmark of one organisation, whereas another devolved responding responsibility amongst a wide array of multidisciplinary staff. The visibility of patient‐staff interactions had the potential to be culturally disruptive, dichotomously invoking either apprehensions of reputational threat or providing windows of opportunity. We surmise that a transparent and conversational feedback response frontstage aligns with the ability to better prioritise backstage improvement. Legitimising the autonomous frontstage activity of diverse staff groups may help shift organisational culture, and gradually ripple outwards a shared responsibility for transparent improvement. [ABSTRACT FROM AUTHOR]

This study explores how pharmacists legitimise the expansion of their clinical work and considers its impact on pharmacists' professional identity work. In the context of pharmacy in the English NHS, there has been an ongoing policy shift towards pharmacists moving away from 'medicines supply' to patient‐facing, clinical work since the 1950s. Pharmacists are continuously engaging in 'identity work' and 'boundary work' to reflect the expansion of their work, which has led to the argument that pharmacists lack a clear professional identity. Drawing insights from linguistics and specifically Van Leeuwen's 'grammar of legitimation', this study explains how the Pharmacy Integration Fund, a nationally funded learning programme, provides the discursive strategies for pharmacists to legitimise their identity work as clinicians. [ABSTRACT FROM AUTHOR]

Link worker social prescribing has become a prominent part of NHS England's personalisation agenda. However, approaches to social prescribing vary, with multiple discourses emerging about the potential of social prescribing and different interpretations of personalisation. The transformational promise of social prescribing is the subject of ongoing debate, whilst the factors that shape the nature of front‐line link working practices remain unclear. Based on 11 months of in‐depth ethnographic research with link workers delivering social prescribing, we show how link workers' practices were shaped by the context of the intervention and how individual link workers navigated varied understandings of social prescribing. Following the work of Mol, we show how link workers drew differentially on the interacting logics of choice and care and trace a multiplicity in front‐line link working practices within a single intervention. However, over time, it appeared that a logic of choice was becoming increasingly dominant, making it harder to deliver practices that aligned with a logic of care. We conclude that interpreting personalisation through a logic of choice could potentially undermine link working practices that privilege care whilst obscuring the need for wider investment in health care systems and the social determinants of health. [ABSTRACT FROM AUTHOR]

The cost of social care, the work conditions experienced by care workers and the quality of care provided by residential homes for older people are all linked, yet we know very little about how this relationship works in practice. Drawing upon an ethnography of two differently priced residential care homes for older people in Southern England, I examine the implications of different financial regimes for care‐giving practices. I show how the scheduling and allocation of resources—conveyed, for example, in formal routines and staffing levels—structure the care workers' time, tasks and activities in each setting. This acts to symbolically demarcate what, or who, is valued. I argue that the availability of resources facilitates and impedes the symbolic culture of care work, shapes care workers' ability to afford dignity to the individuals in their care and affects how care workers experience, and relate to, their labour. I conclude by discussing how current practices of funding and pricing social care have effects seeping beyond the practical and measurable, and into the realm of the symbolic. [ABSTRACT FROM AUTHOR]

The Liverpool Care Pathway for the Dying Patient (LCP) was a prominent set of guidance in the late 2000s and early 2010s within palliative and end‐of‐life care. Developed in England to improve the care of dying patients, it was later adopted in 20 counties. After a public scandal, it was removed from practice in England but remains in other locations, including the Netherlands. Drawing on two sets of ethnographic data, from England and the Netherlands, we consider the ways in which the LCP was engaged with as a form of standardisation aimed at improving practice, how it was deployed in relation to other forms of knowledge, and the political and moral statements that are being made through the (selective) use of it. Looking into the use of the LCP shows that, while the LCP attempts to standardise some of the values associated with palliative care, there are significant differences between how these standardised values are then enacted in different institutional and national contexts and by different individual care professionals. We conclude that the LCP was used to impart moral values, establish protocols of care, and demonstrate professionalism, showing the multiplicity of the use of standards in healthcare practice. [ABSTRACT FROM AUTHOR]

While the growth in usage and practice of varying forms of complementary and alternative medicine (CAM) continues apace, social science has increasingly turned to CAM's often individualistic approach to health and illness. CAM has been perceived as both partly a cause of and a response to the well-documented ideology in modern healthcare of ‘individual responsibility for health’. This occasionally manifests in a ‘victim-blaming’ ideology amongst both orthodox and CAM practitioners alike. These issues emerged as key themes in an ethnographic study of a Centre for spiritual healing in the North of England. By drawing upon a range of qualitative data gained through the researcher's participation at this healing centre, I argue that the healers’ focus on individual responsibility for health is not so much a part of the current socio-political health ideology of ‘victim-blaming’, rather, it is illustrative of an important contemporary social phenomenon: the movement towards the subjectification and personalisation of public life. [ABSTRACT FROM AUTHOR]

Mothers' alcohol consumption has often been portrayed as problematic: firstly, because of the effects of alcohol on the foetus, and secondly, because of the association between motherhood and morality. Refracted through the disciplinary lens of public health, mothers' alcohol consumption has been the target of numerous messages and discourses designed to monitor and regulate women's bodies and reproductive health. This study explores how mothers negotiated this dilemmatic terrain, drawing on accounts of drinking practices of women in paid work in the early parenting period living in Northern England in 2017–2018. Almost all of the participants reported alcohol abstention during pregnancy and the postpartum period and referred to low‐risk drinking practices. A feature of their accounts was appearing knowledgeable and familiar with public health messages, with participants often deploying 'othering', and linguistic expressions seen in public health advice. Here, we conceptualise these as Assumed Shared Alcohol Narratives (ASANs). ASANs, we argue, allowed participants to present themselves as morally legitimate parents and drinkers, with a strong awareness of risk discourses which protected the self from potential attacks of irresponsible behaviour. As such, these narratives can be viewed as neoliberal narratives, contributing to the shaping of highly responsible and self‐regulating subjectivities. [ABSTRACT FROM AUTHOR]

Breastfeeding is recognised globally as the optimal method of infant feeding. For Murphy (1999) its nutritional superiority positions breastfeeding as a moral imperative where mothers who formula‐feed are open to charges of maternal deviance and must account for their behaviour. We suggest that this moral superiority of breastfeeding is tenuous for mothers from marginalised contexts and competes with discourses which locate breastfeeding, rather than formula feeding, as maternal deviance. We draw on focus group and interview data from 27 adolescent mothers from socio‐economically deprived neighbourhoods in three areas of the UK, and five early years professionals working at a Children's Centre in the Northeast of England. We argue that breastfeeding is constructed as deviance at three 'levels' as (i) a deviation from broad social norms about women's bodies, (ii) a deviation from local mothering behaviours and (iii) a transgression within micro‐level interpersonal and familial relationships. Given this positioning of breastfeeding as deviant, breastfeeding mothers feel obliged to account for their deviance. In making this argument, we extend and rework Murphy's (1999) framework to encompass diverse experiences of infant feeding. We conclude with reflections on future research directions and potential implications for practice. [ABSTRACT FROM AUTHOR]

Ideas about disease risk underpin many preventive health strategies. These have assumed even greater importance in recent years as health policies place a growing emphasis on personal responsibility. This is reflected in new national contracts for National Health Service (NHS) dentistry that emphasise informing patients on their oral health risk status to persuade them to be accountable for their health. Thus, 'risk' is now central to the practice of dentistry, particularly primary care delivery. An ethnographic study in dental practices in England looked at how risk is acted on in dental settings. 368 dental appointments were observed in five dental practices over a year. The analysis shows three interrelating forms of risk work. Dentists position risk work as administrative to gain consent, translate risk through temporality to encourage action, whilst protecting rapport and their professional reputation through interactional risk work. This qualitative study demonstrates that the everyday nature of risk work in NHS dental practices is often implicit, defensive and focused on social interaction rather than the explicit discussions of individual lifestyle risks that policymakers assume. The study contributes to the literature on 'risk work' by illustrating how health professionals use risk to manage situationally sensitive contexts. [ABSTRACT FROM AUTHOR]

Patient‐centred care has become the touchstone of healthcare policy in developed healthcare systems. The ensuing commodification of patients' experiences has resulted in a mass of data but little sense of whether and how such data are used. We sought to understand how front‐line staff use patient experience data for quality improvement in the National Health Service (NHS). We conducted a 12‐month ethnographic case study evaluation of improvement projects in six NHS hospitals in England in 2016–2017. Drawing on the sociology of everyday life, we show how front‐line staff worked with a notion of data as interpersonal and embodied. In addition to consulting organisationally sanctioned forms of data, staff used their own embodied interactions with patients, carers, other staff and the ward environment to shape improvements. The data staff found useful involved face‐to‐face interaction and dialogue; were visual, emotive, and allowed for immediate action. We draw on de Certeau to re‐conceptualise this as 'wild data'. We conclude that patient experience data are relational, and have material, social and affective dimensions, which have been elided in the literature to date. Practice‐based theories of the everyday help to envision 'patient experience' not as a disembodied tool of managerialism but as an embedded part of healthcare staff professionalism. [ABSTRACT FROM AUTHOR]

Narratives of self‐responsibility are pervasive in neoliberally oriented contexts, and have been found to engender feelings of shame and failure amongst those affected by poverty. Here, we use findings from research in two low‐income communities in south‐west England to examine how these narratives become embodied within people's daily lives when they intersect with systems of welfare support and the current political drive to upscale treatment for common mental health conditions. Drawing on Bourdieu's notion of symbolic violence, we examine how narratives of self‐responsibility and associated welfare reform strategies impact on the mental health of people living in economic hardship. The data show how such narratives inflict, sustain and exacerbate mental distress and suffering, and how they become naturalised and normalised by individuals themselves. We demonstrate how this situation pushes people to seek support from General Practitioners, and how clinical interactions can normalise, and in turn, medicalise, poverty‐related distress. Whilst some people actively resist dominant narratives around self‐responsibility, we argue that this is insufficient under broader sociocultural and political circumstances, to free themselves from the harms perpetuated by symbolic violence. [ABSTRACT FROM AUTHOR]

Over the last quarter century, non‐medical prescribing in the UK has grown significantly; eight non‐medical professional groups now have authority to prescribe a wide range of medicines, suggesting it could be a potent driver of pharmaceuticalisation. In this article, we present data from a case study of physiotherapists' prescribing practices. UK physiotherapists have had legal rights to prescribe medicines since 2005, but relatively little is known about the contribution they make to expanding patient access to medicines. We approached our study through a lens of governmentality to capture the mentalities and micro‐practices governing physiotherapist non‐medical prescribing. Ethnographic methods were used to gather data from an outpatient orthopaedic service in an NHS Trust in England employing physiotherapist prescribers. From the data, we identified a grid of intelligibility – an organising framework formulated by powerful discourses and technologies of government through which physiotherapist prescribing was acted into being. A primary effect of this grid was the constitution of new physiotherapist subjectivities, mostly as non‐prescribers of medicines contrary to policy intentions, underpinned by a familiar and enduring template of medical professionalism. [ABSTRACT FROM AUTHOR]

Adopting a critical realist perspective, this article examines the emergence of a relatively new non‐professional healthcare role, the assistant practitioner (AP). The role is presented as a malleable construct cascading through and sensitive to structure–agency interaction at different levels of NHS England: the sector, organisation and department. At the core of the analysis is the permissiveness of structures established at the respective levels of the NHS, facilitating or restricting agency as the role progresses through the healthcare system. A permissive regulatory framework at the sector level is reflected in the different choices made by two case study NHS acute hospital trusts, in their engagement with the AP role. These different choices have consequences for how the AP impacts at the departmental level. [ABSTRACT FROM AUTHOR]

We draw on findings from qualitative interviews with health data researchers, GPs and citizens who opted out from NHS England's care.data programme to explore controversies and negotiations around data sharing in the NHS. Drawing on theoretical perspectives from science and technology studies, we show that the new socio‐technical, ethical and economic arrangements were resisted not only on the basis of individual autonomy and protection from exploitation, but also as a collective effort to protect NHS services and patient data. We argue that the resulting opt‐outs were a call for more personal control over data use. This was not because these citizens placed their personal interests above those of society. It was because they resisted proposed arrangements by networks of stakeholders, not seen as legitimate, to control flows and benefits of NHS patient data. Approaching informed consent this way helps us to explore resistance as a collective action for influencing the direction of such big data programmes towards the preservation of public access to healthcare as well as the distribution of ethical decision‐making between independent, trustworthy institutions and individual citizens. [ABSTRACT FROM AUTHOR]

Informed by a discourse analysis, this article examines the framing of equity within the UK's digital health policies between 2010 and 2017, focusing on England's development of NHS Digital and its situation within the UK Government's wider digital strategy. Analysis of significant policy documents reveals three interrelated discourses that are engaged within England's digital health policies: equity as a neoliberal imaginary of digital efficiency and empowerment; digital health as a pathway towards democratising health care through data‐sharing, co‐creation and collaboration; and finally, digital health as a route towards extending citizen autonomy through their access to data systems. It advances knowledge of the relationship between digital health policy and health inequalities. Revealing that while inclusion remains a priority area for policymakers, equity is being constituted in ways that reflect broader discourses of neoliberalism, empowerment and the turn to the market for technological solutionism, which may potentially exacerbate health inequalities. [ABSTRACT FROM AUTHOR]

Although sociological studies of quality and safety have identified competing epistemologies in the attempt to measure and improve care, there are gaps in our understanding of how finance and accounting practices are being used to organise this field. This analysis draws on what others have elsewhere called 'financialisation' in order to explore the quantification of qualitatively complex care practices. We make our argument using ethnographic data of a quality improvement programme for acute kidney injury (AKI) in a publicly funded hospital in England. Our study is thus concerned with tracing the effects of financialisation in the emergence and assembly of AKI as an object of concern within the hospital. We describe three linked mechanisms through which this occurs: (1) representing and intervening in kidney care; (2) making caring practices count and (3) decision‐making using kidney numbers. Together these stages transform care practices first into risks and then from risks into costs. We argue that this calculative process reinforces a separation between practice and organisational decision‐making made on the basis of numbers. This elevates the status of numbers while diminishing the work of practitioners and managers. We conclude by signalling possible future avenues of research that can take up these processes. [ABSTRACT FROM AUTHOR]

Abstract: This article examines the articulation and enactment of racialised classifications in clinical practice guidelines and in accounts of clinical practice. It contributes to debates about racialisation in medicine and its consequences. The research centred on the case study of prescribing guidelines for hypertension in England and Wales, drawing on documentary sources and semi‐structured expert interviews. We found that conceptual and socio‐political uncertainties existed about how to interpret the designation ‘Black patients’ and about the practices for identifying patients’ race/ethnicity. To ‘close’ uncertainties, and thus produce the guidelines and treat patients, respondents drew authority from disparate elements of the ‘topologies of race’. This has implications for understanding processes of racialisation and for the future use of racialised clinical practice guidelines. We argue that clinical practice guidelines play a ‘nodal’ role in racialisation by forming an authoritative material connection that creates a path for translating racialised research into racialised healthcare practice, and that they carry with them implicit conceptual and socio‐political uncertainties that are liable to create inconsistencies in healthcare practice. [ABSTRACT FROM AUTHOR]

Abstract: Patient and public involvement in health research and care has been repeatedly theorised using the metaphor of spaces, knowledge spaces and participatory citizenship spaces. Drawing on data from a three year qualitative study of people involved in health research with organisations across England, this article explores where these spaces fit in a wider social, political and historical landscape. It outlines a theme recurring frequently in the study data: a unified public/patient/service‐user perspective in opposition to a professional/clinical/academic view. This is discussed in relation to Habermas's division between the lifeworld and system. Patient and public involvement is mapped as spaces between these spheres, therefore between the social norms pertaining to them. In this way, involvement spaces are seen as liminal, in‐between or threshold spaces; this concept provides us with new insights on both the opportunities and the conflicts that are integral in the ambiguous, complex interactions which take place in these spaces. [ABSTRACT FROM AUTHOR]

For older people with multiple chronic co-morbidities, strategies to coordinate care depend heavily on information exchange. We analyse the information-sharing difficulties arising from differences between patients' oral narratives and medical sense-making; and whether a modified form of 'narrative medicine' might mitigate them. We systematically compared 66 general practice patients' own narratives of their health problems and care with the contents of their clinical records. Data were collected in England during 2012-13. Patients' narratives differed from the accounts in their medical record, especially the summary, regarding mobility, falls, mental health, physical frailty and its consequences for accessing care. Parts of patients' viewpoints were never formally encoded, parts were lost when clinicians de-coded it, parts supplemented, and sometimes the whole narrative was re-framed. These discrepancies appeared to restrict the patient record's utility even for GPs for the purposes of risk stratification, case management, knowing what other care-givers were doing, and coordinating care. The findings suggest combining the encoding/decoding theory of communication with inter-subjectivity and intentionality theories as sequential, complementary elements of an explanation of how patients communicate with clinicians. A revised form of narrative medicine might mitigate the discursive gap and its consequences for care coordination. [ABSTRACT FROM AUTHOR]

Drinking is viewed by young people as a predominantly social activity which provides an opportunity for entertainment and bonding with friends. Using Bourdieu's concepts of habitus, field and capital, this article explores young people's attitudes and beliefs around alcohol use, influences on behaviour, and the role of peers, with a view to informing the development of preventive interventions. Semi-structured interviews were conducted with 28 young people aged 18-20 in the south west of England. We describe how friends were integral in drinking experiences, and drinking with friends was equated with fun and enjoyment. In this way, the desire for social and symbolic capital appeared to be a key motivator for adolescent drinking. Critically, however, wider cultural norms played the predominant role in shaping behaviour, via the internalisation of widely accepted practice and the subsequent externalisation of norms through the habitus. Applying Bourdieu's theory suggests that population-level interventions that regulate alcohol consumption, and thus disrupt the field, are likely to facilitate behaviour change among young people by driving a response in habitus. [ABSTRACT FROM AUTHOR]

Patient and public involvement has become an integral aspect of many developed health systems and is judged to be an essential driver for reform. However, little attention has been paid to the distinctions between patients and the public, and the views of patients are often seen to encompass those of the general public. Using an ideal-type approach, we analyse crucial distinctions between patient involvement and public involvement using examples from Sweden and England. We highlight that patients have sectional interests as health service users in contrast to citizens who engage as a public policy agent reflecting societal interests. Patients draw on experiential knowledge and focus on output legitimacy and performance accountability, aim at typical representativeness, and a direct responsiveness to individual needs and preferences. In contrast, the public contributes with collective perspectives generated from diversity, centres on input legitimacy achieved through statistical representativeness, democratic accountability and indirect responsiveness to general citizen preferences. Thus, using patients as proxies for the public fails to achieve intended goals and benefits of involvement. We conclude that understanding and measuring the impact of patient and public involvement can only develop with the application of a clearer comprehension of the differences. [ABSTRACT FROM AUTHOR]

The limited existing research on diabetes management and intellectual disabilities ( ID) highlights the need for further exploration of the concept of responsibility. This study explored repertoires of responsibility in accounts of managing diabetes for adults with ID. Fourteen semi-structured interviews were conducted in the UK with seven adults with mild/moderate ID and type 1 or 2 diabetes and seven people who they nominated as supporting their diabetes management. A discursive psychological analysis found that interpretative repertoires relating to competence, independence and accountability were drawn on to construct multiple and sometimes conflicting versions of responsibility. Within these repertoires people with ID were positioned in conflicting ways; as competent, personally responsible, and entitled to independence and choice, but as also lacking competence, dependent on others and incapable of overall accountability. People with ID often took up empowering positions defending against an incompetent identity. Supporters built accounts which negotiated dilemmatic repertoires on the dual responsibilities of empowering adults with ID to self-manage and managing risk to support good and safe care. The implications of available discursive resources and the ways in which they are mobilised are considered. [ABSTRACT FROM AUTHOR]