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The article discusses information about the 27th Sociology of Health and Illness Monograph. Topics covered include the emergence of the construct of overdiagnosis, the impact of diagnostic, prognostic, and treatment uncertainty on the lay-professional interface, and organisational and health system level responses to uncertainty.

An introduction is presented in which the editor discusses articles in the issue on topics including relationships between power, space and dominant discourses; importance of structural dimensions of power between professionals and patients; and role of environment in healthcare services.

This paper intervenes in the dichotomous debate on the 'privatisation' of the UK's National Health Service (NHS). Whilst research suggests that involving private‐sector actors and principles deviates from the founding aims of the NHS to deliver equitable healthcare for all, the opposing argument to 'keep our NHS public' also limits understanding and alternative possibilities. Through focusing on maintaining overarching structures, these campaigns fail to address everyday medical practices that have long been critiqued by those allied with the sociology of health and illness. This paper draws on feminist critiques of public/private to expand the structural economic lens of mainstream political debates and explore how multiple forms of economic, social, cultural, and symbolic capital, operate in everyday healthcare practices. Through an historically‐informed ethnographic exploration of routine hip replacements, I find that capital itself emerges through relations between people and things, and that public/private boundaries play an integral role in forming these relations to instil value on particular patients and forms of labour, demarcating what kind of healthcare is given to whom. I therefore suggest future action should focus on assembling healthcare relations beyond the dualism of public/private categories, to create multiple safe places and relations for all. [ABSTRACT FROM AUTHOR]

In this collection we revisit the enduring phenomenon of uncertainty in health care, and demonstrate how it still offers coherence and significance as an analytic concept. Through empirical studies of contemporary examples of health care related uncertainties and their management, our collection explores the different ways in which uncertainty may be articulated, enacted and experienced. The papers address a diverse range of healthcare contexts ‐ Alzheimer's disease, neonatal surgery, cardiovascular disease prevention, cancer, addiction (use of alcohol and other drugs during pregnancy), mental health/disorders and medical education – and many tackle issues of contemporary relevance, such as an ageing population, and novel medical interventions and their sequelae. These empirical papers are complemented by a further theoretical contribution, which considers the role of 'implicit normativity' in masking and containing potential ethical uncertainty. By mapping themes across the collection, in this introduction we present a number of core analytical strands: (1) conceptualising uncertainty; (2) intersections of uncertainty with aspects of care; (3) managing uncertainty; and (4) structural constraints, economic austerity and uncertainty work. We reflect on the methodological and theoretical stances used to think sociologically about uncertainty in health care, and the strengths, silences and gaps we observe in the collection. We conclude by considering the implications of the insights gained for 'synthesising certainty' in practice and for future research in this area. [ABSTRACT FROM AUTHOR]

One of the most significant developments in healthcare over the past 25 years has been the widespread deployment of information and communication technologies. These technologies have had a wide–ranging impact on the organisation of healthcare, on professional practice and on patients’ experience of illness and its management. In this paper we discuss the ways in which Sociology of Health and Illness has provided a forum for the analysis of these new technologies in healthcare. We review a range of relevant research published in the Journal; papers that address such issues as dehumanisation and emotional labour, professional practice and identity, and the social and institutional shaping of technology. Despite these important initiatives, we suggest that information and communication technologies in healthcare remain relatively under–explored within the Journal and, more generally, by the sociology of health and illness and point to developments in cognate areas which may have some bearing upon the analysis of technology in action. [ABSTRACT FROM AUTHOR]

Modern health‐care systems have customarily approached hepatitis C in ways that resemble the public health approach to HIV/AIDS known as 'HIV exceptionalism'. HIV exceptionalism describes the unusual emphasis on privacy, confidentiality and consent in approaches to HIV and was partly developed to address HIV/AIDS‐related stigma. In the case of hepatitis C, exceptionalist approaches have included diagnosis and treatment by specialist physicians and other 'boutique' public health strategies. The recent availability of highly effective, direct‐acting antivirals alongside goals to eliminate hepatitis C have heralded dramatic changes to hepatitis C health care, including calls for its 'normalisation'. The corollary to exceptionalism, normalisation aims to bring hepatitis C into routine, mainstream health care. This article draws on interviews with stakeholders (n = 30) who work with hepatitis C‐affected communities in policy, community, legal and advocacy settings in Australia, alongside Fraser et al.'s (2017, International Journal of Drug Policy, 44, 192–201) theorisation of stigma, and Rosenbrock et al.'s (1999, The AIDS policy cycle in Western Europe: from exceptionalism to normalisation. WZB Discussion Paper, No. P 99‐202) critique of normalisation to consider the perceived effects of hepatitis C normalisation. Stakeholders described normalisation as a stigma‐reducing process. However, they also expressed concerns about the ongoing stigma and discrimination that is not ameliorated by normalisation. We suggest that in centring normalisation, changes in health care may exaggerate the power of technological solutions to transform the meanings of hepatitis C. [ABSTRACT FROM AUTHOR]

Doctors are typically portrayed as active agents in their work lives. However, this paper argues that this construction of agency ignores the effects of the healthcare structures that constrain choice, which in turn affects population health outcomes. Medical training pathways, regional boundaries, and rationalisation all have a long‐lasting impact on the provision of healthcare. Using a mobilities lens to examine the movement of doctors, this paper examines how the expectation of movement built into training programmes perpetuates unequal access to healthcare. Long waiting times, poor care quality and lack of preventative care all perpetuate health inequalities; as one of the socio‐economic determinants, access to healthcare affects health outcomes. [ABSTRACT FROM AUTHOR]

The shift towards recovery‐oriented mental health care has led to the extensive growth of peer support in contemporary service delivery. When enacting peer support, peer workers (PWs) use their lived experiences of mental illness to provide support to individuals experiencing mental health difficulties. While PWs are increasingly an integrated part of mental health services, the way in which peer support unfolds in everyday practices remains understudied. Drawing on ethnographic fieldwork from Danish mental health centres, this paper investigates how peer workers and users enact experiential knowledge and expertise to support one another. Theoretically, this paper draws on a micro‐sociological approach that comprehends expertise as an interactional accomplishment enacted within institutional arrangements. First, the analysis shows how PWs and users develop affective relations based on shared illness experiences that enable the enactment of expertise. Second, it demonstrates how PWs and users engage in these relations by exchanging sympathy and knowledge according to different situational demands. Third, it shows how experiences of relational limitations make service users contest the value of experiential knowledge and PWs' position as valid experts. Centrally, this paper contributes to a general discussion of expertise and the implications of bringing lived experiences into mental health services. [ABSTRACT FROM AUTHOR]

China's 2009 health care reform agenda has been referred to as one of the most ambitious health policy programmes in modern history. Significant investment has combined with new structures, incentives, and regulations that have aimed to improve access, as well as gain greater control over a health care market much criticised for putting profit before patients. A range of health services research has been undertaken to analyse these efforts. Sociological perspectives have also been documented yet up to now a review and synthesis combining these various contributions has not been undertaken. By drawing on the lens of McDonaldization, the paper presents a narrative review that analyses the extent to which China's 2009 reform agenda has increased efficiency, calculability, predictability, and control over service provision. The review identifies elements of McDonaldization within China's 2009 reform agenda, however, notable gaps remain. In response to the limits of McDonaldization as a lens for understanding China's health care reform, the paper calls for alternative perspectives that are better able to understand the sociocultural dynamics shaping service provision, as well as an interdisciplinary research agenda that is able to generate new insights and understanding regarding health care in China. [ABSTRACT FROM AUTHOR]

This paper explores the questions: What has work published in Sociology of Health and Illness contributed to our understanding of ‘healthcare organisation’? What are the key research issues for the future? The paper reviews past articles with these questions in mind and uses the first issue of the Journal as a starting point for identifying themes and issues which have remained relevant throughout the first 25 years of its history. I argue that, though the disparate contributions in this area sometimes fail to build on earlier research, when read together they offer a valuable picture of a complex range of healthcare settings and their social organisation. The importance of insights gained from other areas of sociological work is emphasised and some significant examples are identified. The willingness to cross boundaries into other disciplines is also recognised as a strength and this is seen as an important issue for future research, as is increased attention to international comparative research. In similar vein the author argues that the multiplicity of methodological approaches allows the reader to weigh the value of different kinds of data and to look for common underlying patterns of action. It is suggested that future work could usefully revisit past studies, so that we consolidate and accumulate knowledge of the field and avoid a cycle where we continually retread old ground. [ABSTRACT FROM AUTHOR]

The UK National Health Service (NHS) is changing. Consecutive UK industrial strategies have supported the shift from an NHS that provides free‐at‐point‐of‐delivery healthcare to one that also facilitates research. Said to promote healthcare's triple aim of 'better health, better healthcare, and lower cost' (Wachter, 2016, 3), the digitisation of patient records is a core part in opening routine aspects of the health system to potential research. In this paper, we thematically analyse 11 policy documents and ask, how does the NHS discuss its decision to digitise patient records and what are the implications of such practices on the citizen? We document how (1) digitisation is presented as a collective endeavour for patients and NHS professionals, offering new possibilities for patients to participate in their own health and that of the population through research and, (2) digitisation contributes to the building of an efficient health system. Through this analysis we reflect on how discussions of digitisation present uncritically the potential of Electronic Health Records and big data analytics to improve care and generate wealth through research, and reconfigure patienthood, by placing research participation as a routine part of accessing NHS healthcare. [ABSTRACT FROM AUTHOR]

Three decades of conversation analytic investigations of medical interaction have produced a rich collection of findings of sociological interest, from a diverse array of encounters. This paper briefly outlines the development of this field to provide a context for the special issue. The paper discusses how studies of doctor-patient interaction have revealed the ways in which participants organise the medical visit to accomplish tasks such as diagnosing and recommending treatment for illness, and how doctors and patients address various interactional issues and dilemmas that arise as they undertake these tasks. It then highlights a growing number of CA studies that explore medical settings and activities beyond the doctor-patient encounter. In doing so, it charts the distinctive interactional practices that emerge, for example, where participants are engaging in hands-on treatment, medical practitioners are interacting with one another, or various technologies are employed during the encounter. Finally, papers in this special issue are introduced and shown to build upon this latter tradition. The papers address distinctive practical problems and institutional dilemmas that arise in healthcare encounters and medical settings beyond dyadic doctor-patient interaction, with a focus on the participants’ orientations to policy, their distinctive modes of participation, and the use of technology. [ABSTRACT FROM AUTHOR]

This paper addresses selection practices in a Danish phase 1 unit specialised in precision medicine in the field of oncology. Where precision medicine holds the ambition of selecting genetically fit medicine for the patient, we find that precision medicine in the early trial setting is oriented towards selecting clinically and genetically fit patients for available treatment protocols. Investigating how phase 1 oncologists experience and respond to the moral challenges of selecting patients for early clinical trials, we show that inclusion criteria and patient categories are not always transparent to patients. Lack of transparency about inclusion criteria has been interpreted as morally problematic. Yet drawing on social science studies of 'unknowing', we argue that silence and non‐transparency in interactions between oncologists and patients are crucial to respect the moral agency of patients at the edge of life and recognise them as belonging to the public of Danish health care. In the discussion, we consider the practice of placing 'unfit' patients on a waiting list for trial participation. Rather than representing an ethical and political problem, we argue, the waiting list can act as a valve enabling oncologists to navigate the scientific and as well as the moral uncertainties in phase 1 oncology. [ABSTRACT FROM AUTHOR]

The sociology of childbirth emerged in the 1970s largely as a result of influences from outside sociology. These included feminism, maternity care activism, the increasing medicalisation of childbirth, and evidence-based health care. This paper uses the author's own sociological 'career' to map a journey through four decades of childbirth research. It demonstrates the importance of social networks and interdisciplinary work, particularly across the medical-social science divide and including cross-cultural perspectives, argues that the study of reproduction has facilitated methodological development within the social sciences, and suggests that childbirth remains on the periphery of mainstream sociological concerns. [ABSTRACT FROM AUTHOR]

Genomic medicine has captured the imaginations of policymakers and medical scientists keen to harness its health and economic potentials. In 2012, the UK government launched the 100,000 Genomes Project to sequence the genomes of British National Health Service (NHS) patients, laying the ground for mainstreaming genomic medicine in the NHS and developing the UK's genomics industry. However, the recent research and reports from national bodies monitoring genomic medicine's roll‐out suggest both ethical and practical challenges for health‐care professionals. Against this backdrop, this paper, drawing on qualitative research interviews with general practitioners (GPs) and documentary analysis of policy, explores GPs' views on mainstreaming genomic medicine in the NHS and implications for their practice. Analysing the NHS's genomic medicine agenda as a 'sociotechnical imaginary', we demonstrate that whilst sociotechnical imaginaries are construed as collectively shared understandings of the future, official visions of genomic medicine diverge from those at the forefront of health‐care service delivery. Whilst policy discourse evokes hope and transformation of health care, some GPs see technology in formation, an unattainable 'utopia', with no relevance to their everyday clinical practice. Finding space for genomics requires bridging the gap between 'work as imagined' at the policy level and 'work as done' in health‐care delivery. [ABSTRACT FROM AUTHOR]

Abstract: In this paper I explore how the papers in this volume offer ways of thinking about materialities of care in terms of political ecologies, including hierarchies of value as well as assemblages, in which strategic agendas are made present in everyday practices, with profound and ordinary affects, as well as effects. I show how power can work through the association of multiple and heterogeneous materials and social processes to create ‘thresholds’, as spaces through which people must pass in order to be included as patients, and which circulate specific imaginaries over what counts as an appropriate need. I go on to suggest how some material practices are made mundane and immaterial, that is inconsequential, so that by drawing attention to their importance in how care is done (or not done) the papers help disrupt the commonplace production and reproduction of the ‘neglected things’ (Puig de la Bellacasa ) of healthcare environments, and by so doing help reimagine what is important for occasions to actually be caring. I then shift to thinking about a sensibility, one that is highly valued in this collection of articles, that helps illuminate different imaginaries of care to those that dominate healthcare environments, an approach that I have called elsewhere ‘relational extension’, and in the example I offer here show how shifts in extension as a form of motility disrupts stabilities and their reproduction, to accomplish different forms of world‐making. [ABSTRACT FROM AUTHOR]

Abstract: This paper explores how the materiality of dress mediates and shapes practices of care in the context of dementia. Earlier research called for an approach to conceptualising care that recognised the role played by everyday artefacts. We extend this to a consideration of dress and dressing the body in relation to people with dementia that involves the direct manipulation of material objects, as well as the materiality of bodies. The paper draws on an ESRC funded study Dementia and Dress, which examined experiences of dress for people with dementia, families and care‐workers using ethnographic and qualitative methods. Our analysis explores the process of dressing the body, the physicality of guiding and manipulating bodies into clothing, dealing with fabrics and bodies which ‘act back’ and are resistant to the process of dressing. We consider how the materiality of clothing can constrain or enable practices of care, exploring tensions between garments that support ease of dressing and those that sustain identity. Examining negotiations around dress also reveals tensions between competing ‘logics’ of care (Mol ). [ABSTRACT FROM AUTHOR]

The article examines the concept of medicalisation. Topics covered include how medicalisation has been criticised by some sociologists because of its seeming negativity about medicine and its fading relevance compared to concepts such as biomedicalisation and pharmaceuticalisation, the development of the concept of medicalisation, and the role of medicalisation in late-modern social life and culture.

The decommissioning of a health‐care service is invariably a highly complex and contentious process which faces many implementation challenges. There has been little specific theorisation of this phenomena, although insights can be transferred from wider literatures on policy implementation and change processes. In this paper, we present findings from empirical case studies of three decommissioning processes initiated in the English National Health Service. We apply Levine's (1979, Public Administration Review, 39(2), 179–183) typology of decommissioning drivers and insights from the empirical literature on pluralistic health‐care contexts, complex change processes and institutional constraints. Data include interviews, non‐participant observation and documents analysis. Alongside familiar patterns of pluralism and political partisanship, our results suggest the important role played by institutional factors in determining the outcome of decommissioning processes and in particular the prior requirement of political vulnerability for services to be successfully closed. Factors linked to the extent of such vulnerability include the scale of the proposed changes and extent to which they are supported at the macrolevel. [ABSTRACT FROM AUTHOR]

This paper explores nurses' experiences as members of primary care organisations set up to develop and commission health services for local communities. Nurses, alongside GPs and other health professionals, were given a place on the governing bodies (boards) of Local Health Groups - a move widely welcomed by the nursing profession as long overdue recognition of the important contribution nurses and nursing could bring to the policy arena. Nurse board members faced a number of challenges in their attempts to contribute to and influence local health policy. This ethnographic study (which involved non-participant observation of 33 board meetings and interviews with 29 board members including nurses) suggests that medical authority and control, and hierarchical power relations between doctors and nurses on the board, were seen by nurses as significant obstacles to their participation in this new policy arena. In response to their perceived lack of power and subordinate status, nurses employed a number of strategies to negotiate their participation as board members - these included 'getting it right', 'achieving the right balance', 'self-presentation' and 'unassertiveness'. These strategies reflected and reproduced gendered identities and relations of power and raise important questions regarding the influence of nurses and nursing within policy making. [ABSTRACT FROM AUTHOR]

This paper draws on the work of Giorgio Agamben to understand how the social organisation of care transitions can reduce people to their 'bare' life thereby making harmful and degrading treatment seemingly legitimate. The findings of a 2‐year ethnographic study show how some people experience hospital discharge as undignified, inhumane and unsafe process, expressed through their lack of involvement in care planning, delayed discharge from hospital and poorly coordinated care. Our analysis explores how these experiences stem from the way patients are constituted as 'unknown' and 'ineligible' subjects and, in turn, how professionals become 'not responsible' for their care. The result being that the person is reduced to their 'bare' life with limited value within the care system. We suggest that the social production of 'bare life' is an inadvertent consequence of reconciling and aligning multiple disciplines within a complex care system. [ABSTRACT FROM AUTHOR]

Abstract In this paper we describe and analyse results from an empirical study designed to provide insight into factors facilitating and/or inhibiting the emergence of the much-heralded ‘informed patient’ and its sociological equivalent, the ‘reflexive patient’ or ‘reflexive consumer’. In particular, we seek to examine the relationship between information and empowerment in a healthcare context and assess the significance of the Internet in mediating this relationship. The paper draws on data from interviews with 32 mid-life women concerned to know about HRT for the relief of menopausal symptoms. Having analysed these women's ‘information practices’, we conclude that constraints on the emergence of the informed patient identity exist within both patient and practitioner communities and within the space occupied by both in the medical encounter. In particular, in this paper we identify a tension caused by the emphasis on ‘information for choice’ in the informed patient discourse which itself obscures the potential conflict between lay and expert/medical knowledges in the clinical encounter. [ABSTRACT FROM AUTHOR]

This paper argues that children, as an important social group, repay study in connection with the sociology of health and illness. The paper outlines the neglect of children within medical sociology and goes on to open up a discussion towards a sociology of child health. The paper makes three main points. First, consideration of the case of health and illness helps understanding of children's social positioning as a minority group. Secondly, children present a clear case for considering people as embodied health care actors. Thirdly, taking account of children in the sociology of health requires rethinking the division of labour and inter-generational relationships within it. [ABSTRACT FROM AUTHOR]

This paper offers an interpretation of contemporary developments in Britain's National Health Service which suggests that a major transformation is under way, the contours of which, while visible, are not yet fully appreciated or understood. The analysis is in sharp contrast with that recently proposed by Klein and deliberate comparisons are drawn. The paper is in three main sections. The first briefly summarises Klein's position. The second takes issue with certain of his views, notably those on structural change, but also to some extent those on the relevance of the private sector. Welfare pluralism is posited as the most plausible future for health care and as a phenomenon as yet not well understood in Britain's health care sector. [ABSTRACT FROM AUTHOR]

It is the purpose of this paper to examine the relationship between the production of new scientific knowledge and the application of that knowledge to medical practice. The paper focuses, first, on the growth of the scientific enterprise and argues that the expanding medical division of labor is the profession's accommodation to the increased size of its body of knowledge. The paper goes on to discuss the emergent role of a new category of workers in that division of labor, clinical researchers. The second major focus of the paper concerns the relationship among medical specialists, who must allocate the new scientific discoveries among themselves. The final portion of the paper identifies the components of the process which accomplishes the task of distributing medical work among the specialty communities. The issue of primary concern to this discussion, which appears only as an underlying theme until the concluding section, is the effect of this allocation process on the structure of the medical profession and the type of medical care it delivers. [ABSTRACT FROM AUTHOR]

Moving away from paternalism to more equal forms of interaction in the patient–doctor relationship has been seen in positive light by policymakers, patients' rights advocates and scholars alike. Nonetheless, against the background of commercialisation and consumerism, empirical research showcases how reduced asymmetries bring in tensions and friction between patients and doctors (Greenfield et al. 2012). This paper contributes to the discussion through the examination of the patient–doctor relationship in the niche setting of private transnational healthcare markets which involve patients travelling overseas for care and where commodification, consumerism and care go hand‐in‐hand. It is geographically focused on two large cities in South‐Eastern Europe as settings where health care is provided to foreign patients – Athens and Istanbul – and empirically draws on qualitative interviews with doctors who run small/medium practices. The findings highlight that, despite excessive consumerism, power asymmetries are not mitigated but patient vulnerability shapes the patient–doctor relationship. In the transnational context, the patient faces an additional source of vulnerability: a condition of foreignness. As such, the findings stress that one relationship model (the consumerist) does not, per se, replace an older one (e.g. the Parsonian). Instead, the consumer–provider dimension co‐exists with the client–expert, patient–doctor and, finally, host–guest relation. [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]

Forms of large‐scale change, such as the regiona l re‐distribution of clinical services, are an enduring reform orthodoxy in health systems of high‐income countries. The topic is of relevance and importance to medical sociology because of the way that large‐scale change significantly disrupts and transforms therapeutic landscapes, relationships and practices. In this paper we review the literature on large‐scale change. We find that the literature is dominated by competing forms of knowledge, such as health services research, and show how sociology can contribute new and critical perspectives and insights on what is for many people a troubling issue. [ABSTRACT FROM AUTHOR]

This article examines how HIV policies and the funding priorities of global institutions affect practices in prenatal clinics and the quality of healthcare women receive. Data consist of observations at health centres in Lilongwe, Malawi and interviews with providers (N = 37). I argue that neoliberal ideology, which structures the global health field, produces a fragmented healthcare system on the ground. Findings show two kinds of healthcare practices within the same clinic: donor‐funded NGOs took on HIV services while government providers focused on prenatal care. NGO practices were defined by surveillance, where providers targeted pregnant HIV‐positive women and intensively monitored their adherence to drug treatment. In contrast, state‐led practices were defined by rationing. Government providers worked with all pregnant women, but with staff and resource shortages, they limited time and services for each patient in order to serve everyone. This paper builds on concepts of therapeutic citizenship and clientship by exploring how global health priorities produce different conditions, practices and outcomes of NGO and state‐led care. [ABSTRACT FROM AUTHOR]

The article presents calls for abstracts of research papers which concern topics such as quality and safety technologies, organizational policies, and service experience in the sociology of health.

This ethnography within ten English and Welsh hospitals explores the significance of boundary work and the impacts of this work on the quality of care experienced by heart attack patients who have suspected non‐ST segment elevation myocardial infarction (NSTEMI) /non‐ST elevation acute coronary syndrome. Beginning with the initial identification and prioritisation of patients, boundary work informed negotiations over responsibility for patients, their transfer and admission to different wards, and their access to specific domains in order to receive diagnostic tests and treatment. In order to navigate boundaries successfully and for their clinical needs to be more easily recognised by staff, a patient needed to become a stable boundary object. Ongoing uncertainty in fixing their clinical classification, was a key reason why many NSTEMI patients faltered as boundary objects. Viewing NSTEMI patients as boundary objects helps to articulate the critical and ongoing process of classification and categorisation in the creation and maintenance of boundary objects. We show the essential, but hidden, role of boundary actors in making and re‐making patients into boundary objects. Physical location was critical and the parallel processes of exclusion and restriction of boundary object status can lead to marginalisation of some patients and inequalities of care (A virtual abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA). [ABSTRACT FROM AUTHOR]

Abstract: In many countries government policy is becoming increasingly reliant on citizens taking greater responsibility for their health and wellbeing and limiting their consumption of public services. In this paper I develop Foucauldian perspectives on the work required to create and maintain responsibilised subjects, focusing on the role of ‘pastors’ – specialists, experts and therapists who promote desirable subjectivities (Waring and Latif ). Drawing from ethnographic research, I consider how government policies for the promotion of self‐care within the English healthcare system not only place increased emphasis on patients taking responsibility for their own health and wellbeing, but also seek to constitute new pastoral subjectivities as responsible for conducting the conduct of patients. I look at efforts to constitute pastoral subjectivities through an assemblage of management knowledge, educational practices and training materials. I argue that efforts to enrol and train pastors are unlikely to accomplish governmental objectives because of the availability of alternative guides for action drawn from professional training, established routines, and forms of social belonging. [ABSTRACT FROM AUTHOR]

Abstract: Biomedical research aimed at the development of therapies for chronic and late‐onset conditions increasingly concentrates on the early treatment of symptom‐less disease. This broad trend is evidenced in prominent shifts in contemporary dementia research. Revised diagnostic criteria and new approaches to clinical trials propose a focus on earlier stages of disease and prompt concerns about the implications of communicating test results associated with the risk of developing dementia when no effective treatments are available. This article examines expectations of the implications of learning test results related to dementia risk, based on focus group research conducted in the UK and Spain. It points to the extended social and temporal aspects of the dementia risk experience. Three key dimensions of this risk experience are elaborated: living ‘at risk’, represented in efforts to reduce risk and plan for the future; ‘with risk’, through vigilance towards cognitive health and earlier or prolonged contact with healthcare services; and finally, ‘beyond risk’ through a cessation of the self in its current social, legal and financial form. A virtual abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA [ABSTRACT FROM AUTHOR]

Abstract: This article explores the complicated and often‐contradictory notions of choice at play in complex care management (CCM) programmes in the US healthcare safety net. Drawing from longitudinal data collected over two years of ethnographic fieldwork at urban safety‐net clinics, our study examines the CCM goal of transforming frequent emergency department (ED) utilisers into ‘active’ patients who will reduce their service utilisation and thereby contribute to a more rational, cost‐effective healthcare system. By considering our data alongside philosopher Annemarie Mol's (2008) conceptualisation of the competing logics of choice and care, we argue that these premises often undermine CCM teams' efforts to support patients and provide the care they need – not only to prevent medical crises, but to overcome socio‐economic barriers as well. We assert that while safety‐net CCM programmes are held accountable for the degree to which their patients successfully transform into self‐managing, cost‐effective actors, much of the care CCM staff provide in fact involves attempts to intervene on structural obstacles that impinge on patient choice. CCM programmes thus struggle between an economic imperative to get patients to make better health choices and a moral imperative to provide care in the face of systemic societal neglect. (A virtual abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA). [ABSTRACT FROM AUTHOR]

This paper examines the professionalising of geriatric medicine in the UK roughly between the 1940s and the 1970s and locates it in terms of the broader context of the relationship between the professions and the state. It looks at how this relationship shaped geriatric medicine's professional jurisdiction, including the discourses of expertise on the one hand and the constituting of the 'subjects' of such expertise on the other. In contrast to other sociological approaches to the professions, which highlight the negative impact of state encroachment on professional territory, this paper contends that without the backing of the Ministry of Health the specialty may never have established itself in the face of prolonged opposition from rival specialists. However, such support was predicated on the specialty's highlighting particular legitimating discourses and practices at the expense of others, and in framing this in terms of specific policy concerns around an ageing population. Whilst this imprinted the profession with the stamp of governmentality, it also contributed to the broader problematising of old age in the twentieth century. The paper concludes by considering the legacy of this context of professionalisation for the profession today. [ABSTRACT FROM AUTHOR]

Genetic counselling as a medical encounter is characterised by the centrality of the provision of information. Much of the counselling session is filled by information delivery about the symptoms, the prognosis and the transmission of the disease, the risks involved and the possibilities for genetic testing. The present paper is a study of how information is delivered in actual genetic counselling sessions. The data consist of 10 video-recorded sessions from a genetics clinic in Finland, and the methodology is based on conversation analysis. The paper focuses on the doctor's talk in a specific interactional context, the slot after a candidate understanding by a client. The analysis shows that the doctors have two basic orientations: they work towards securing correct understanding and they display being attuned to what the information means to the clients, particularly to whether it is positive or negative to them. The latter orientation is related to what has been called ‘the benign order of everyday life’ ( ). The findings in the paper offer a possibility for a discussion about the principles and practices of genetic counselling. [ABSTRACT FROM AUTHOR]

The paper has three main aims. First, to trace – through the pages of Sociology of Health and Illness – the changing ways in which lay understandings of health and illness have been represented during the 1979–2002 period. Second, to say something about the limits of lay knowledge (and particularly lay expertise) in matters of health and medicine. Third, to call for a re–assessment of what lay people can offer to a democratised and customer–sensitive system of health care and to attempt to draw a boundary around the domain of expertise. In following through on those aims, the author calls upon data derived from three current projects. These latter concern the diagnosis of Alzheimer’s disease in people with Down’s syndrome; the development of an outcome measure for people who have suffered a traumatic brain injury; and a study of why older people might reject annual influenza vaccinations. [ABSTRACT FROM AUTHOR]

The task of examining just how the concept of ‘organisations’ has fared in Sociology of Health and Illness in its first 25 years is in some ways unrewarding. The answer has to be – ‘not at all well’. But why is this and does it matter? Part one of this paper considers what research on health care organisations was being conducted in the early years of the Journal and why that work was not viewed with favour by sociologists. Part two examines the growing gulf between those who saw themselves principally as responding to the call for a sociology of health and illness informed by broader sociological theory, and those who regarded themselves more as analysts of health policy and practice. Postmodernism, curiously, has begun to open up something of a route back. Just what might be done to create a closer rapprochement between those calling for theory and those wanting to address some of the day to day challenges of the delivery and experience of health care in the 21[sup st] century are topics for the final section. [ABSTRACT FROM AUTHOR]

This paper seeks to contribute to the limited body of work that has directly explored lay understandings of the causes of health inequalities. Using both quantitative and qualitative methodology, the views of people living in contrasting socio–economic neighbourhoods are compared. The findings support previous research in suggesting that lay theories about causality in relation to health inequalities, like lay concepts of health and illness in general, are multi–factorial. The findings, however, also illustrate how the ways in which questions about health and illness are asked shape people’s responses. In the survey reported on here people had no problem offering explanations for health inequalities and, in response to a question asking specifically about area differences in health experience, people living in disadvantaged areas ‘constructed’ explanations which included, but went beyond, individualistic factors to encompass structural explanations that gave prominence to aspects of ‘place’. In contrast, within thecontext of in–depth interviews, people living in disadvantaged areas were reluctant to accept the existence of health inequalities highlighting the moral dilemmas such questions pose for people living in poor material circumstances. While resisting the notion of health inequalities, however, in in–depth interviews the same people provided vivid accounts of the way in which inequalities in material circumstances have an adverse impact upon health. The paper highlights ways in which different methodologies provide different and not necessarily complementary understandings of lay perspectives on the causes of inequalities in health. [ABSTRACT FROM AUTHOR]

This paper presents data from a recently completed ESRC funded ethnography of social relations and case formulation in an integrated child health service, comprising paediatric inpatient and outpatient, child and adolescent mental health and child development services. Children present to the services with symptoms or troubles for which there are often competing biological, neurological, genetic and/or psychosocial models of causation. As a consequence, clinicians’ talk is oriented to deciding between three main potential types of case formulation – medical, psychosocial and not just medical. These three formulations are not static ideal-types. They are highly contestable and require complex practical and rhetorical work, through which facts and evidence are selectively invoked and different parties to the case are granted attributes which construct and reconstruct past events to render ambiguous symptoms or events understandable. In particular, moral judgements and complex characterizations about the child’s parents, or significant others, often form an indispensable warrant for these formulations. By analysing professional narratives about cases, this paper develops previous ethnographic work on the classification in medical work of children and adults as good or bad, appropriate or inappropriate, culpable or blameless, and renders visible a repertoire of moral formulations about childhood and child care. In particular, judgements about the adequacy of parental love are central to clinical reasoning. [ABSTRACT FROM AUTHOR]

Working from a Foucauldian perspective, this paper examines the discourse of informal care and addresses three questions. When was it first possible to speak of 'the informal carer'? What are the characteristics of the discourse of informal care? And, what are the conditions of the possibility of the informal carer's recognition? Following an analysis of the appearance and conceptualisation of the informal carer in policy and related discourse since the 1970s, the visibility of this figure is situated in the context of the historical transformation of the medical gaze. It is argued that two broad axes of the gaze's ongoing transformation--its devolution to 'relays' and its extension to the whole population and the 'whole person'--underpinned the shift in emphasis from care in the community to care by the community in the 1970s, and the associated development of the discourse of informal care. [ABSTRACT FROM AUTHOR]

This paper contributes to the sociological study of humour in health care settings by analysing its use by community mental health team members dealing with referrals made by consultant psychiatrists. It is about humour and hierarchy, and specifically about humour as a strategy used by rank and file team members to resist or attenuate instructions coming from powerful professionals. The paper draws on tape-recorded data from meetings of community mental health teams and describes the ways in which humour is used by participants to subvert or challenge existing occupational hierarchies. [ABSTRACT FROM AUTHOR]

This paper contributes to the development of theory and research on inequalities in health. Our central premise is that these are currently limited because they fail adequately to address the relationship between agency and structure, and that lay knowledge in the form of narrative has a significant contribution to make to this endeavour. The paper is divided into three sections. In the first section we briefly review the existing, largely quantitative research on inequalities in health. We then move on to consider some of the most significant critiques of this body of work highlighting three issues: the pursuit of overly simple unidimensional explanations within 'risk factor' epidemiology and the (probably inevitable) inability of this research tradition to encompass the full complexity of social processes; the failure to consider the social context of individual behaviour and, in particular, the possibility for, and determinants of, creative human agency; and, thirdly, the need for 'place' and 'time' (both historical and biographical) to be given greater theoretical prominence. In the final section of the paper the potential theoretical significance of 'place' and 'lay knowledge', and the relationship between these concepts, in inequalities research is explored. Here we suggest three developments as a necessary condition for a more adequate theoretical framework in this field. We consider first the need for the conceptualisation and measurement of 'place' within a historical context, as the location in which macro social structures impact on people's lives. Second, we argue for a re-conceptualisation of lay knowledge about everyday life in general and the nature and causes of health and illness in particular, as narratives which have embedded within them explanations for what people do and why -- and which, in turn, shape social action. Finally, we suggest that this narrative knowledge is also the medium through which people locate themselves with... [ABSTRACT FROM AUTHOR]

This paper investigates inequalities in children's reported morbidity by parental social class compared with indicators of material disadvantage, using data for children aged 0 to 16 years from the British General Household Surveys for 199 1-94. Family structure, employment status and receipt of benefit are more closely associated with differentials in health for children than parental social class. Children in lone parent families living on Income Support are most likely to report chronic illness, whereas for children living with two parents the unemployment of the family head is most clearly associated with reported morbidity. These health inequalities are more pronounced in children under 10 years than children aged 10-6 years. Children living in local authority housing were significantly more likely to report chronic illness. South Asian children were less likely to have a longstanding limiting illness compared to the white population. This research shows that the economic position of the family, and especially material deprivation, is more closely associated with children's health status than social class. [ABSTRACT FROM AUTHOR]

While sociologists earlier this century often used insights derived from psychoanalytic theory in their writings, contemporary sociology has largely tended to ignore this body of work. This is as true of medical sociologists as it is of others, despite the fact that the 'founding father' of medical sociology, Talcott Parsons, used psychoanalytic perspectives extensively in his theorising on the social aspects of medicine and health. In this paper I make a case for a return to a medical sociology that incorporates understandings of subjectivity derived from psychoanalytic writings, with particular reference to the medical encounter and the illness experience. The paper begins with an overview of psychoanalytic sociology. I go on to review the major insights Parsons developed in his writings and the work of other writers who have more recently used psychoanalytic theory productively in theorising the sociocultural dimensions of medicine and health care. The paper concludes with some thoughts about future directions for taking up the psychoanalytic perspective in the sociology of health and illness. [ABSTRACT FROM AUTHOR]

In a recent paper in Sociology of Health and Illness, Svensson (1996) makes the case for adopting the negotiated order perspective as the most appropriate theoretical framework for understanding patterns of doctor-nurse interaction. Analysing interview data with nursing staff from surgical and medical wards in five Swedish hospitals, Svensson identifies key changes in the health care context which he suggests have created 'negotiation space' for nurses, leading to the evolution of new working relationships with doctors. In examining the relationship between negotiation processes and the wider structural context, Svensson addresses a theme that has remained an enduring interest of critics and supporters of the negotiated order perspective alike. Drawing on data generated on a surgical and a medical ward in a UK District General Hospital, this paper attempts to make a further contribution to this debate and also to sociological understanding of doctor-nurse relationships, by analysing some features of hospital work which inhibited face-to face inter-occupational negotiations but which nevertheless resulted in the modification of the formal division of labour between nursing and medicine. The implications of these findings for the negotiated order perspective are considered, and the question is raised as to what researchers working within this tradition understand by 'negotiation' and how it can be studied. [ABSTRACT FROM AUTHOR]

Health promotion specialists and health promotion services within the health service have been neglected by policy makers and medical sociologists. This is perhaps surprising, given the high profile of health promotion on the health policy agenda. This paper presents the findings of an exploratory sociological study into the nature and function of health promotion services within the 'reformed' British National Health Service. The analysis draws on qualitative interviews with health promotion specialists, directors of public health and other health workers whose work involves the promotion of health. The paper argues that health promotion services do not fit easily into the purchaser provider divide and that they have experienced considerable organisational change and uncertainty. Four factors have further compounded this lack of fit: a lack of consensus as to what health promotion specialists work should be about; a lack of any secure knowledge base; prevailing images of health promotion and of health promotion specialists; and feelings of vulnerability about the future of health promotion. Furthermore, health promotion specialists are finding it difficult to shed their principles and values and take on the dominant enterprise culture which is characteristic of the new public management. The paper concludes by suggesting three further reasons why health promotion specialists have been marginalised: their insecure occupational status which in turn is linked to a lack of jurisdiction associated with the content of their work; the contradictions which are inherent in the knowledge base of health promotion, and the increasing application of 'modernist' evaluative frameworks, derived from economics, to health promotion interventions. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to review the various strands of academic commentary on the origins of the reforms of the British NHS announced in Working for Patients and implemented from 1991. The intention is to point to the very different ways in which this major event was interpreted and to question some of the interpretations advanced of the reforms. Ranging the various perspectives along a continuum from macro-level accounts (at the level of global or international trends) to micro-level perspectives (which concentrate on developments internal to health care systems), the paper draws attention to the multifaceted character of the various explanations that have been advanced and argues that no one perspective can satisfactorily account for the reforms. A degree of ecleticism may therefore be involved in producing a comprehensive explanation, and the paper draws attention to some parallels between accounts written from rather different ideological perspectives. [ABSTRACT FROM AUTHOR]

Using Israel as a case study, the paper considers the social mechanisms by means of which the medical profession seeks to maintain its boundaries and control in a social context characterised by the recent arrival of twelve thousand immigrant physicians from the former Soviet Union. This situation poses a threat to the veteran medical profession which is described as combining elitist and proletarian elements in an uneasy balance. In the past the principal mode of resolution with regard to this duality has taken the form of demonstrative assertions of the elitist component. With the large influx of immigrant doctors, three mechanisms geared to maintain control have been utilised: (i) the formal licensing examination for general practice; (2) full control of employment options in the health care system and (3) a widespread negative stereotype regarding the level of immigrant physicians' professional skills. The paper discusses these mechanisms and their implications for the profession. [ABSTRACT FROM AUTHOR]

This paper examines the efforts of physicians to cope with changing role expectations particularly the integration of gatekeeping expectations. The subjects of the study are US physicians who are members of a prepaid practice group that is affiliated with a Health Maintenance Organisation. The respondents say that they are committed to gatekeeping; however, they complain about the frustrations associated with this function. They differ in the extent to which they complain. The paper focuses on factors which account for this variation. Two factors are discussed in detail -- specialty differences and structural characteristics associated with the office site. The discussion begins with a review of the general sociological literature which employs the gatekeeping concept. [ABSTRACT FROM AUTHOR]