ASA Decennial Conference - Anthropology and Science

Negotiating virtual realities: anthropology in and for the science of health services research

Contact Convenor: Dr. Guro Huby

Department of Community Health Sciences,
Primary Care Research Group, University of Edinburgh
Edinburgh EH8 9DX

Tel. 0131 650 9463

guro.huby@ed.ac.uk 

Co-Convenor: Dr Elizabeth Hart

liz.hart@nottingham.ac.uk 

Panel abstract

Health services research (HSR) is a new and burgeoning ‘science’, central to the government’s drive to create a cost-effective and high quality health service. HSR is a young discipline, based on multidisciplinary and multi-methods research. Energetic and innovative, it is theoretically undeveloped and tends towards systems of information management which leave significant areas of experience and behaviour unexamined. Consequently, although the success of HSR is premised on widespread ‘cultural change’ its almost formulaic approach to knowledge produces a ‘virtual reality’ of health service organisation, limited in its ability to penetrate the grey area between policy and practice. However, this is precisely the marginal space in which anthropologists locate themselves by virtue of their commitment to an explication of local context and the interpenetration of systems and lives.

As such we recognise that people's experience and knowledge of the health service is often at odds with that embodied - and to some extent enforced – through the dominant models of HSR. It is a complex organisation undergoing constant change, where few maintain an overview and where knowledge to guide action is lacking, or, at best, grey and contested. Anthropologists working in this environment have to move between and negotiate these different realities, including their own. This involves an appreciation of context and an ability to uncover and make explicit the different root metaphors that underpin knowledge production and guide action in the different ‘science communities’ of anthropology and HSR. We suggest that in this regard anthropologists have an important contribution to make to a better understanding of the limitations as well as potential of the ‘science’ of HSR, including as a force for organisational change. This international panel is organised around original papers presenting examples of applied anthropological work in HSR, and overviews and discussions theorising anthropological involvement in this field.

Hart, E and Hazelgrove, J. (2001) Understanding the Organizational Context for Adverse Events in the Health Service: The Case of Cultural Censorship. Quality in Health Care, 10 (4), 257-262.

Lambert, H. and McKevitt, C. Anthropology in Health Research: From Qualitative Methods to Multidisciplinarity, British Medical Journal (in press)

Ortner, S. B. (1973) On Key Symbols, American Anthropologist, 75:1338-1346.

Oakley, A. (2000) Experiments in Knowing: Gender and Method in Social Sciences, Cambridge, Polity Press.

Savage, J. (2000) The Culture of ‘Culture’ in National Health Service Policy Implementation. Nursing Inquiry 7 (4):230-238.

Strathern, M. (ed) (2000) Audit Cultures: Anthropological Studies in Accountability, Ethics and the Academy. London: Routledge

Terrell, J. E. (2000) Essay: Anthropological Knowledge and Scientific Fact, American Anthropologist, 102 (4):808-817

Introductory remarks: The NHS audit culture: what role for anthropology?

Guro Huby, University of Edinburgh & Liz Hart, University of Nottingham

The panel convenors will introduce the six session papers through an overview  of current NHS organisation and the role of research within it. The health service (in common with private enterprise and other public services ((Strathern 2000 on higher education)) is changing towards strong central control, locally and individually internalised through audit and clinical governance. In the British NHS, the centralising function of the ‘audit culture’ is offset by a piecemeal funding structure and a blurring of hierarchical control. Panel papers examine and compare these developments in different national and local contexts, and with ethnographic detail.

Is this form of organisation a new cultural form in the making, where the place of anthropology is in need of a rethink?. Or is it simply another time-and-space specific manifestation of the workings of power and money – forces anthropologists manage perfectly well with existing tools?  These six papers explore the theme of the NHS as a modern organisation from anthropological perspectives. Discussions include the impact of policy on professional practice; the tensions inherent in the use of audit and clinical governance as forms of management control; definition of organisational culture and the role of anthropologists in revealing its competing  realities, contradictions and ambiguities.

- Strathern M 2000 Audit Cultures Routledge

“I can’t get no satisfaction” or “It ain’t wotcher do it’s the way tha'tcha do it” (or the way Thatcher did it?) Is it enough or even possible for health services to seek to produce merely the absence of disease?

Ronnie Frankenberg, Honorary Professor associate, University of Brunel, University Fellow, University of Keele

It may be that Marx’s greatest contribution to social science was not his, now regarded as mistaken, view that the production of commodities produced surplus value, but that, paradoxically, too narrow a view of productive outcomes distracts attention from much else that is produced at the same time. The paper will discuss with examples why the analysis of too limited outcome measures, at the expense of studies of process of the kind practised by medical anthropologists, produces evidence-based medicine which looks good on paper but which doesn’t smell right in practice. It will suggest that health service management often employs vulgar anthropology in the form of a reified concept of culture alongside an unhelpful vulgar Marxism in which economy is all and that this intensifies the dissatisfactions they set out to allay. Anthropological studies offer the possibility of helping to understand why both professionals and patients appear to behave irrationally and in defiance of “evidence”.

Clinical governance, accountability and the construction of professional identity

Jan Savage, Royal College of Nursing, London

Policy has become a central instrument in the organisation of society, with changing forms of governance reshaping the way that individuals construct themselves and their conduct. This paper looks at clinical governance as a recent policy initiative that ostensibly restructures not only the UK National Health Service, but also the subjectivity of health care professionals. 

Clinical governance can be understood as a framework for a range of activities that seek to promote clinical effectiveness and cost-effective care. It is premised in part on NHS-wide adoption of centrally-developed protocols to ensure 'evidence-based practice' and facilitate audit. Clinical governance demands a heightened, but ill-defined, accountability of its clinicians.  It prescribes the nature of clinical practice, but also introduces new ambiguities by simultaneously undermining (by prescriptive guidelines) and promoting (by devolving responsibility for their local adaptation) practitioners’ capacity to act independently. Clinical governance thus reshapes the conduct of clinicians and the ways in which they construct themselves.

This paper draws on ethnographic work in primary care. Focusing on clinical decision making and accountability, it considers how practice nurses, who have traditionally practised in a space between nursing and medicine, reconfigure their professional identity in the context of clinical governance

Audit, control and empowerment: using ‘care pathways’ in the evaluation of integrated health and social care teams for older people

Guro Huby, University of Edinburgh

‘Care pathways’ are standardised maps of a patient’s journeys through care systems. Evaluation of pathways centers on recording instances where practice deviates from the accepted norm.

‘Care pathways’ can be a ‘top down’ instrument of control by shaping practice to a certain view of cost-effectiveness and quality which constitute a ‘virtual reality’ only tenuously linked to the complexities of daily care practice. However, as models they can also be an instrument of empowerment by simplifying the care process to allow practitioners to articulate and reflect on practice on their own terms.

This paper draws on material from a programme of self-evaluation  with and for multidisciplinary integrated teams for older people in three Scottish Primary Care Trust areas. The teams sit uneasily among mainstream health and social care structures, on whom they nevertheless depend for management, and teams often complain of lack of strategic direction and support. The evaluation uses the idea of ‘pathways’  to empower the teams to take more control over their situation.

I will discuss how this evaluation is interpreted and used by different players: the teams, their management and myself, and how  ‘control’ and ‘empowerment’ shift, as flip sides of the same coin, according to context.  

Competing realities and experiences: the ‘patient centred’ model versus clinical audit

Alexandra Greene, University of St Andrews

This paper draws on material from an action-research project concerned with multidisciplinary health care for young people with type I diabetes in Scotland. The multidisciplinary approach incorporates members from very different disciplinary backgrounds, holistic and biomedical, and with it a collection of multifarious ‘ways of knowing’ about care-delivery. The aim is to foster a philosophy of democratic care for the young. Indeed such collaborative professionalism, it is argued, encourages a shift away from dominant biomedical models towards psychological models of patient centred care, based on patient empowerment and negotiation. Problems arise however, when health professionals believe that such holistic approaches clash with formalistic measures of audit, where symbols of success rest more on improved outcome measures than relationships of concordance. It is here I argue, between the competing anxieties of psychological and biomedical professionalism that the anthropological perspective intrudes to uncover experiential knowledge, and the competing realities between policy and practice.  Moreover, that the anthropologists’ skill lies in his or her ability to navigate a journey between professional boundaries and contexts to reveal a space for professional synergy and empowering styles of practice for young people.

A culture of contradictions in the NHS: a perspective from organisational anthropology

Liz Hart, Queen’s Medical School, University of Nottingham

This paper discusses the contribution of organisational anthropology to an understanding of the National Health Service as a modern organisational form. It presents an overview of debates about organisational culture, drawing on anthropology and management theory, identifying different ways in which the concepts of culture and organisation are defined and used.  It suggests that successive governments have attempted to re-shape the health service as a modern organisation, one in which rational organisation is not just a means to an end but an end it itself (of which clinical governance and audit are both expressions). At the organisational level this political imperative generates a tension between the increasing globalisation of policies and management strategies on the one hand and, on the other, the increasing impact of local cultures on everyday practices in health and social care. I illustrate my argument with ethnographic data from a study of the local organisation of an Intermediate Care policy in the form of a transitional residential rehabilitation service for older people in six residential homes in the East Midlands.