Making connections: studies of the social organisation of healthcare
Address for correspondence: Lesley Griffiths, Centre for Health Economics and Policy Studies, School of Health Science, University of Wales, Swansea, Singleton Park, Swansea SA2 8PP. e-mail: firstname.lastname@example.org
Abstract 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.
Over the last 25 years Sociology of Health and Illness has published a large volume of work that bears on the issue of healthcare organisation, even though it has not always been framed in those terms. As well as papers focusing directly on the ways in which healthcare systems are formally organised, directed and managed (e.g.Hunter 1979, Williams, Calnan et al. 1993, Green and Armstrong 1993, Gross 1994, Hughes 1996, Traynor 1996, Coburn and Rappolt 1997, Armstrong 1998, Milewa, Valentine and Calnan1999) it is important to include work on the division of labour between healthcare workers, issues of relative status, power and occupational identity, including those around professions and professionalisation (e.g.Eaton and Webb 1979, Stacey 1980, Larkin 1981, Weitz 1981, May 1992, Allen 1997, 2000, Berg et al. 2000), and relationships between different occupational sectors and between patients and healthcare workers (e.g.Dartington 1979, Jeffrey 1979, Wiener, Strauss et al. 1979, Alaszweski and Meltzer 1979, Blau 1980, Silverman 1981, Baruch 1981, Hilliard 1981, Meredith 1993, Norris 2001). All these areas contribute to our understanding of the way that healthcare is delivered and the ‘organisation’ that underlies that delivery. There are three main aspects of the work of the journal which I wish to discuss in relation to the question set for me.
First I want to consider the issue of the continuity and coherence of the work. This arises in relation to the variety of topics and the range of studies which are encompassed in the Journal over the last 25 years. Although this diversity might be taken as evidence of fragmentation and failure to build on past work, it is also possible to present it in a positive way which positions the reader as the assembler of diverse fragments, and emphasises the value of this body of empirical data. As we know, the study of the organisation of healthcare involves many aspects, processes and actors, and many apparently diverse contributions may be seen as having something to offer to our picture of this complex whole. In the same way, I want to suggest that some of the best work has been characterised by a willingness to move beyond the boundaries of our sub-field and to incorporate insights from other disciplines.
The second area for discussion concerns method. Once again the sheer variety of methods and approaches represented in the Journal can be perceived as a flaw but in the same way it can also be seen as a strength providing the reader with the opportunity to evaluate the usefulness of different kinds of findings and to assess whether there are general patterns which remain discernible even when the methodological prism is changed.
The third aspect of the work is related to the first two and involves the ways in which future studies need to build on what has already been done. On many occasions work in the Journal fails to make connections with earlier studies which address similar topics or touch on similar conceptual issues.
Directions for future research will be suggested against this backdrop of the need to consolidate and build on what has already been done. This will be with a view to encourage insights by introducing and elaborating theories and methods from other disciplines and areas where these offer the possibility of advantage over established approaches.
Organisational sociology has one of the longest histories of any area of sociology. Arguably, however, it is also one of the least successful, if we measure success in terms of producing findings which can be utilised to improve the predictability of organisational reforms or the effectiveness of organisational management (c.f.Starbuck 1982, Weick 2001). Additionally there seems to be little consensus on whether we are nearer to understanding the experience of organisational employees and service users. Some may question whether this matters, arguing that sociology is an analytical science which should restrict its project to scholarly analysis rather than generating knowledge which has practical implications. But this seems to me a difficult position to sustain. After all most of us work in organisations that are funded from public monies precisely to make a difference to existing services and I do not think we should be ashamed of this goal. But set against this yardstick, our understanding of the organisation of healthcare seems to represent a poor return on the resources invested. One reason for this may be the underdevelopment of the relationships between the sociology of health and illness and other areas of sociology; another is the lack of cross-fertilisation of ideas between sociology and other disciplines which research organisations and their contexts. The obvious contenders are social psychology, economics, political science, health service research and the hybrid discipline of organisational studies. And just as sociologists might benefit from a better awareness of the concepts, frameworks and methods of these cognate disciplines, it seems reasonable to argue that sociological approaches and perspectives could add an extra dimension to the work of researchers in these fields.
Generally, the relationship between organisational sociology and the sociology of health and illness has been rather distant. A very few, like David Silverman who had written an influential text on organisations (1970), moved easily between the two fields. On the whole though, ideas have not passed quickly between the two sub-disciplines. One prominent example is the negotiated order perspective developed by Strauss and his associates to analyse the hospital. Although this offered a general perspective on organisations and stimulated extensive debate and empirical research within the sub-discipline, organisational sociologists were rather slow to see its potential.
Where a flow of ideas has occurred it has usually been from mainstream sociology to our sub-discipline. Sometimes health sociologists have borrowed concepts and frameworks to make sense of empirical studies, and in doing so generated new insights that could make a significant contribution to debates in organisational sociology. One nice example is Dopson and Waddington's (1996) research on reform in the NHS, which applies Norbert Elias's sociological approach, and offers a new line of analysis in the study of organisational change.
Strands of organisational research
The study of the social organisation of healthcare could be said to be implicit in every article published in the Journal. In this short paper, however, the focus will be on those studies most overtly directed towards organisational issues, healthcare reform and its implementation, the changing nature of the NHS as an organisation, and comparisons with other national systems; the division of labour and boundaries between occupational groups involved in the delivery of healthcare; and the relationships between organisational employees and service users. As we shall see, Volume 1, Number 1 of the Journal provides an invaluable snapshot of the range of issues that was to preoccupy contributors for some years. Many later articles that touch on the organisation of healthcare have explicit links with these pioneering papers.
I want to change the original running order and start with David Hunter's piece on decision making and resource allocation in two health authorities, because this paper maps out the territory for a strand of research concerned explicitly with the organisation of healthcare systems which continues down the years. Hunter's paper explores decision-making in the NHS at the level of district managers who are located above that part of the service concerned with direct clinical care and below the higher tiers of the NHS concerned with national policies and strategy. This study represents one of the earliest explorations of the constraints and opportunities which shape organisational change. It also offers an extremely useful insight into informal processes arguably only apparent because of Hunter's commitment to present ‘the actor's view of reality’ (1979: 47) and to escape a ‘theoretical straightjacket’ (1979: 53). The paper is interesting not just for what it tells us about the changes which have taken place in the implementation of healthcare reform, but also the sociology employed to understand these changes.
The debates around rational decision making and incrementalism survive in aspects of more recent theorising in this field. Hunter's insight, however, that the dynamics of decision making at local level have the ability to confound government directives and reforms remains a powerful reminder that in order to understand organisations we must understand people accomplishing organisation in a multitude of locally situated interactions. His willingness to employ a multi-paradigmatic approach took the debate forward and helped open the way for more empirically grounded studies informed by interactionist approaches. His commitment to qualitative methods and inductive theory building has been taken up in several subsequent papers. Thus two contributions in the 1996 Volume by David Hughes (1996) and Michael Traynor (1996) both trace roots back to Hunter's early work and continue the story by mapping the historical changes in policy and offering further snap-shots of the continuously shifting policy implementation cycle. Both these authors also import concepts from other disciplines. Hughes draws on ideas about political innovation from anthropology and rhetoric from discursive psychology which are deployed to enhance the picture of the NHS management reforms. Traynor uses ideas from discursive psychology and literary analysis to explore the impact of these reforms.
Research on the changing nature of the healthcare system has been carried forward in different ways by authors such as Davies (1987), Thompson (1987), Williams et al. (1993), Armstrong (1998), Hughes and Griffiths (1999), Harrison and Dowswell (2002) and Milewa et al. (1999). One limitation of this work is that the healthcare system under scrutiny has usually been our own NHS. This means that there has been little comparative analysis or examination of global trends in health system reform, such as the rise of managed care, a development whereby governments have sought to contain the costs of healthcare by shifting responsibility for managing the funding of services to private insurance schemes. However, a number of recent articles are beginning to fill this gap. Scheid's (2000) paper explores the impact that managed care has had on mental health services in the USA. Other contributions by Bourgeault et al. (2001), Albrecht (2001) and Heritage et al. (2001) further examine the impact of managed care on access to treatment. If the evidence from these papers is taken seriously it is clear once again that government reforms in healthcare are subverted and reshaped in numerous face-to-face interactions producing consequences which, in many cases, have increased costs and reduced transparency, apparently inverting the original intention behind the development.
Although accounting for only a small proportion of the Journal's content, this strand of organisational analysis is showing signs of progress in terms of the development of theoretical models which recognise the complexity of health systems. Hartley's paper in the March 2002 Issue describes the impact of managed care on the relationships between healthcare professionals, the state and consumers of healthcare, based on the theory of countervailing powers. ‘The countervailing powers framework (Hafferty and Light 1995, Light 1993, 2000) locates professions within a field of institutional and cultural forces and parties, and tries to articulate their interrelations. At its most general level, the perspective holds that one party (such as the state, a profession, corporate interests or consumers) may gain dominance by subordinating other parties. These, in time, countermobilise to redress imbalances produced by the dominance of one party’ (2002: 179). The advantage afforded by this model is that it places the focus clearly on relationships between actors and interest groups within a wider institutional and organisational context. This paper moves between a number of levels examining the role of nurse midwives and their relationships with physicians, the tensions that arise as a result of competition between professionals, the role of consumers, and the wider policy context of managed care. One of its strengths is the attempt to integrate macro-perspectives on policy and the role of the state with micro-perspectives on the working practices of individuals and groups. My own feeling is that this concern to make linkages between the macro-, meso- and micro-levels might be more effective if researchers were to treat the distinction between these ‘levels’ as a phenomenon interactionally accomplished by organisational members and the topic of research. It may now be time to apply the same ethnomethodologically inspired approach to the topic of formal and informal aspects of organisational life. Revisiting and challenging these taken-for-granted ‘structures’, which have formed the basis for a great deal of organisational research, may allow more fruitful insights than continuing to explore realities. These, after all, may be shaped more by pre-existing social science assumptions than the concerns of those involved in the organisation of healthcare.
Although I started with the clearest example, all of the papers in the inaugural issue touch on aspects of healthcare organisation. Peter Conrad's article on the interplay between three facets of medical dominance and their social control functions raised many of the questions that were to re-surface in subsequent discussions around professional dominance. This paper argues that researchers need to demonstrate, rather than simply assert, the growth of medical dominance in society, pointing out that what seems to be medical control is often instigated by the state or other institutions. In effect, Conrad locates the medical profession within a wider institutional and organisational context by reminding us that ‘medicalisation’ is often facilitated by agents external to medicine. This paper also makes a link with mainstream sociology that will come up many times down the years, discussing Talcott Parsons’ work on the sick role. Parsons’ consideration of the sick role was firmly contextualised in his work on the social system, arguably making the theoretical insights derived from this work some of the most resilient in the sociology of health and illness. Conrad makes connections between the sick role, gatekeeping and re-categorisation of deviance as sickness, and their social functions and his exhortation to ‘discover and explicate the linkages between medicine and other social control agencies’ (1979: 9). These are re-visited in several subsequent papers concerned with organisational processes, such as patient intake and categorisation. Once again the need for micro-level studies which flesh out the ideas expressed is clearly signposted.
Dartington (1979) explores fragmentation and integration in health services and maps out the problem of the interface between hospital and community. His work pre-figures many of the debates which still reverberate today around integration and conflict between the various agencies charged with delivering health and social care. This paper is concerned with organisation in terms of the wider inter-agency framework of care and provides a starting point for debates around issues of community care (Thomas 1997), the role of informal carers (Heaton 1999) and the relationships between health and social care agencies (Fineman 1991, Hart 2001). Although the Journal has published some work on the private sector (e.g. Thorogood 1992, Cant and Calnan 1992, Wiles 1993, Calnan et al. 2000), the interface between the NHS and other care agencies remains an under-represented area. Institutional or environmental approaches to organisations suggest a need to widen the focus to include relationships with informal carers and between the NHS and cognate organisations (Jaffee 2001).
The concern with understanding the relationships between policies, their implementation and the working practices of healthcare professionals is clearly relevant to the paper on boundary encroachment by Eaton et al. (1979), which foreshadows later work on boundary management and encroachment and also more specific research on the shifting jurisdiction over drug prescribing and the implications for the medical profession (Harding and Taylor 1997, Britten 2001). The debates on profession, professionalism and the division of labour continue in much of the work published in the Journal. This strand also offers us some of the strongest empirical studies at the micro-level of healthcare. Berg's (1992, 1996) careful empirical work on patient records and the construction of objectivity and its deployment in medical practices stands out as an example of a strong micro-level study, and clearly benefits from links with the sociology of scientific knowledge. Other good examples include papers by Svensson (1996) and Allen (1997, 2000), which develop the negotiated order perspective to illuminate the work activities and relationships between doctors and nurses at the boundary between these occupations. Allen's work clearly signposts the importance of interactionist approaches in understanding the organisation of healthcare work and relationships between occupational sectors, differences in intra-occupational status and the ways in which context impinges on these issues. Allen also attempts to clarify what analysts mean by the concept of negotiation, and her papers constitute good empirical examples of work which seeks to refine concepts which have wide applicability to the sociology of health and illness.
The paper by Jeffrey (1979) has become a classic on typification or categorisation by staff and the ways these practices shape the careers of patients. This paper can be seen as one example of work which explores some of the ideas set out by Conrad in the same issue (1979). Papers by Hughes (1980), Dingwall and Murray (1983), Latimer (1997), Hughes and Griffiths (1999), Griffiths (2001), Dodier and Camus (1998), White (2002) and others continue to debate and discuss this central feature of staff activity and its consequences, both for patients and the overall organisation of healthcare. This paper can in many ways be seen as setting the tone for a variety of investigations into the ways in which staff typification activities affect the quality of service afforded to patients. There is a clear connection between this paper and those which have more explicitly explored the consequences of reforms devised to manage resources rationally and the unintended outcomes of those reforms (Gross 1994, Light and Hughes 2001, Prior 2001, Joyce 2001, Griffiths 2001). Some of this work has been influenced by Lipsky's (1980) ideas on street-level bureaucracy and processes by which policy is adapted and remade by those delivering a service. This is reflected in micro-level work which has been one of the Journal's strengths down the years (e.g. May and Kelly 1982, Silverman 1983, Dingwall and Murray 1983, Hanson 1985, Hughes 1989, Heritage et al. 2001).
We may now, however, be at a juncture where we need to work harder to make connections between the micro-level and the macro-level of the organisation and its interfaces with the wider society. As I have suggested, one way is to treat these distinctions as accomplishments and resources for sense-making by organisational members, and to examine the recursive processes involved in such activity. Past studies offer some pointers by suggesting how general concepts like categorisation, typification and labelling can be applied to elucidate organisational process such as intake, selection, prioritisation and disposal. Vassy (2001) has recently argued that we need to build on a further stage of micro-level studies of this kind so that we have better information about impact on patient outcomes, and a clearer perception of how the local decisions of individual actors shape the service on offer.
The final paper in the first issue (Heller et al. 1979) is also concerned with deviance, in this case in relation to mental health problems in West Texas. We may be a little more sophisticated in our use of language today than in 1979, and in this paper the labels ‘middle class’ and ‘lower class’ are applied to sections of the populations with little explanation of the basis of this classification. But the description of West Texas women and the ways in which they are disadvantaged by ‘impersonal bureaucratic institutions’ offers us an opportunity to revisit middle-level studies of the organisational impact of labelling processes to complement the micro-level work represented by Jeffery's study.
As well as providing a baseline for studies which have developed and reworked these themes over the years, the papers in the first issue had a number of shared themes. The common focus of the papers by Conrad, Jeffrey and Heller et al. on forms of deviance reflected the status of that concept at that time and the historic link between the medical sociology group and the National Deviancy Conference. Although the language has changed this substantive area continues to be important.
In the same way that a superficial reading can interpret the variety of topics included in the Journal as evidence of a fragmented discipline, the variety of methods utilised can initially be seen as evidence of a lack of scientific discipline, rigour or integration. Debates over methods have been taken up in significant numbers of contributions, and organisational sociology remains an area where the quest for appropriate methods continues. We can see a considerable development in the way in which data are created, handled and presented over the years. For example in Hunter's qualitative piece in the first issue we are given a pre-digested view of interview and observation data whilst actually being offered only very little ‘raw’ data within the text. The methods used to collect and analyse the data are not described in great detail but it is difficult to account for this omission 25 years on. In other papers in the same issue we can see that copious data extracts are supplied and more detailed descriptions of the methods employed are offered.
The variety of approaches to organisational research and the methodological sophistication involved appear to increase over time, but whether there is consensus around the best methods for the task (or even what the task may be) continues to be a moot point. Few would disagree that complex social arrangements, such as organisations, need to be explored using equally complex arrays of social research methods. Moreover, there is certainly evidence of increasing complexity if we follow the path from early interview studies such as Hunter's to Berg's actor-network-theory-influenced analysis of texts, records, and policy documents combined with observation, surveys and interviews.
The Journal has published several significant papers which have focused on the way methods employed in the study of healthcare organisation might be reconsidered. One of the earliest of these appeals was made by Dingwall in 1980 in a paper that argues for greater sensitivity to the details of social interaction and its various forms. Dingwall concludes that ‘the restoration of a comparative focus and a re-examination of Sacks’ original writings [on conversational structures] may open important avenues for the empirical grounding of statements about wider social structures and their realisation in everyday life’ (1980: 151). The importance of longitudinal and comparative approaches was endorsed by Silverman in the preface to the first Special Issue (1981), which also argued for a more sophisticated analysis of talk in organisational life. In this Special Issue (Strong 1981, Silverman 1981, Baruch 1981, Rayner 1981, Hilliard 1981) we also see some of the earliest beginnings of ‘policy ethnography’, an approach which aims to explore policy implementation from the actors’ standpoint by studying the iterative relationships between policy makers, policy, managers, healthcare professionals and patients. With the increasing pace of policy changes and increasing complexity in arrangements for the delivery of care, extreme care needs to be paid to the selection of methods which make an attempt to capture the complexity of such arrangements. Policy ethnography can fill an important gap as its commitment to the processual aspects of organisational life affords a perspective which can properly explore organisations in action. This approach allows for the development of work on healthcare organisation which accommodates and builds on insights from ethnomethodology. Thus, for example, organisation can be understood as an ongoing and recursive accomplishment of members in interaction, and this activity forms the focus of research. The emphasis on members’ interaction also offers a framework for affording a rapprochement with conversation analysis and other approaches to talk and communication which present talk and text as the tangible (and researchable) medium of social action.
Willingness to innovate and to combine established approaches with novel insights from other areas offers opportunities to enhance future work. Gareth Williams’ (1984) work on patient narratives as a means of better understanding the experience of those on the receiving end of healthcare opened the way for narrative analysis to be considered as one possible approach. Although this method is rarely used in those studies specifically directed towards the organisation of healthcare, it offers exciting possibilities for those who seek to explore organisation as an example of co-ordinated and meaningful social action (Gubrium 1993). Dingwall (2001) has recently reminded us of how useful the work of the Chicago school can be in analysing collective behaviour in his work on a contemporary myth. There can be no doubt that the Journal has championed the exploration of a variety of methods in the work which it has published and unlike similar journals in other parts of the world has not sought to dictate which methods should or should not be appropriately employed. This freedom has allowed the sociology of health and illness an arena for development which reflects and supports the multi-faceted quest for knowledge appropriate in a social science.
Over the last 25 years then Sociology of Health and Illness has offered us a resource which can be useful on a number of counts. First, healthcare and experience have been documented over time, providing a vital historical perspective which offers us the ability to move back and forth between then and now, to chart the development and demise of various policy, economic, technical and social changes, and their impact on patient care and work experience for a range of occupations. We are able to construct the history of health and illness from a variety of vantage points, to compare and contrast findings, and to draw conclusions about the changing organisation of healthcare. As Elias (1987) puts it, the Journal offers us the chance to avoid ‘the retreat into the present’.
Secondly we also enjoy the distinct advantage of retrospectively being able to link together areas of interest which may at first appear to be unconnected. The relevance of Jeffrey's (1979) description of typification in action in casualty may at first sight appear to have little in common with Heller's (1979) description of the class-bound experience of mentally ill women in Texas. The common thread of deviance, however, allows us to begin a comparison which can yield useful insights for social exclusion and the ways in which these processes are constructed, reproduced and supported rhetorically. One of the most challenging aspects of synthesis depends on making linkages between the various levels discernible in healthcare organisation. The variety of topics and approaches included in the journal and which initially appear to reflect a disheartening fragmentation of the discipline begin to appear as a rather different type of phenomena once one begins to explore the linkages between apparently discrete areas. Light and Hughes (2001) suggest that: ‘Sociologically, what matters are the power relations’, perspectives and agendas of the relevant parties. This is as relevant at the macro-level of national political decisions, as it is at the meso-level of US HMOs or British Primary Care Trusts, and the clinical micro-level. Thus the first research objective is to get inside the ‘black box’ of organisations at different levels of the healthcare system to gauge what is happening ‘on the ground’. Arguably what we have had in the Journal over the last 25 years is a body of work which opens the black box at various levels to shed light on relationships between healthcare professionals and those in cognate organisations, between professional colleagues, and between professionals and patients. Overall, however, there remains a dearth of studies at what have been described as the macro- and meso-levels, particularly studies which employ methods which are designed to penetrate the relevant organisations. Additionally, there are very few studies which attempt to explore the relationships between levels and to begin to map out the cross-over between formal and informal aspects of organisational life.
I have argued that new connections need to be made between disparate studies which have been carried out. I have also said that the boundaries between mainstream sociology, organisational sociology and the sociology of health and illness can be and ought to be crossed. This is not an original point and there are many contributions which have already taken steps to put this into practice (e.g.Clarke's (1981) emphasis on the benefits of a multiple paradigm approach to the sociology of health and illness, Dingwall's (1980) call for a rapprochement between conversation analysis and ethnomethodology, Silverman's (1981, 1983) use of ethnography to understand policy implementation, Prout's (1996) use of actor network theory). Other studies have used the work of Parsons and Foucault, both authors whose relevant work for the sub-discipline was firmly contextualised within the study of whole societies. As we have seen, a similarly fruitful cross fertilisation existed when it came to the methods employed in the studies reported in the journal.
Earlier I identified the need for more work on the interfaces between organisations which are formally devised to deliver healthcare and health and related areas, such as social care. In particular, it is clear that those studies which employ approaches and methods designed to explore informal structures and processes, alongside features and structures which might be described as those which constitute formal organisations, are most likely to offer an improved understanding. I have also suggested that studies which allow for the exploration of linkages (formal and informal) between levels of healthcare organisation, and from policy making to service use, would also allow us to develop understandings which can be put to practical use. For example, although there are many excellent studies of communication between patients and healthcare workers (Heath 1982, Drass 1982, Fisher 1984, Silverman 1981, 1983, Pilnick 2001), these studies do not always address the question of how they might feed into organisational structures and processes. The work of Garfinkel (1967, 1986) on ethnomethodology, and some of the work of Giddens (1984) around structuration, both offer starting points for exploration of these linkages. Policy ethnography offers us an approach which allows these linkages to be researched in action and support, for this strategy can readily be found in the work of authors who are not explicitly working in the area of the sociology of health and illness. For example, using conversation analysis, Boden (1994) has emphasised the importance of studies of talk for understanding organisations. ‘People ( … ) talk their way to solutions, talk themselves into working agreements, talk their coalitions into existence, talk their organisational agendas, and, occasionally talk through or past each other. Moreover, through their talk they not only reproduce the institutionalised arrangements of the organisation and its environment, but significantly create and recreate fine distinctions that actually make the organisation come alive’ (1994: 52). From social psychology the work of Weick (1979, 1995, 2001) on sense-making in organisations encourages a willingness to see the activity of members at the ‘micro-level’, i.e. in interaction, as the main focus for organisational research. The location of members at different ‘levels’ in the organisational ‘structure’ should not discourage us from the commitment to explore organisation as an ongoing, everyday, recursive accomplishment of members in interaction with each other. Weick (2001) describes the ways in which such interactions provide the building blocks of organisations, and also supports the claim that if our aim as researchers is to offer an understanding of organisations which is robust, and allows for improvements in the effectiveness of social arrangements, then our approach must reflect the activity of those we study.
As social scientists engaged in the social organisation of healthcare research, it may well be the case that a practice of pursuing ‘small wins’ or ‘small flops’, and revisiting, reflecting on, consolidating and integrating these studies, will allow us to make sense of studies already completed in ways which, having clarified the questions we want to ask, offer clear directions for future work.
I have suggested that there is enormous scope for building on the work already published in the Journal. The new generation of health sociologists would do well to revisit some of these past studies to create new connections between work in apparently dissimilar areas or using different methodological approaches. I have explained my own preference for work which treats organisations as complex, ongoing accomplishments of knowledgeable social actors and why I see policy ethnography as offering particular strengths as a research approach in this field. I have mentioned the importance of locating work done in a wider context and the need for work which offers us the ability to make international comparisons. I have identified the advantages of the historical perspective that the Journal is able to offer. I have also suggested the potential benefits that would accrue from a greater willingness to dissolve the boundaries between subfields, and also between sociology and cognate disciplines, and I have cited some examples which I feel have usefully imported methods and concepts across the various divides.
My final point is to encourage a willingness to look outside the boundaries of sociology itself for improved ways to research healthcare organisation. Sociologists must be reflexive about the organisation of the sociology of health and illness and be willing to apply some of the lessons which confront us in our study of other organisations. In this instance the social action around boundary creation, maintenance and the disadvantages and unintended consequences of such activity strike some of us as resonating particularly strongly with some of our own practices.