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Keywords:

  • formal organisations;
  • organisational analysis;
  • sociology of organisations;
  • health policy;
  • NHS

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Legacies and lacunae
  5. Health care reform, health policy and sociology
  6. Into the present
  7. Prospect and potential
  8. Acknowledgements
  9. References

Abstract 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 21st century are topics for the final section.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Legacies and lacunae
  5. Health care reform, health policy and sociology
  6. Into the present
  7. Prospect and potential
  8. Acknowledgements
  9. References

Sociology of Health and Illness– as is the way with new journals – was born in a period of great optimism. A new sub-discipline was emerging, intent on freeing itself from operating entirely as an applied field, its problems defined by others rather than by the sociological community itself. The decision to devote the annual conference of the British Sociological Association (BSA) to the topic and the successful publication of two conference volumes (Dingwall et al. 1977, Stacey et al. 1977), pointed to a moment of consolidation and advance. Reviews of the field, though they offered important cautions, largely told a similar story (Illsley 1975, Stacey with Homans 1978). The Journal's editorials have repeatedly invited papers from a range of approaches. Why then is it that study of the organisations in and through which health care is delivered and the organisation of health care itself seem to have featured so little in a quarter century corpus of work?

Building blocks for a study of organisational phenomena were undoubtedly in place when the Journal began its life. A mid-60s student, I had cut my sociological teeth on the many expositions of Weber's ideal type of bureaucracy. I had devoured the classic empirical work of American organisational sociology – Selznick's examination of bureaucracy and democracy in the Tennessee Valley Authority (1966 [1949]), Gouldner's types of industrial bureaucracy (Gouldner 1954) and Blau's account of mid-20th century American public employment agencies (Blau 1963). Freidson (1963) had not only invited more study of the hospital, but had gathered together an impressive set of contributors to demonstrate the potential that it offered. By the time that the Journal arrived in the UK, more than 30 years had passed since the foundation of the NHS. The moment was right for reviews of this grand exercise in organisation and planning, and sociologists reflected this (Stacey 1976, Atkinson et al. 1979). The first British textbooks in medical sociology contained substantial sections on organisational matters (Cox and Mead 1975, Tuckett 1976), though later, and for a long while, the theme was all but completely to drop from view.

In this paper, I shall suggest a number of reasons why ‘organisations’ has remained so minor a theme in the Journal. I will refer to the magic of the micro in the early years and the shifts and realignments in the middle years that pulled sociology and health policy apart. Once postmodernism began to dominate, it seemed that organisations qua organisations would slip still further down the agenda. Paradoxically, however, this may not be the case. The understanding of organisational process and design – in the guise of governance, public sector renewal and the quest for ‘modernisation’– has much to gain from a closer relation with a sociological community with an understanding of the contested politics of expertise, the rise of social movements and pervading questions of power and domination.

On a more personal note, this paper reviews a period that coincides with my own career as a sociologist and in preparing it, I have repeatedly been struck by how little attention, as a mid-20th century sociologist, I paid to the person behind the text. In today's more reflexive climate, my questions are routinely ‘who works with whom?’ and ‘what are the identities and alliances being forged and solidified by this work?’ While not able to follow up these questions very fully here, I have interspersed the account with aspects of my own biography. When Mills (1959: 8) made his famous remarks about sociology linking personal troubles and public issues, he had in mind the personal troubles of ‘other people’. In writing this review, I found myself repeatedly coming to the rueful conclusion that perhaps Mills meant me too.

Legacies and lacunae

  1. Top of page
  2. Abstract
  3. Introduction
  4. Legacies and lacunae
  5. Health care reform, health policy and sociology
  6. Into the present
  7. Prospect and potential
  8. Acknowledgements
  9. References

The Journal has always aimed to capture the variety of work in the field and to reflect its diversity. A trio of papers in the very first issue was vividly to bear this out as far as the study of organisations was concerned. ‘Normal Rubbish’ set out doctors’ typifications of good and bad patients in an accident and emergency setting (Jeffrey 1979). A contribution on referral processes analysed the fragmented transitions between hospital and community for older patients (Dartington 1979) and a study of decision-making in two Scottish Health Boards explored the extent of decentralisation in planning and the resource imbalances that occurred (Hunter 1979).

It was the first of these three that proved the most influential. Jeffery's paper featured a micro-level, interactionist and phenomenological approach in a genre fast developing, particularly among the Aberdeen group of sociologists whose work was to shape the field (Bloor 1996). It attracted a critique in the Journal (Dingwall and Murray 1983) and was also cited widely over the years. And yet, in Jeffery's work, as in the interactionist work that followed, organisations – in the sense of formally established goal-oriented structures with clear authority structures and boundaries – were the backdrop to the analysis rather than the subject of the investigation itself.

Strauss and his colleagues, indeed, had earlier laid down a gauntlet. ‘Students of formal organisation’, they argued, ‘overestimate the more stable features of organisations’ (Strauss et al. 1963: 148). Order, they contended ‘is something at which members of any society, any organisation, must work’ (1963: 148). The notion of a negotiated order, developed in the context of psychiatric hospitals, was taken forward in these early years in the Journal (Hunter 1981, Roth 1984, also, with less of an organisational focus, Hanson 1985). Both here, and in the interactionist corpus more generally, the enduring features of organisation of work tend to slip from view. The overall impression, one might argue, is that a sociology struggling to be of and not in medicine achieved that result by becoming a sociology in organisations rather than of them1. Judith Blau was all but alone in providing a direct challenge. In her account of the organisation of care in two contrasting settings delivering psychiatric care for children in the USA, she took the alternative position. The assumption behind her study, she stated firmly, is that social structure is an a priori. It ‘has consequences for, among other things, ideology, social exchange, and the nature of decision-making’ (Blau 1980: 282). Sellerberg (1991) in a Swedish study was later to take a somewhat similar position, stressing centralised regulation and non-negotiability2.

Such a line of argument was not at all fashionable in this field in the UK. David Silverman had reviewed conventional work on organisations at the start of the 1970s. He identified five existing schools – human relations, organisational psychology, socio-technical systems, structural-functionalism and decision-making. All five, he argued, ‘looked for explanations in terms of the impersonal mechanisms by which systems secure their stability’ (Silverman 1970: 216). They reified the formal organisation, treating its goals as unproblematic, and ignoring the manner in which the social world was constructed. None adequately acknowledged the subjective meanings that actors brought to the situation. Only one – structural functionalism – actually derived from a sociological frame of reference. But structural functionalism was being discredited. To attempt to study ‘organisations in their own right’ struck at the very foundations of the discipline.

To consider organisations in this way ignores the nature of social life and excludes the very problems which provide the distinctive concerns of Sociology, i.e. the manner in which the social-world is socially constructed and sustained (1970: 218–9).

Silverman's subsequent work and that of colleagues at Goldsmiths’ College, as witnessed in a special issue of the Journal in 1981, followed through on this. Different as this might be compared with other ethnographic work that characterised the Journal, it was similar in eschewing anything that smacked of reification of the organisation.

Located through most of the 1970s inside the world of organisational analysis that Silverman described, my picture was somewhat more fine-grained. The Tavistock Institute, on the one hand transferring the insights of its clinical work to the psycho-dynamics of organisations3 and on the other building on open systems and socio-technical systems thinking (Sofer 1961, Miller and Rice 1967), was on my mental map. It produced a core of scholars and a set of publishing outlets fairly much of its own – the publication of Dartington's article in the Journal being quite an exception. A link with the Fabian heritage was also visible. David Towell, for example, migrated from the Tavistock Institute to become social research advisor at Fulbourn Hospital, involving staff in a series of action research oriented studies in that psychiatric care setting (Towell and Harries 1979), before moving to the King's Fund. The King's Fund, the Hospital Internal Communications Project (Wieland and Leigh 1971, Revans 1972), the work of the Nuffield Provincial Hospitals Trust (see e.g.McLachlan 1977), the expanding volume of work from the Brunel team, closely associated with NHS reorganisation (see e.g.Kogan et al. 1971, Rowbottom et al. 1973, Jaques 1978) – all focused very much on making social science insights and evaluation skills usable for managers in health care settings. There was a clear ‘administrative impetus’ (Stacey with Homans 1978: 283–4) to all of this4. Indeed, Illsley (1975) warned at this point that civil servants were threatening to replace doctors in shaping the field.

For me – in my first academic post and part of a team focused on applying industry-based studies (Woodward 1965) to hospitals – the alternative was the Aston Programme. This seemed to be a more academic project, exploring relations between aspects of organisational structure (Pugh and Hickson 1976, Pugh and Hinings 1976). But I could find nothing to match the excitement of that early sociological work on organisations. I felt adrift. I was happier writing about professions (Davies 1972) than with a paper on the ‘day job’ of studying organisation structures per se, albeit that the latter was accepted for a sociological volume (Davies and Francis 1976). In a review of the relevance of organisation theory, I bemoaned the limited and limiting nature of organisation theory, the ‘wholesale defection’ of sociologists, the failure to continue to ask ‘why?’ questions and to explore relations of power and domination (Davies 1979). Looking back, it was perhaps significant that I elected at that point to work part time with The Open University. Tutoring on a sociological theory course brought me back to Durkheim, Marx and Weber.

Throughout the 1980s, the organisation – be it hospital, clinic or health centre – continued to provide the backdrop rather than the foreground of sociological contributions to the Journal. Individual papers stood out as giving some purchase on organisational functioning through their vivid ethnographic description or skilful juxtaposing of interview materials. Stacey (1980), for example, reported on a multi-disciplinary assessment centre for pre-school, handicapped children. Hughes and colleagues (1987) provided a picture of ‘Ward 20’ and the everyday life of teenagers in a mental handicap hospital and Rawlings (1989) discussed the symbolic significance of hygiene in a hospital setting. But taking forward a more systematic understanding of organisations was rarely the main preoccupation. Ontological angst combined with fears of management combined to keep the concept of formal organisation at bay.

Health care reform, health policy and sociology

  1. Top of page
  2. Abstract
  3. Introduction
  4. Legacies and lacunae
  5. Health care reform, health policy and sociology
  6. Into the present
  7. Prospect and potential
  8. Acknowledgements
  9. References

For a brief moment towards the end of the 1980s, it looked as if sociological interest in the reorganisation of the NHS would be rekindled in the light of the Griffiths general management reforms. Thompson (1987) followed Hunter's earlier article by focusing on coalitions and conflicts in the new structures. I managed to place a piece arguing that fundamental reshaping of the NHS was emerging and that the introduction of a new cadre from industry, if successful, would give an underpinning to this (Davies 1987). Apart from a brief moment a decade later when one issue of the journal carried two papers on the discourse employed by general managers (Hughes 1996, Traynor 1996), however, there were few signs that momentum was gathering.

Books from the researchers who had secured health policy research funding from the Social Science Research Council at the end of the 1970s began to appear in social administration, public administration and political science lists. In 1991, Phil Strong, in one of his characteristically vivid turns of phrase, opened a review of Harrison, Hunter and Pollitt (1990) for Sociology of Health and Illness with the sentence –‘(s)ome curate's eggs are still worth eating’. He complained, however, that there was no wonderment about strangeness, no comment on ‘how odd the world is’ and that sociologists got barely any mention (Strong 1991: 433). The review that immediately preceded this looked at things the other way round. A collection under the title ‘The Sociology of the NHS’ (Gabe, Calnan and Bury 1991), I reasoned, should surely help distinguish between sociology and health policy. Yet somehow it did not do so (Davies 1991). Mike Filby was more direct. ‘Engaging’, ‘cogent’, ‘illuminating’ and ‘pacey’ as was the work of Harrison and Pollitt (1994), he wanted more on the historical and patriarchal domination of the health professions. References to Foucault and a proper tracing of the concept of the ‘frontier of control’ back to its conceptual roots were on his wish list (Filby 1995).

It was not perhaps so much that Griffiths had ‘caught sociologists on the hop’ (Cox 1991) but rather that the health policy analysts grounded their work in a detailed grasp of the contemporary policy and organisational scene that sociologists never sought to match. Their eclectic journeys over the terrain of political science and sociology would always seem inadequate to the specialists. In the steady stream of health policy analysis emerging from the late 1980s onwards, only one major figure from the sociology of health and illness field emerged. Phil Strong whose precarious contract research career had taken him into a newly-established nursing policy unit, worked alongside Jane Robinson to examine the fate of nurses in the new structures. Their resulting book, with its detailed use of quotation and its sociological insights, provided a highly accessible and engaging account of organisational life in the NHS (Strong and Robinson 1990). The view from within this sub-discipline, however, was somewhat disparaging (Bloor 1996: 555) and the book only made it as far as the ‘shorter notices’ in the reviews section of the Journal5.

Others have reflected on this unhappy sociology/health policy join at greater length. David Hunter, invited to review what medical sociology had to offer to the organising and managing of health care, felt that the contribution was ‘in danger of not being made’ (Hunter 1990: 213). There was macro and micro work, but the intermediate level ‘where policy and organisational processes tend to be concentrated’ seemed not to be an altogether legitimate sociological concern. Joel Richman provided a sociological account of this neglect. First, government policy-makers, management scientists and others, he argued, deployed the ‘rationality of one-dimensional formal principles’ of organisational design. They remained at a distance from the day-to-day of hospitals, and started from the assumption that key concepts –‘health’, ‘care’ and ‘patient’, for example, – were simple and uncontested (Richman 1987: 138). Secondly, the patronage of doctors that gave access to the doctor/patient encounter did not easily translate into a move to a study of ‘the administration’. And thirdly, the hospital, unlike the capitalist business organisation, held no strategic significance for the left. UK studies of hospitals and of health care policy tended to be a matter of piecemeal borrowings from elsewhere.

What then was appearing in the Journal by the early 1990s to illuminate organisational aspects of health care? The negotiated order perspective continued to energise writers (Green and Armstrong 1993). It came to focus more, however, on boundary issues between professional groups than on broader organisational practices (see Hughes 1988, 1989, Svensson 1996 – and later Daykin and Clarke 2000, Stevens et al. 2000, Norris 2001; Allen 2000). Emotional labour, planted early on (Strauss et al. 1982), started to become a much clearer theme – sometimes with an organisational focus (James 1992), but more often not. Individual papers again illuminated the changing organisational and policy contexts of health work – a study of computerised patient data systems in renal care (Dent 1990), a paper on American health maintenance organisations (HMOs) for example (Budrys 1993) and a vivid account of hospice care (Lawton 1998). A yen for rather more on organisations and the organisational context of these practices found occasional expression. Margaret Reid (1989: 119), for example, reviewing what she felt was a ‘journalistic’ account of a London community care centre, argued that

we need this kind of valuable evidence – that the NHS can provide fertile ground for developing supportive health care and not at the expense of the patient.

Overall, however, there was still no strong sense of a growing corpus of work on the theme of organisations. It was not that organisational developments in the NHS were being ignored in the academic world. Pettigrew and colleagues (1992) provided an important and wide-ranging study, with much closely observed empirical content on service change. This work was followed up four years later in a volume addressing key themes of new public management and patterns of power and accountability under the Tory quasi-market reforms (Ferlie et al. 1996). Shelved in libraries and bookshops under management or organisation behaviour, however, there has continued to be little traffic between this kind of work and what counts as a sociology of organisations in the health field work (see also Mark and Dopson 1999, Ashburner 2001). Organisational studies, says a recent commentator, have grown out of their base in sociology (Ferlie 2001). Whether the phrase denotes a trajectory or an escape is unclear6. The Journal, for whatever reason, seems to have carried no reviews.

Into the present

  1. Top of page
  2. Abstract
  3. Introduction
  4. Legacies and lacunae
  5. Health care reform, health policy and sociology
  6. Into the present
  7. Prospect and potential
  8. Acknowledgements
  9. References

The gulf between writers on health policy and organisation and sociologists of health and illness has undoubtedly widened in recent years. The influence on the Journal both of Foucauldian and broader postmodernist thinking has been apparent. Concepts such as embodiment, identity, self, narrative, biography, history and risk have prevailed and once again, ‘the organisation’ has been viewed with antipathy. All this would seem a long way from developments in the NHS – the creation, for example, of new kinds of primary care trusts, the emergence of national service frameworks and the new national standard-setting and monitoring bodies. Taking a review of six new books on the sociology of embodiment, for example, it is difficult to see how any kind of consideration of formal organisational arrangements could begin to figure (Turner 1991). And yet, there is a sense in which – through several rather different strands of thinking – organisational phenomena are beginning to come to the fore again. Three particular developments are striking.

First, in a paper in the Journal revisiting and developing and extending Strong's earlier arguments about medical imperialism, Simon Williams (2001) focused on discontent with the prevailing social constructionist approach. One of his arguments (following Conrad 1992) was that medicalisation operates at levels beyond doctor-patient interaction – notably, for the purposes of this paper, at the institutional level. Pursuing this theme, Williams underlines the importance of the state and of corporate constraints on medical power. He refers to shifting clinical boundaries, the rise in litigation and the turn towards complementary medicine. He discusses lay reskilling and active trust/radical doubt as key developments. He cites the recent NHS Plan and the introduction of clinical governance – phenomena that in an earlier era sociologists would perhaps have been content to leave to the policy analysts or to subsume under more abstract discussions of medical dominance. Recent issues of the Journal have begun to explore the significance of new organisational forms and policy developments (see, for example, Milewa et al. 1999, Carpenter 2000, Gunaratnam 2001, Harrison and Dowswell 2002, Hartley 2002, Whittock et al. 2002)7. It is notable too that textbooks, in the late 80s and early 1990s devoid of mention of matters of health care organisation and hospitals, are today also revisiting questions of policy change and the organisation of services (Nettleton 1995: chapters 8 and 9; Annandale 1998: part 3; Clarke 2001: chapter 9).

Secondly, and influenced by Foucault, David Armstrong argued in the Journal for recognition of a ‘fundamental shift in the meaning of the space occupied by the hospital bed’ (Armstrong 1998: 447). His focus was on the re-conceptualisation of activity – new notions of surveillance and risk in particular. But he made direct links with organisational changes – the growing salience of day care, ambulatory services and patterns involving altogether more traffic through previously impermeable hospital walls. The Foucauldian concept of governmentality has also been important in bringing sociologists in recent years in close contact with themes of commissioning, rationing and service planning (Hughes and Griffiths 1999, Joyce 2001). Growing sociological interest in the issue of rationing, indeed, culminated in a special Journal issue late in 2001.

Finally, postmodern and post-structuralist theorising on organisations may itself now be beginning to suggest some new ways forward. An article by Fox (1994) offers a brief guide. Drawing on writers such as Reed (1989), Clegg (1990), Cooper and Burrell (1988), he notes the move away from the organisation as rationality reified towards the organisation as a process which creates a rationalisation and objectification of social life through the fabrication of discourses of knowledge. This constructed rationality, he argues, entails obscuring the contradictions of a situation and because of this, there is constant resistance. A position seemingly similar to the social interactionist corpus that has dominated the Journal, however, turns out not to be so:

in the postmodernist study of organisation, routine is not an outcome of a shared worldview, but the opposite: the imposition of control and constraint by the empowered, through techniques of power mediated by discourse . . . The concern of the postmodern social analyst is not primarily with the minutiae of the outward manifestations of activities . . . but with how these activities . . . serve(s) discourse (Fox 1994: 18–19).

In practice, the theme of continual challenge and disruption receives strong emphasis in his accounts (see also Fox 1995) and for this reason and perhaps because of the empirical subject matter, the line with the negotiated order perspective appears a finer one than it is necessarily the case. Postmodern analysis can deal with situations where resistance is muted, channelled and diverted, and indeed where the spoiling of identities through binary othering (Davies forthcoming) is so powerful a process that it needs collective effort so that subjectivities can be reconstituted, and imagined alternatives can emerge. Such collective efforts are occurring, of course in the health field – not least, through the formation of user support groups and social movement organisations (see e.g. Williams 1989, Rogers and Pilgrim 1991, Crossley 1998, Damen et al. 2000). As highlighted by Fox, postmodern organisation theorising, it seems, has the capacity to offer a taste of the interactionist cake, while at the same time enjoying something of a structuralist flavour.

Prospect and potential

  1. Top of page
  2. Abstract
  3. Introduction
  4. Legacies and lacunae
  5. Health care reform, health policy and sociology
  6. Into the present
  7. Prospect and potential
  8. Acknowledgements
  9. References

If Stacey was right more than a decade ago that there was ‘room for a great deal more sociological work on the organisation of health care’ (Stacey with Homans 1978: 300), just what kind of work is needed? And how might it find and retain its distinctively sociological bearings? From my viewpoint, it is the realignments between the health care professions and between professions, patients and public, that merit particular attention. It is time for sociology to re-engage with the formal organisations that are being created and transformed to adapt to a new climate of ‘modernisation’ of public services and to tease out the impacts of this. In this final section of the paper I sketch in three broad themes for study and comment on some of the ways in which they might start to find some theoretical grounding.

Health care in and beyond the hospital

The hospital, the clinic and the asylum have provided the parameters for what sociological analysis there has been of the formal structures of health care. To think health in the public mind is still to think hospitals. And yet, as Armstrong (1998) has noted, the asylums are now largely closed, and the hospital is now playing a less central role both in its place in the life of the patient and its place in the budget of health care. Developments have gathered pace since 1997 under New Labour. The tracking of actual patient journeys through health and social care services is worth singling out. At one level, this is simply an audit tool. Instead of asking about hospital performance – the well-known throughput measures of deaths and discharges, attention focuses on the patient trekking back and forth – to the GP, to the hospital for tests and results, to the GP, to hospital again and so on. Patient journey data have proved to be a lever for substantial redesign – the elimination of entire visits, the shrinking of waiting times, the creation of one stop diagnostic test centres, the removal of a traditional series of steps in the journey to surgery. At another level, and often with the support of patient lobby groups and professionals, understanding patient journeys has given a basis for starting to put into place new kinds or organisations under the banner of ‘modern’, patient-centred care. Managed clinical networks for cancer care, for example, break down the hospital walls, putting specialist and generalist doctors together with members of the home care team and using IT for virtual as well as real communication. What is the sociological significance when health care no longer coincides with the physical boundaries of organisations and when site management and service management are moving apart as health and social care are moving together? As yet, almost no attention has been paid to the factors prompting the new organisational arrangements, the contradictions in them, their potential impact on patient and professional identities and on conceptualisations of health and health care. The invitation to new thinking about organisation, so powerfully present in Armstrong's article more than a decade ago, has been little heeded.

Re-divisions of health care labour

An array of trends now seems set to transform the traditional, doctor-dominated healthcare division of labour. One precipitating factor has been the dramatically changed media representation of medicine in the wake of scandals over the Bristol doctors, the Alder Hey organ retention issue, and the case of GP Harold Shipman. Public attention has focused on what seems to be an unending catalogue of questionable medical practice, destabilising deference and trust and bringing into question long-established frameworks of professional self-regulation. This in turn gives impetus to a government already convinced of a need for a fundamental ‘culture change’, if its high-street one-stop shops for health care, its nurse-led telephone advice services and its healthy-living centres are to take hold. Behind the multitude of modernisation bodies and the new use of education funding and contracts of employment as levers for change, is thinking that is deeply critical of traditional demarcations between the healthcare professions. New strategic directions have been outlined for each main clinical group. Innovative practice fed by staff shortages and workload pressures in trusts brings nurses and pharmacists, for example, to the fore in primary care. Demonstration projects supported from the centre document some of the issues involved (e.g.Read et al. 1999). Under the banner of opportunity for all, government lifelong learning policy opens up possibilities for new kinds of practitioners, unrecognisable through the old professional labels and boundaries. The rise in popularity of complementary practitioners and the integration of some of these into the fold of recognised professions is a further force for change. The threat to classic professional identity and medical dominance is all the greater given the climate of unprecedented doubt and distrust. It is not just that the organisational arrangements that are starting to be put in place no longer support the institution of profession, they are in some senses in flat contradiction to it. And the old props to medical authority of class, gender and race, though still there, are crumbling as recruitment starts to broaden, and practice begins to be questioned from within. It is hard to see how Sociology of Health and Illness can continue to evaluate its central themes of medicalisation and professional dominance without engaging much more directly with the organisational and policy shifts that are now taking place.

Stakeholder organisations – recontaining and reconceptualising resistance?

A key part of New Labour's modernisation project, building on consumerist developments of the previous administrations, has been a quest to elicit the active involvement of people as citizens and service users in priority-setting, service delivery and monitoring of performance in public services (Milewa et al. 1999). This move has coincided with the destabilisation of professional authority noted above. It has been aided by the growing strength of a consumer movement in health – acting to give support and advice to individuals, to lobby for change but also being given a direct place in decision-making venues (Allsop et al. 2002). This is particularly notable in the lay memberships of the new national standard-setting and monitoring bodies created in the NHS Plan, in the mandatory requirement that these bodies have a service user and public involvement strategy, and in their consequent experimentation with new patient and partner Councils. How will these national level organisations with overt service user stakeholders operate? How far will they be able to put in place practices to facilitate dialogue? How will national and local user involvement mechanisms relate? Will there be a real shift from provider power and new social relations of decision-making beyond bureaucracy and beyond professional dominance? Are we witnessing the rise of new, postmodern organisations as they seek to reconceptualise and re-contain resistance in ways quite different from the familiar organising frames of bureaucracy and profession? Health-care in these respects may become a key site for understanding major themes, the decline of deference and the fragmentation of authority, the quest for social integration in a reconstituted public sphere. Janet Newman (2001: chapter 7) rightly draws attention to the contradictions of New Labour's moves as they threaten to cut across representative democracy and engage or fail to engage with issues of difference and diversity. A study of contradictory lay experiences on statutory regulatory bodies for professions gives some empirical support to this (Davies 2001). Newman's work also makes clear, however, that the new scholarship on governance, networks and open systems is coming from sources outside sociology. It would be ironic indeed if a discipline so centrally concerned with questions of institutional change, legitimacy, professional expertise and social inclusion were to neglect these topics.

What would help to take some of these themes forward? A willingness to engage with some of the most recent theorising about organisations is clearly important. The earlier critiques of writers such as Silverman and Richman are now in key respects out of date and postmodernist thinking on organisations is developing further8. A readiness in the sub-discipline – starting now with a more confident foundation in sociological theory – to explore developments in adjacent areas, particularly political science and political sociology as they engage with changes in the forms of the state and democratic renewal – also seems particularly important. But there is also a matter of creating a closer and more productive relation between theorising of whatever hue and the practice of research. Fox castigated the modernist writers on organisations for failing to achieve a perspective that ‘stands beyond the discourse it criticises’ (Fox 1995: 60). Good sociology, to my mind, always stands beyond what participants know and understand – but it does not always face away from those participants in the manner that our sub-discipline has tended to do in its preoccupation with its own standing in relation to its theorists.

For some, an agenda such as that sketched in this section will be read as a return to the past – to a time when the sociology of health and illness was an applied social science whose problems were defined by others. I have tried to show, however, that the questions that this agenda raises are questions about alternative social relations and social structures, and about constructing the kinds of social solidarity that can energise and expand our horizons. Sociology needs to take seriously the politics of NHS ‘modernisation’ and the aspirations which lie behind it. There is a recognition in it – albeit fleeting, imperfectly sustained, and influenced by power relations from the past – that healthy lives and healthy organisations are deeply intertwined.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Legacies and lacunae
  5. Health care reform, health policy and sociology
  6. Into the present
  7. Prospect and potential
  8. Acknowledgements
  9. References

This paper could not have been completed without the energy and organisational skills of Julie Savage. She not only provided the vital ‘legwork’ chasing references and ordering material and brought electronic search skills, she had an ability to summarise and reflect on documents as someone who had come into the sociology of health and illness at a different time and with different interests. I would like to record my thanks to her and also to Mike Dent for comments on an earlier draft.

Notes
  • 1

    The negotiated order perspective became associated with the study of doctors and patients and later in particular, nurses and doctors. Strauss et al. (1963), however, envisaged something wider and included negotiation with lay administrative staff as part of a potential programme of work.

  • 2

    Both papers drew on the work of Goffman (1961) on total institutions, and on the tradition of attempting to counter dehumanising care that was also present in the UK – see Wing and Brown (1970), King, Raynes and Tizard (1971) and Miller and Gwynne (1972) on longstay residential care. This tradition maintains more of a link with organisations, but, studies of therapeutic communities apart, it did not find its way strongly into the Journal. For a more recent comment on this strand as part of the modernist discourse, see Fox (1995: Chapter 3).

  • 3

    The power of this is only now being more broadly acknowledged – with the rediscovery, for example, of Menzies (1960), the focus on emotions, and publications such as, for example, Obholzer and Roberts (1994). For a recent work in the Journal focusing on organisation, emotions and racial harassment, and demonstrating some of the potential here, see Gunaratnam (2001).

  • 4

    The work of Stacey and her colleagues, firmly located in a sociology department, was itself an important exception, managing to respond to the call for recommendations for practical organisational change, but at the same time to set these in a wider context. See Stacey et al. (1970), Hall and Stacey (1978).

  • 5

    It is notable in the context of the argument here and in the previous section, that Strong himself had departed from a straightforward anti-reification position, arguing that it was as important to look to the system as to the individuals who work within it. His engagement in the introduction to his early book with Goffman's concept of ‘frames’ and his own notion of ‘role formats’ was designed to deal with this (Strong 1979). I am grateful to Basiro Davey for pointing this out to me.

  • 6

    See Ferlie (2001: 24–5) and compare the editors’ introduction, p13.

  • 7

    Articles from outside the UK dealing with new organisational practices have also emerged, see for example Hn Tjora (2000), Berg et al. (2000), Dew (2000). Carpenter's review of mental health policy introduces and calls for more specific comparative work (Carpenter 2000).

  • 8

    See, for example, the sets of debates in Organization, 7, 3, 2000 and in Organization Studies, 18, 1, 1997. Feminist work on organisations is also important and has little acknowledgement in the Journal. It may also be helpful at present to revisit the Tavistock Institute studies given the growing interest in emotions in organisations and the issues which emerge when professionals confront lay people not in the established orderly relations of consultation and care, but as equals in the committee (Brooks and Lomax 2002).

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Legacies and lacunae
  5. Health care reform, health policy and sociology
  6. Into the present
  7. Prospect and potential
  8. Acknowledgements
  9. References
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