Edward Murphy was admitted to hospital with sudden loss of speech, then co-ordination. He had suffered a left frontal lobe infarction resulting in a right hemiplegia (paralysis) and dysphasia (difficulties in processing and formulating language). Married, with one son, Edward's wife, Rhondda, was pregnant. On admission Edward was completely dependent on nursing staff. He was immobile, incontinent and unable to comprehend any auditory or visual information. Two weeks later he began to develop some awareness and started to mobilise with the physiotherapists. However, although his dysphasia had improved, Edward had profound communication difficulties. Over the course of his CTG, both Edward and his wife suffered from depression and the multidisciplinary team often disagreed as they struggled to negotiate satisfactory arrangements for Edward and his family. During Edward's eight months in hospital a variety of care packages was explored, ranging from discharge to home through to placement with a foster family. He was eventually placed in a residential home, where he settled well, attending the day hospital for therapy once a week.
In many respects Edward's circumstances are unusual given his age and social circumstances, but we have selected his case for illustrative purposes because it best exemplifies the key dimensions of CTGs present in the cases we studied. In addition by focusing on the details of a single case, rather than developing a thematic analysis across all cases, we are able clearly to demonstrate the interaction of social process over time and how they are shaped by a multitude of structural, socio-political and organisational factors. This approach has been used to powerful effect elsewhere (Lawton 1998).
CTGs vary in the number of players they involve. In relatively simple CTGs the principal game players comprise the client and a single service provider. More complex CTGs, such as those studied for the purposes of this research project, involve many players, each with different biographies and knowledge. Players also have different levels of experience in playing the game and their power to shape its course varies enormously. Following Elias we predict that as the power differential between the players decreases game complexity increases, amplifying the probability of unexpected outcomes. This is highly significant given recent policy moves in the UK directed at equalising the asymmetries which have historically conditioned inter-professional and professional-user relationships in the public sector. The existence of divergent goals and cultural norms linked to different players also contributes to increased complexity and uncertainty in the course of any CTG.
The players involved in Edward's case were: Edward; his wife (Rhondda); Edward's son, parents, sister, and sister-in-law; consultant; speech and language therapist; senior occupational therapist; occupational therapist; social worker; relief social worker; two senior house officers; senior physiotherapist; physiotherapist; chiropodist; two residential home proprietors; day centre nursing staff; day centre doctor; dermatologist; senior staff nurse; deputy ward manager; ‘PP Homes’ manager; and a researcher. They were representatives from a complex field which encompassed an acute NHS Trust, local authority social services and the private care home sector. This meant that his CTG had to be played out across inter-agency boundaries with different cultures, finances, geographical boundaries, management structures, priorities, professional allegiances and planning cycles. This field is not wholly determined by the CTG players but clearly conditions their abilities to make certain moves.
Resource availability also shapes the complexity of CTGs. Lack of resources can stall a game or lead players into different moves in order to circumvent barriers to progress. The two sites in this study were marked by significant socio-economic differences. The cases in Area 1 lived in electoral wards with higher levels of socio-economic deprivation than those in Area 22. At the time of the study the allocation of health and social services budgets in Wales was based on a weighted per capita basis and therefore failed to fully recognise higher levels of disadvantage (An attempt to address the growing inequalities in health via a review of the funding mechanism is currently underway as the Welsh Assembly Government consult on the changes recommended by Professor Townsend in his report on the allocation of NHS resources in Wales [Townsend 2001]). Although Edward was fortunate enough to live in Area 2, his CTG was shaped by the limited support and facilities for young disabled people. This illuminates a further feature of CTGs which increase their complexity: the atypicality of a case. As Strauss et al. (1985) note, relatively straight-forward trajectories are those which follow a pattern which is well understood by the players concerned and conform to standard operating procedures. Health and social care provision is increasingly being driven by standardised care pathways, national guidelines and local protocols (Berg 1997a,b). CTG complexity will be shaped by the relative balance of routine and non-routine features which characterise a given case.
Edward's CTG was also fashioned in significant ways by disagreement over goals. On one side were Edward and the speech and language therapist who wanted a home discharge. On the other, his wife and the social worker claimed that with a young family to care for Rhondda would be unable to cope and the discharge would be unsafe. Initially a home discharge had been planned and arrangements were put in place to prepare for this, including a home assessment. However the ways in which individual players can shift the trajectory off course became clear during the home assessment when tensions between players became evident and the visit was terminated prematurely owing to the couple's distress.
These issues were then discussed at a case conference called by the speech and language therapist, which included all members of the multidisciplinary team, Rhondda and Edward's son and sister-in-law. Edward's mother and father were invited to the meeting by the speech and language therapist, but arrived late. The meeting began with the speech and language therapist explaining to the family that the purpose of the case conference was to ‘decide with the family and everybody where Edward is going to go’ following discharge from the unit. The speech and language therapist acknowledged Rhondda's concerns and argued that it was important to reach a decision about Edward's discharge destination so that time and effort was not wasted making arrangements if returning home was not a viable option. However, despite her even-handed presentation of the meeting's purpose, throughout the discussion the speech and language therapist (SALT) was at pains to express her preferred position or goal (a home discharge) and/or undermine Rhondda's (RM) justification for her decision not to have Edward home. This is illustrated in the following extract, in which the conversation focused on Edward's communication problems:
SALT to RM: It's the communication that bothers you most.
RM: Mmm. Yeah, because it's no, you can't have a ( . . . ) he can't come up and tell me. You know? ‘I want this’ or you know? [ . . . ] He couldn't tell me ‘I'm tired’ or ‘I've got a pain here’. He can't describe things to me.
SALT: What about then if you asked him questions based on what you think it might be?
RM: Yeah, but I'm there forever aren't I ((Gives an example)) [ . . . ]
SALT: So, you couldn't live with that level of pressure?
RM: (.) See, I don't know. I don't know, like I can't say what he would be like at home?
(Case conference – tape recording)
Here then, the speech and language therapist locates responsibility for the CTG difficulties with Rhondda: it is her inability to cope with the pressure of managing Edward's communication difficulties that has placed the discharge arrangements in jeopardy. The discussion then focuses on community support, which the relief social worker (R.SW) explains is rather limited: a Day Centre is available some days a week but no home care. The scenario described by the social worker indicates a starker view of the reality of taking Edward home than that portrayed by the speech and language therapist and this prompts her to concede the ‘defeat’ of her preferred option. In so doing, however, it is Rhondda's inability to cope rather than the lack of support available to her that she constructs as the decisive factor:
R.SW: But erm (.) I think you've got to be aware that if we are going with the home situation, the responsibility is going to be levelled on your shoulders for most of the time. [ . . . ] So you've got to know what you’re taking on and, you know, what the situation is. [ . . . ] It is a permanent responsibility to know where we’re going with that. And I think it is necessary for us to work with that because, you know, for something to last, or be OK for a couple of months, isn't any good. Because we’re not talking about a couple of months.
SALT: Well, if that is the case, Rhondda, basically you’re saying that you can't have him home. I'm not trying to put words in your mouth but we have to be clear about what the options are.
(Case conference – tape recording)
The meeting is then refocused to consider what new arrangements need to be made in order to make progress in Edward's case. Nevertheless, despite the apparent agreement reached at the case conference meeting that Edward would be unable to return home, throughout the duration of his hospital admission, key members of the multidisciplinary team continued to press for this outcome. This might be seen as an illustration of the difficulty of any one player or set of players being able to control the overall shape of the game. The following discussion takes place two months after the case conference:
SALT: I suggested to Raquel (relief social worker) that since his communication has improved a little, perhaps she would reconsider whether she (Rhondda) would have him at home. [ . . . ]
Senior Staff Nurse: I've spoken to her and she said no way.
SALT: And what's her reason this time?
Senior Staff Nurse: Still that she's got a lot on her plate. That she's now nearly, nearly due [ . . . ] and he's not going to have time to settle in.
(Multi-disciplinary team meeting – fieldnotes)
The tension between the SALT and Rhondda are very evident in this extract. Formally, CTGs are co-operative games, underpinned in the UK by a policy rhetoric which emphasises the centrality of individually-tailored packages of care, negotiated in partnership with users and their carers and, where appropriate, characterised by interprofessional and interagency collaboration and team working. However, our cases revealed inter and intra professional disagreements, disagreements between members of the multi-disciplinary team and families, and disagreements between different members of the same family including patients. Notice, in the above extract, how the SALT subtly undermines Rhondda's credibility through the implication that her ‘reasons’ not to have Edward home are situated and shifting, i.e. excuses, rather than being founded on substantive concerns. Edward's case was also shaped by the existence of a strained relationship between his wife and his own relatives: Rhondda's decision not to have Edward home was informed by the belief that she would receive no help from Edward's family:
RM: Well, like I say (.) well because as you say, [ . . . ] the care is not going to be there, it will be me (.) then, you know? Obviously his family is not here ((attending case conference)), which is a prime example. So, erm, you know?
(Case conference – tape recording)
As in the classic case of the prisoner's dilemma (Axelrod and Hamilton 1981)3, players have to make strategic decisions about whether to compete or co-operate with other players in order to expedite their game plan and this can result in regrouping and alliance formation. CTGs can be transformed into competitive games or at least contain competitive elements, thereby increasing their complexity. Such competition can be overt or covert and, as Elias (1978) has observed, it can result in different divisions and alignments within the overall game structure, which impact on its course and direction. All players are alert to the possibility that competitive sub-games may develop and attempt to guess how others are playing in order to anticipate their next move.
The disagreements over Edward's discharge arrangements resulted in the development of competitive elements in his CTG. For example, certain members of the multidisciplinary team expressed suspicion that Rhondda was attempting to use Edward's condition to assist her application for re-housing even though a decision appeared to have been taken that he was not going home:
Senior occupational therapist: His wife rang our main department this week. She wanted to have a copy of my home visit report, regarding housing (.) And she's seen me since but hasn't acknowledged this, so it's all a bit peculiar. Whether she's trying to go ahead with the housing situation regardless of where he's going. I'm not sure. [ . . . ]
Senior staff nurse: I think she is still using his case as the reason to get re-housed.
(Multidisciplinary team meeting – tape recording)
Irrespective of the veracity of these claims (which we were unable to establish), it is possible to see in this extract an example of the way in which an account of Edward's wife's motives are constructed which clearly comes into conflict with any notion of having Edward's best interests at heart. Rhondda's behaviour is formulated as both dishonest and governed by self-interest, as she ‘uses his case as the reason to get rehoused’. Thus a kind of moral blaming is taking place whereby her refusal to support the favoured outcome and care for her husband at home is linked to other proffered information, which is selectively interpreted, so as to discredit her character. This representation of Rhondda's motives has a clear function in terms of the competitive game; she is discredited as a player and her input into the game can justifiably be disregarded by those who remain committed to the goal of determining the ‘best’ outcome for Edward.
Elias predicts that as game complexity increases, players may fragment and regroup. This is evident in Edward's CTG which was shaped by a number of key co-operative alliances. Central to this was his relationship with the speech and language therapist (SALT). Owing to his communication difficulties the speech and language therapist took a lead role in his case and was a strong advocate for Edward throughout. In addition, when Rhondda indicated her reluctance to have Edward home, the speech and language therapist and other team members attempted to establish an alliance with Edward's parents in order to achieve their preferred objectives:
Senior occupational therapist: We wanted to get his parents involved. His wife was talking about sending him to London. His parents live in South Wales and I don't think they'd be happy with that. So, we want to give them the option. We don't want them to turn around at a later date and say ‘Nobody asked us what we wanted’. It’ll be good to get them involved anyhow because it'd be awful for him to feel abandoned.
In the event, the attempt to secure a co-operative relationship with Edward's parents was unsuccessful. The family arrived late for the crucial case conference, by which time all the key decisions had been made. Furthermore, they were unable to offer to care for Edward at home because they planned to be overseas for a prolonged period. It is revealing to note that Edward's parents’ actions – their failure to attend case conference meetings and their plans for overseas travel – do not lead to the same negative formulation of character that Rhondda receives. This suggests that the team's reactions to Rhondda are in part a reflection of the fact that her actions contravene cultural expectations about the relationship between husband and wife which require commitment for better for worse, in sickness and in health and highlight how, in any given CTG, a range of different social norms are available to players which can be brought into play as a warrant for action in a particular situation (Hughes and Griffiths 1997). CTG complexity will be enhanced if there are multiple conflicting cultural norms available in a given case.
In this case, realising that her decision had alienated her from certain members of the multidisciplinary team, Rhondda formed an alliance with the social worker, who was more sympathetic to her situation and in so doing brings into play another cultural norm: that parents should prioritise the needs of their children:
Relief social worker: Rhondda is aware that she's become the villain of the piece.
SALT: What, on the unit?
Relief social worker: Yes. She's not stupid. She's confided in me about having him back. It would be the easiest thing in the world for her to have him back, to go along with everything and pretend there's no problem. But she's being very wise.
It is helpful to remind ourselves of the contrast between this version of Rhondda's behaviour ‘she's being very wise’ and that produced by the hospital based team in the previous extract (‘she's using him to get rehoused’). The social worker's alliance with Rhondda continued to be a powerful influence on Edward's trajectory and served to bring the direction of Edward's care closer to what was desirable to Rhondda despite what was by now a clear challenge from the speech and language therapist (supported by some members of the hospital team) as to what might be the best outcome in this case.
The disagreements within the multidisciplinary team and between certain team members and Edward's wife resulted in a struggle to control the pace of the decision-making processes about Edward's discharge arrangements. This was evident during the case conference meeting. Ordinarily it is the social worker (R.SW) who would take the lead role in organising discharge, however, as Edward's self-appointed advocate, the speech and language therapist (SALT) adopted an assertive role by seizing the initiative when it became apparent that Rhondda did not wish to have Edward home:
SALT: So, erm, my next issue really is because of his communication (.) we need to get across to Edward that that is the situation before we think about offering him other situations, and see what there is. He's to be given the opportunity to say what he feels about that.
SALT: [ . . . ] I think that that is probably the next move. [ . . . ] But because of his understanding problem we still have to take time to get that across to him rather than whisk him away and put him somewhere where he's not really come to terms with the fact that he's not going home.
(Case conference – tape recording)
It is at this point that it emerged that the social worker and Rhondda have already arranged to visit alternative accommodation and, despite the speech and language therapist's (SALT's) efforts to control the pace of the game, the social worker (R.SW) offers a different plan, retaining control over the timing of events:
R.SW: Well, I've already spoken to Rhondda about Cheshire Homes which (.) I've made quite a lot of enquiries and to my mind it's the only option for him. [..] It's thin on the ground that cater for people in residential setting with disabilities . . . [ . . . ] Rhondda has already made arrangements to go this afternoon . . .
SALT: Oh, right.
R.SW: . . . to have a look at it. So, we let you go ahead with that. Encourage you to go ahead and ask all the questions you want. And then come back to me and say what your impressions are, because, correct me if I'm wrong, say for instance that you hated it and you thought, ‘No, this is not the place for Edward.’ You know? We'd have to rethink things completely. So, at this stage, I don't think it would be, erm, (.) constructive to start the process of Edward understanding about the home situation.’
(Case conference – tape recording)
This example of developments away from the main field of play is one of many in our data and clearly illustrates that CTGs take place within a network of games. Furthermore, as Elias observes, as complexity increases the likelihood of players having access to all relevant information is compromised. We suggest that it is this type of incident that contributes to players’ perception that the game has taken on a course of its own which is beyond the control or comprehension of any one player.
It then emerged that the speech and language therapist (SALT) was about to go on holiday for two weeks. It is possible therefore that her position was informed by her desire to ensure that Edward was informed of his wife's decision before starting annual leave, providing another example of the way in which games interpenetrate one another. After some discussion, however, it was agreed that nothing more would be communicated to Edward until Rhondda had visited alternative accommodation and the speech and language therapist (SALT) had returned from her holiday. As Elias predicts, however, increased CTG complexity increases the possibility of unanticipated outcomes and, in Edward's case, this was evident in the actions of the speech and language therapist (SALT) who, despite the agreement reached at the case conference, informs Edward about his wife's decision not to have him home. Furthermore, she fails to communicate this information to Rhondda or other key members of the multidisciplinary team in the case, contributing further to the inability of any one team member to access all the knowledge and information available in order to judge the impact of any next move:
Senior staff nurse: Megan ((speech and language therapist, who is now on holiday)) told him [about his wife's decision not to have him home]. But unfortunately, nobody had phoned his wife to tell her that he knew they were no longer going to be together. And of course, then she came in on Tuesday not knowing what was wrong with him and he was all upset. [ . . . ] She went ballistic, that it was unprofessional, that he shouldn't have been told, if he was told, somebody should have called her and told her. And she's not happy with the whole situation at all.
(Multidisciplinary team meeting – tape recording)
The fragmented picture with which players in Edward's CTG were operating was also evident later in this case when it emerged that the social worker (R.SW) was also unaware of the speech and language therapist's (SALT's) actions. The following extract reports on a conversation between the researcher and the social worker about Edward's case:
R.SW: Since from the meeting we’ll have a fortnight while Megan (SALT) is away because nothing . . . everything is in limbo until Megan comes back because nobody is even remotely thinking. Even if she'd gone there and thought it was wonderful, nobody was gonna tell him anything about it until Megan is back.
Senior occupational therapist: ((Peggy, who has overheard our conversation, interjects)): He has been told.
R.SW: He has?
Senior occupational therapist: Yeah, he has because Megan couldn't go away without telling him. He knew something was up. So she has told him that Rhondda cannot have him at home.
Senior occupational therapist: There was no way that she could leave it because she came out of the meeting and he knew something was going on.
R.SW: Right. And so she's told him. Right, in that case . . .
Senior occupational therapist: If you want to look in his medical notes, she's written a whole thing on it.
R.SW: Is he all right?
Senior occupational therapist: He's been OK.
Occupational therapist: He's indicated his own wishes as well in terms of where he wants to go. She's written it all down. [ . . . ]
R.SW: Right. Well I'm glad you told me that. I was not aware of that. Erm, she wasn't either was she because (.) she was under the impression that he didn't know anything about this at the moment. So she needs to be told that because obviously it's going to present an awkwardness between them. He knows what she's thinking, but she doesn't know that he knows that she knows. [ . . . ]
Senior occupational therapist: Well, if you’re happy to tell her that's fine. [ . . . ]
Occupational therapist: I think that what it was, when they finished the meeting Rhondda walked straight past him. And he could see that she was in floods of tears. And obviously she didn't make any attempt to speak with him, so (.)
R.SW: Right. Right. So matters sort of came to a head. Well, anyway, that's life isn't it.
(Fieldnotes – tape recorded conversation)
Rhondda and the multidisciplinary team explored a number of options for Edward when it was decided that he would not be returning home. They finally settled on the ‘PP Home’, a specialist facility designed to encourage independent living. As Edward's discharge date approached, however, it emerged that the ‘PP Home’ would be unavailable as there had been a delay in vacating the place he had been assigned. Edward was aggrieved by this turn of events and alternative arrangements in a residential care home had to be organised temporarily. Within a week of his discharge, a ‘PP Home’ place then became available. Having settled into alternative accommodation and dissatisfied by the withdrawal of the original offer, Edward refused the place. His communication difficulties meant that he had been excluded from participating in many of the meetings to discuss his future but in this case the decision to remain was his own. The varying degrees of power or influence available to each player and the way in which participation in different stages of the game offers opportunities to enhance that influence over events are poignantly illustrated by Edward's difficulties. He was clearly unaware of an informal ‘rule of the game’ and his failure to adequately demonstrate enthusiasm for an independent living centre by taking a place immediately meant that he was unlikely to be given a second chance when another place became free:
SW: I think they've got the view that if he doesn't go there now, then they don't want to know him. [ . . . ] if he doesn't show the enthusiasm and commitment to it now, then that's your chance gone, sort of thing.
At the end of the study, Edward had settled well into his new accommodation from where he attended the day hospital for therapy once a week.