Papers by Deborah Swinglehurst
Social Science & Medicine, 2014
In 2004, the English Department of Health introduced a technology (Choose and Book) designed to h... more In 2004, the English Department of Health introduced a technology (Choose and Book) designed to help general practitioners and patients book hospital outpatient appointments. It was anticipated that remote booking would become standard practice once technical challenges were overcome. But despite political pressure and financial incentives, Choose and Book remained unpopular and was generally used reluctantly if at all. Policymakers framed this as a problem of 'clinician resistance'. We considered Choose and Book from a sociological perspective. Our dataset, drawn from a qualitative study of computer use in general practice, comprised background documents, field notes, interviews, clinical consultations (directly observed and videotaped) and naturally occurring talk relating to referral to hospital in four general practices. We used strong structuration theory, Giddens' conceptualisation of expert systems, and sensitivity to other sociological perspectives on technology, institutions and professional values to examine the relationship between the external environment, the evolving technology and actions of human agents (GPs, administrators, managers and patients). Choose and Book had the characteristics of an expert system. It served to 'empty out' the content of the consultation as the abstract knowledge it contained was assumed to have universal validity and to over-ride the clinician's application of local knowledge and practical wisdom. Sick patients were incorrectly assumed to behave as rational choosers, able and willing to decide between potential options using abstracted codified information. Our analysis revealed four foci of resistance: to the policy of choice that Choose and Book symbolised and purported to deliver; to accommodating the technology's socio-material constraints; to interference with doctors' contextual judgements; and to adjusting to the altered social relations consequent on its use. We conclude that 'resistance' is a complex phenomenon with socio-material and normative components; it is unlikely to be overcome using the behaviourist techniques recommended in some health informatics and policy literature.
Data, analytic and methodological considerations in studies of clinician-patient communication
The role of the electronic patient record in the clinical consultation
The Routledge Handbook of Language and Health Communication, 2010
Research evidence growing, yet conclusions still: evidence is conflicting no definitive sol... more Research evidence growing, yet conclusions still: evidence is conflicting no definitive solutions more research needed Gap between the rhetoric (be it Tony Blair ten years ago, or Barack Obama today) and the reality of 'failed' programmes ... Awareness of a broader ...
Acta Psychiatrica Scandinavica, 2004
Office for National Statistics (2002) Social Trends 32. The Stationery Office, London.
Abstract
Background: The quality of information recorded about patient care is considered key to ... more Abstract
Background: The quality of information recorded about patient care is considered key to improving the overall
quality, safety and efficiency of patient care. Assigning codes to patients’ records is an important aspect of this
documentation. Current interest in large datasets in which individual patient data are collated (e.g. proposed NHS
care.data project) pays little attention to the details of how ‘data’ get onto the record. This paper explores the work
of summarising and coding records, focusing on ‘back office’ practices, identifying contributors and barriers to
quality of care.
Methods: Ethnographic observation (187 hours) of clinical, management and administrative staff in two UK general
practices with contrasting organisational characteristics. This involved observation of working practices, including
shadowing, recording detailed field notes, naturalistic interviews and analysis of key documents relating to
summarising and coding. Ethnographic analysis drew on key sensitizing concepts to build a ‘thick description’ of
coding practices, drawing these together in a narrative synthesis.
Results: Coding and summarising electronic patient records is complex work. It depends crucially on nuanced
judgements made by administrators who combine their understanding of: clinical diagnostics; classification systems;
how healthcare is organised; particular working practices of individual colleagues; current health policy. Working with
imperfect classification systems, diagnostic uncertainty and a range of local practical constraints, they manage a moral
tension between their idealised aspiration of a ‘gold standard’ record and a pragmatic recognition that this is rarely
achievable in practice. Adopting a range of practical workarounds, administrators position themselves as both formally
accountable to their employers (general practitioners), and informally accountability to individual patients, in a coding
process which is shaped not only by the ‘facts’ of the case, but by ongoing working relationships which are
co-constructed alongside the patient’s summary.
Conclusion: Data coding is usually conceptualised as either a technical task, or as mundane, routine work, and usually
remains invisible. This study offers a characterisation of coding as a socially complex site of moral work through which
new lines of accountability are enacted in the workplace, and casts new light on the meaning of coded data as
conceptualised in the ‘quality of care’ discourse.
Keywords: Electronic patient records, Ethnography, Quality of care, Coding, Classification, Administration
Background: This article considers the moral notion of care in the context of Quality of Care dis... more Background: This article considers the moral notion of care in the context of Quality of Care discourses. Whilst care
has clear normative implications for the delivery of health care it is less clear how Quality of Care, something that is
centrally involved in the governance of UK health care, relates to practice.
Discussion: This paper presents a social and ethical analysis of Quality of Care in the light of the moral notion of
care and Bourdieu’s conception of symbolic violence. We argue that Quality of Care bureaucracies show significant
potential for symbolic violence or the domination of practice and health care professionals. This generates
problematic, and unintended, consequences that can displace the goals of practice.
Summary: Quality of Care bureaucracies may have unintended consequences for the practice of health care.
Consistent with feminist conceptions of care, Quality of Care ‘audits’ should be reconfigured so as to offer a more
nuanced and responsive form of evaluation.
Keywords: Care, Quality of care, Ethics of care, Bourdieu, Symbolic violence, Audit
In 2004, the English Department of Health introduced a technology (Choose and Book) designed to h... more In 2004, the English Department of Health introduced a technology (Choose and Book) designed to help general practitioners and patients book hospital outpatient appointments. It was anticipated that remote booking would become standard practice once technical challenges were overcome. But despite political pressure and financial incentives, Choose and Book remained unpopular and was generally used reluctantly if at all. Policymakers framed this as a problem of 'clinician resistance'. We considered Choose and Book from a sociological perspective. Our dataset, drawn from a qualitative study of computer use in general practice, comprised background documents, field notes, interviews, clinical consultations (directly observed and videotaped) and naturally occurring talk relating to referral to hospital in four general practices. We used strong structuration theory, Giddens' conceptualisation of expert systems, and sensitivity to other sociological perspectives on technology, institutions and professional values to examine the relationship between the external environment, the evolving technology and actions of human agents (GPs, administrators, managers and patients). Choose and Book had the characteristics of an expert system. It served to 'empty out' the content of the consultation as the abstract knowledge it contained was assumed to have universal validity and to over-ride the clinician's application of local knowledge and practical wisdom. Sick patients were incorrectly assumed to behave as rational choosers, able and willing to decide between potential options using abstracted codified information. Our analysis revealed four foci of resistance: to the policy of choice that Choose and Book symbolised and purported to deliver; to accommodating the technology's socio-material constraints; to interference with doctors' contextual judgements; and to adjusting to the altered social relations consequent on its use. We conclude that 'resistance' is a complex phenomenon with socio-material and normative components; it is unlikely to be overcome using the behaviourist techniques recommended in some health informatics and policy literature.
The introduction of computers into general practice settings has profoundly changed the dynamics ... more The introduction of computers into general practice settings has profoundly changed the dynamics of the clinical consultation. Previous research exploring the impact of the computer (in what has been termed the 'triadic' consultation) has shown that computer use and communication between doctor and patient are intricately coordinated and inseparable. Swinglehurst et al. have recently been critical of the ongoing tendency within health communication research to focus on 'the computer' as a relatively simple 'black box', or as a material presence in the consultation. By re-focussing on the electronic patient record (EPR) and conceptualising this as a complex collection of silent but consequential voices, they have opened up new and more nuanced possibilities for analysis. This orientation makes visible a tension between the immediate contingencies of the interaction as it unfolds moment-by-moment and the more standardised, institutional demands which are embedded in the EPR ('dilemma of attention'). In this paper I extend this work, presenting an in-depth examination of how participants in the consultation manage this tension. I used linguistic ethnographic methods to study 54 video recorded consultations from a dataset collected between 2007 and 2008 in two UK general practices, combining microanalysis of the consultation with ethnographic attention to the wider organisational and institutional context. My analysis draws on the theoretical work of Erving Goffman and Mikhail Bakhtin, incorporating attention to the 'here and now' of the interaction as well as an appreciation of the 'distributed' nature of the EPR, its role in hosting and circulating new voices, and in mediating participants' talk and social practices. It reveals e in apparently fleeting moments of negotiation and contestation e the extent to which the EPR shapes the dynamic construction, display and circulation of authority in the contemporary consultation.
Objective: To investigate how electronic templates shape, enable and constrain consultations abou... more Objective: To investigate how electronic templates shape, enable and constrain consultations about chronic diseases.
Objective: To explore general practitioners' (GP) perspectives on the meaning of 'timeliness' in ... more Objective: To explore general practitioners' (GP) perspectives on the meaning of 'timeliness' in dementia diagnosis.
One of the most pervasive changes in general practice is the introduction of the electronic patie... more One of the most pervasive changes in general practice is the introduction of the electronic patient record (EPR). The EPR supports both immediate clinical and anticipatory care (e.g. management of risk factors). Incorporating the EPR into social interaction is a complex task which is achieved discursively, clinician and patient responding to interactional contingencies as the consultation unfolds. Clinicians are presented with a 'dilemma of attention' as they seek to deal with the immediacy ('here and now') of the interpersonal interaction and the institutional demands ('there and then') of the EPR.
Cosmetic boob jobs' or evidence-based breast surgery: an interpretive policy analysis of the rati... more Cosmetic boob jobs' or evidence-based breast surgery: an interpretive policy analysis of the rationing of 'low value' treatments in the English Abstract Background: In England the National Health Service (NHS) is not allowed to impose 'blanket bans' on treatments, but local commissioners produce lists of 'low value' procedures that they will normally not fund. Breast surgery is one example. However, evidence suggests that some breast surgery is clinically effective, with significant health gain. National guidelines indicate the circumstances under which breast surgery should be made available on the NHS, but there is widespread variation in their implementation. The purpose of this study was to explore the work practices of 'individual funding request' (IFR) panels, as they considered 'one-off' funding requests for breast surgery; examine how the notion of 'value' is dialogically constructed, and how decisions about who is deserving of NHS funding and who is not are accomplished in practice. Methods: We undertook ethnographic exploration of three IFR panels. We extracted all (22) breast surgery cases considered by these panels from our data set and progressively focused on three case discussions, one from each panel, covering the three main breast procedures. We undertook a microanalysis of the talk and texts arising from these cases, within a conceptual framework of interpretive policy analysis. Results: Through an exploration of the symbolic artefacts (language, objects and acts) that are significant carriers of policy meaning, we identified the ways in which IFR panels create their own 'interpretive communities', within which deliberations about the funding of breast surgery are differently framed, and local decisions come to be justified. In particular, we demonstrated how each decision was contingent on [a] the evaluative accent given to certain words, [b] the work that documentary objects achieve in foregrounding particular concerns, and [c] the act of categorising. Meaning was constructed dialogically through local interaction and broader socio-cultural discourses about breasts and 'cosmetic' surgery.
Objective: To identify characteristics of consultations that do not conform to the traditionally ... more Objective: To identify characteristics of consultations that do not conform to the traditionally understood communication 'dyad', in order to highlight implications for medical education and develop a reflective 'toolkit' for use by medical practitioners and educators in the analysis of consultations.
Objective To describe, explore, and compare organisational routines for repeat prescribing in gen... more Objective To describe, explore, and compare organisational routines for repeat prescribing in general practice to identify contributors and barriers to safety and quality. 
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Papers by Deborah Swinglehurst
Background: The quality of information recorded about patient care is considered key to improving the overall
quality, safety and efficiency of patient care. Assigning codes to patients’ records is an important aspect of this
documentation. Current interest in large datasets in which individual patient data are collated (e.g. proposed NHS
care.data project) pays little attention to the details of how ‘data’ get onto the record. This paper explores the work
of summarising and coding records, focusing on ‘back office’ practices, identifying contributors and barriers to
quality of care.
Methods: Ethnographic observation (187 hours) of clinical, management and administrative staff in two UK general
practices with contrasting organisational characteristics. This involved observation of working practices, including
shadowing, recording detailed field notes, naturalistic interviews and analysis of key documents relating to
summarising and coding. Ethnographic analysis drew on key sensitizing concepts to build a ‘thick description’ of
coding practices, drawing these together in a narrative synthesis.
Results: Coding and summarising electronic patient records is complex work. It depends crucially on nuanced
judgements made by administrators who combine their understanding of: clinical diagnostics; classification systems;
how healthcare is organised; particular working practices of individual colleagues; current health policy. Working with
imperfect classification systems, diagnostic uncertainty and a range of local practical constraints, they manage a moral
tension between their idealised aspiration of a ‘gold standard’ record and a pragmatic recognition that this is rarely
achievable in practice. Adopting a range of practical workarounds, administrators position themselves as both formally
accountable to their employers (general practitioners), and informally accountability to individual patients, in a coding
process which is shaped not only by the ‘facts’ of the case, but by ongoing working relationships which are
co-constructed alongside the patient’s summary.
Conclusion: Data coding is usually conceptualised as either a technical task, or as mundane, routine work, and usually
remains invisible. This study offers a characterisation of coding as a socially complex site of moral work through which
new lines of accountability are enacted in the workplace, and casts new light on the meaning of coded data as
conceptualised in the ‘quality of care’ discourse.
Keywords: Electronic patient records, Ethnography, Quality of care, Coding, Classification, Administration
has clear normative implications for the delivery of health care it is less clear how Quality of Care, something that is
centrally involved in the governance of UK health care, relates to practice.
Discussion: This paper presents a social and ethical analysis of Quality of Care in the light of the moral notion of
care and Bourdieu’s conception of symbolic violence. We argue that Quality of Care bureaucracies show significant
potential for symbolic violence or the domination of practice and health care professionals. This generates
problematic, and unintended, consequences that can displace the goals of practice.
Summary: Quality of Care bureaucracies may have unintended consequences for the practice of health care.
Consistent with feminist conceptions of care, Quality of Care ‘audits’ should be reconfigured so as to offer a more
nuanced and responsive form of evaluation.
Keywords: Care, Quality of care, Ethics of care, Bourdieu, Symbolic violence, Audit