Lesley Griffiths

Humour as Resistance to Professional Dominance in Community Mental Health Teams

This paper contributes to the sociological study of humour in health care settings by analysing its use by community mental health team members dealing with referrals made by consultant psychiatrists. It is about humour and hierarchy, and specifically about humour as a strategy used by rank and file team members to resist or attenuate instructions coming from powerful professionals. The paper draws on tape-recorded data from meetings of community mental health teams and describes the ways in which humour is used by participants to subvert or challenge existing occupational hierarchies.

Categorising to exclude: the discursive construction of cases in community mental health teams

This paper examines meetings in which community mental health teams (CMHTs) process referrals from psychiatrists and GPs, to determine whether or not patients should be ‘allocated’ to caseloads. It focuses on the discursive construction of cases, and the way in which some patients are marked out as inappropriate referrals in a process of implicit categorisation that avoids open reference to pejorative or exclusionary labels. While team members do not present their actions as ‘rationing’, references to inappropriateness occur in close proximity to references to resource pressures and claims that referrals are not subject to proper ‘gatekeeping’. Staff may channel such patients towards less intensive treatment options, request more information to delay acceptance on to caseloads, or reject referrals as inappropriate. Thus the care offered to patients not defined as ‘seriously mentally ill’, but referred in the belief that they could benefit from CMHT input, was subject to de facto rationing.

Accomplishing team : teamwork and categorisation in two community mental health teams

This paper describes the social organisation of two newly-formed community mental health teams, examining their differing relationship with team psychiatrists and the resulting constitution of team activities. Different ways of accomplishing ‘team’ had consequences for the ways mental illness was categorised and the target population for services was framed. The attendance or non-attendance of psychiatrists at team meetings, and the framing of meetings as ‘allocation’ or ‘review’, critically affected the nature of teamwork. One team took advantage of the absence of the psychiatrist to resist the bureaucratic framing of its task as ‘allocation’, and gained some autonomy by delaying acceptance of ‘inappropriate’ patients onto caseloads. The second team met regularly with its psychiatrist and was allowed a voice in the ‘review’ of cases, but discussions and decisions fell largely under the control of the dominant professional. Transcripts of team meetings are analyzed to show how the two teams develop divergent discursive repertoires, which are then deployed in the categorisation of patients. The team who meet without the psychiatrist attempt to control their workload by developing a relatively exclusionary definition of serious mental illness which excludes the ‘worried well’, while the other team take a more inclusive approach.

Purchasing in the British NHS: does contracting mean explicit rationing?:

Early commentators on the British NHS reforms argued that the new requirements for health authorities to carry out formal assessments of the health needs of their local populations and contract for clinical services, would force them to be clear about what they purchased and did not purchase. It was predicted that implicit rationing by doctors would give way to explicit rationing by health authorities. Apart from the rationing question per se, there were suggestions that contracts might be used to channel resources towards clinically effective treatments and exclude treatments that are of little benefit. This article draws on a qualitative study of the work of a health authority contracting team to suggest that the picture is more complex. We argue that, rather than occasioning a shift to explicit rationing, contracting has resulted in new forms of implicit rationing. In this connection we discuss: (a) the authorization of ‘extra-contractual referrals’– cases not covered by contracts; (b) health authority pressure on hospitals to limit activity where they seem likely to exceed contracted activity levels; and (c) the impact of the UK Governments Patients Charter initiative, which sometimes diverts resources to achieve waiting times guarantees at the expense of other clinically urgent cases.

Purchasing in the NHS: administered or market contracts?

Contract appears to be enjoying a renaissance in contemporary Britain. The legal theorist Patrick Atiyah (1995) has argued that the return to liberal market policies after 1979 was reflected in a revival of classical contract principles: that, as the wisdom of collective and bureaucratic decision making was challenged, the domain of activities covered by contract expanded at the expense of public regulation. Atiyah is concerned primarily with de-regulation and the resurgence of the doctrine of freedom of contract in private markets. However, if anything, ‘contractualisation’ has had an even more profound impact on the public services, which are undergoing the most radical re-structuring seen since the 1940s. The increasing scope of the contract principle is apparent both in the growth of ‘contracting out’ since the early 1980s, and experiments with internal markets and other quasi-market variants in the 1990s (Harden, 1992; Le Grand and Bartlett, 1993; Harrison, 1993; Vincent-Jones, 1994a; 1994b; Hudson, 1994; Tarn, 1994). ‘Market testing’, ‘franchising’ and ‘management contracts’ are other specific mechanisms that have developed out of competitive tendering.

Opening Pandora's box? Freedom of information and health services research.

The introduction, or extension, of freedom of information legislation in Britain and other Western countries seems certain to influence the climate for health services research. However, researchers should be clear that, although such legislation may improve access to certain types of data, it will also create new problems and dilemmas. Statutory freedom of information regimes are likely to raise difficult issues of adaptation and compliance for health service bodies. Researchers may find that this translates into reluctance to agree access and accentuates difficulties in managing field relationships. They may, inter alia, face difficult dilemmas in deciding whether, or how, to report non-compliance, judging whether to extend research into areas where consent has not been obtained and weighing the benefits of using the official rules to insist on disclosure against the dis-benefits of jeopardising relationships. Health services researchers should regard freedom of information legislation, not simply as a resource, but a topic deserving study in its own right.