Governing the ethical consumer: identity, choice and the primary care medical encounter

'Don't freak out if you get a letter saying cancer patient pathways!': Communication work between different demands in cancer care

This article explores healthcare professionals' experiences of their work with patient communication in standardised cancer patient pathways (CPPs). The theoretical and methodological framework for this study is institutional ethnography. Data were collected through semi-structured interviews with 72 healthcare professionals, including general practitioners, specialist physicians and other hospital staff, in five Norwegian hospitals. The study reveals four aspects of communication work that illuminate how the CPP policy mediates the way healthcare professionals interact with patients through communicating continuity, communicating (by dodging) the dreaded C-word, communicating patient participation, and communicating the relevance of time. Healthcare professionals' balancing of their different experiential realities run as a common thread through the four aspects of communication work identified in this study. The CPP policy, with its explicit focus on transparency, speed, and time frames creates challenges in an already delicate situation.

The role of patients in the governance of a sustainable healthcare system: A scoping review

Patients, healthcare providers and insurers need a governance framework to establish the ‘rules of use’ to deliver more responsible use of services. The objective of this review was to provide an overview of frameworks and analyze the definitions of patient accountability to identify themes and potential gaps in the literature. Fifteen bibliographic databases were searched until July 2021. This included: MEDLINE, EMBASE, CINAHL, PsycINFO, SPORTDiscus, Allied and Complementary Medicine Database, Web of Science, HealthSTAR, Scopus, ABI/INFORM Global, Cochrane Library, ERIC, International Bibliography of the Social Sciences, Sociological Abstracts, Worldwide Political Science Abstracts and International Political Science Abstracts. Searches were also completed in Google Scholar. Inclusion criteria included articles focused on accountability of patients, and exclusions included articles that were not available, not written in English, with missing information, and commentaries or editorials. In total, 85530 unique abstracts were identified, and 27 articles were included based on the inclusion criteria. The results showed that patient accountability is rarely used and poorly defined. Most studies focused on what patients should be held to account for and agreed that patients should be responsible for behaviours that may contribute to adverse health outcomes. Some studies promoted a punitive approach as a mechanism of enforcement. Most studies argued for positive incentives or written agreements and contracts. While many studies recognized the value of patient accountability frameworks, there was a concern that these frameworks could further exacerbate existing socioeconomic disparities and contribute to poor health-related behaviours and outcomes (e.g., stigmatizing marginalized groups). Shared models of accountability between patients and healthcare providers or patients and communities were preferred. Before committing to a patient accountability framework for improving patient health and sustaining a healthcare system, the concept must be acceptable and reasonable to patients, providers, and society as a whole.

Maneuvering the care puzzle: Experiences of participation in care by frail older persons with significant care needs living at home

PURPOSE

Despite evidence that older persons want to be involved in care, little is known about how frail older people with significant care needs living at home experience participation in care provided by different stakeholders. This study investigates the experiences of participation in care by older people following their involvement in an intervention of a health care model called Focused Primary care (FPC).

METHODS

Individual semi-structured interviews were conducted with 20 older persons in five municipalities in Sweden.

RESULTS

The results show that older persons highlighted opportunities and limitations for participation on a personal level i.e., conditions for being involved in direct care and in relation to independence. Experiences of participation on organizational levels were reported to a lesser degree. This included being able to understand the organizational system underpinning care. The relational dimensions of caregiving were emphasized by the older persons as the most central aspects of caregiving in relation to participation.

CONCLUSIONS

Primary care should involve older persons more directly in planning and execution of care on all levels. An ongoing connection with one specialized elderly team and a coordinating person in Primary care who safeguards relationships is important for providing participation in care for frail older persons with significant care needs living at home.

Medical consumerism in the UK, from 'citizen's challenge' to the 'managed consumer'-A symbol without meaning?

Background

In Britain's National Health Service (NHS), medical consumerism is disliked by many doctors but managed by NHS leaders. Managed consumers have choices about treatment options, but are expected to help contain costs, improve quality of care, take part in clinical research and advocacy, and increase productivity. There are so many meanings for medical consumerism that it can be categorized, in post‐structuralist terms, as a ‘symbol without meaning’, but meanings are plentiful in the NHS.

Policy expectations

Choices made by discriminating consumers were expected to improve the quality of medical care for all. Extending choice to the many, and not restricting options to the few, would allow gains from choices to accumulate, so that choice would sustain social solidarity. Managed consumerism would in theory, therefore, instil reasonable choices and responsible behaviours in a moralized citizenry, across the nation. The advocates of New Labour's espousal of medical consumerism expected the accumulative effects of customer choices to challenge professional and occupational power, erode the medical model of health and illness, constrain professional judgements, and open the NHS to new ways of working. Almost all their expectations have been thwarted, so far.

Conclusions

Managed consumerism is far from being a meaningless symbol. This discussion paper explores the territory of managed consumerism and suggests realistic ways to make it more effective in shaping the NHS.

Patient & Public Contribution

We developed the arguments in this discussion paper with insights provided by a lay expert (see Acknowledgements) with experience of consumerism in both public sector management and a disease‐related charity.

Patient preferences: a Trojan horse for evidence-based medicine?

The evidence-based medicine (EBM) movement has long acknowledged the relevance of patient preferences and values. According to EBM, clinicians first clarify the medical evidence about the benefits and burdens of the treatment in question and then, as a second step, elicit values and preferences from patients. Importantly, however, values are placed on patient-relevant outcomes. Surrogate endpoints are only used if their validity is proven. This article shows that some recent patient-preference studies attribute value to surrogate endpoints even when there is no improvement in patient-relevant outcomes. The article points out their foundation in neoclassical economics and discusses their clash with principles of EBM and medical ethics.

When choice becomes limited: Women's experiences of delay in labour

Choice and patient involvement in decision-making are strong aspirations of contemporary healthcare. One of the most striking areas in which this is played out is maternity care where recent policy has focused on choice and supporting normal birth. However, birth is sometimes not straightforward and unanticipated complications can rapidly reduce choice. We draw on the accounts of women who experienced delay during labour with their first child. This occurs when progress is slow, and syntocinon is administered to strengthen and regulate contractions. Once delay has been recognized, the clinical circumstances limit choice. Drawing on Mol’s work on the logics of choice and care, we explore how, although often upsetting, women accepted that their choices and plans were no longer feasible. The majority were happy to defer to professionals who they regarded as having the necessary technical expertise, while some adopted a more traditional medical model and actively rejected involvement in decision-making altogether. Only a minority wanted to continue active involvement in decision-making, although the extent to which the possibility existed for them to do so was questionable. Women appeared to accept that their ideals of choice and involvement had to be abandoned, and that clinical circumstances legitimately changed events.

What Influences Patients' Decisions When Choosing a Health Care Provider? Measuring Preferences of Patients with Knee Arthrosis, Chronic Depression, or Alzheimer's Disease, Using Discrete Choice Experiments

OBJECTIVE

To investigate what influences patients' health care decisions and what the implications are for the provision of information on the quality of health care providers to patients.

DATA SOURCES/STUDY SETTING

Dutch patient samples between November 2006 and February 2007.

STUDY DESIGN

Discrete choice experiments were conducted in three patient groups to explore what influences choice for health care providers.

DATA COLLECTION

Data were obtained from 616 patients with knee arthrosis, 368 patients with chronic depression, and 421 representatives of patients with Alzheimer's disease.

PRINCIPAL FINDINGS

The three patients groups chose health care providers on a different basis. The most valued attributes were effectiveness and safety (knee arthrosis); continuity of care and relationship with the therapist (chronic depression); and expertise (Alzheimer's disease). Preferences differed between subgroups, mainly in relation to patients' choice profiles, severity of disease, and some background characteristics.

CONCLUSIONS

This study showed that there is substantial room for (quality) information about health care providers in patients' decision processes. This information should be tailor-made, targeting specific patient segments, because different actors and factors play a part in their search and selection process.

Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study

Introduction

Patient safety research has tended to focus on hospital settings, although most clinical encounters occur in primary care, and to emphasize practitioner errors, rather than patients' own understandings of safety.

Objective

To explore patients' understandings of safety in primary care.

Methods

Qualitative interviews were conducted with patients recruited from general practices in northwest England. Participants were asked basic socio‐demographic information; thereafter, topics were largely introduced by interviewees themselves. Transcripts were coded and analysed using NVivo10 (qualitative data software), following a process of constant comparison.

Results

Thirty‐eight people (14 men, 24 women) from 19 general practices in rural, small town and city locations were interviewed. Many of their concerns (about access, length of consultation, relationship continuity) have been discussed in terms of quality, but, in the interviews, were raised as matters of safety. Three broad themes were identified: (i) trust and psycho‐social aspects of professional–patient relationships; (ii) choice, continuity, access, and the temporal underpinnings of safety; and (iii) organizational and systems‐level tensions constraining safety.

Discussion

Conceptualizations of safety included common reliance on a bureaucratic framework of accreditation, accountability, procedural rules and regulation, but were also individual and context‐dependent. For patients, safety is not just a property of systems, but personal and contingent and is realized in the interaction between doctor and patient. However, it is the systems approach that has dominated safety thinking, and patients' individualistic and relational conceptualizations are poorly accommodated within current service organization.

New technology and illness self-management: Potential relevance for resource-poor populations in Asia

Advances in technology have made it possible for many standard diagnostic and health monitoring procedures, traditionally carried out by qualified personnel within medical facilities, to be reliably undertaken by patients or carers in their own homes with a minimum of basic training. There has also been a dramatic increase in the number and diversity of both sources of information on health issues and the possibilities for sharing information and experiences over ICT-based social networks. It has been suggested that these developments have the potential to 'empower' patients, reducing their dependence on providers and possibly improving their quality of care by increasing the volume and timeliness of diagnostic data and encouraging active self-management of their condition, for example through lifestyle changes. Perhaps more significantly, it is also seen by many economies with ageing populations as a way to contain high and ever rising healthcare costs. It has also been suggested that a move to greater self-management supported by expert networks and smart phone technology could improve the treatment of many millions of patients with chronic diseases in low and middle income economies that are also confronting the potential cost implications of epidemiological and demographic transitions, combined with the higher expectations of a more educated and knowledgeable population. There is now limited evidence that some fairly basic e- and mHealth interventions, for example in the areas of MNCH, malaria and HIV/AIDS can have a positive impact, even in resource-poor contexts. The aim here is to explore the extent to which further investment in technology could play a role in the development of an effective and affordable health sector strategy for at least some developing economies. It is suggested that the effectiveness of the approach may be highly dependent on the specific health conditions addressed, the nature of existing health systems and the overall socio-economic and cultural context.

Understanding Help Seeking for Chronic Joint Pain: Implications for Providing Supported Self-Management

Osteoarthritis-related joint pain is prevalent and potentially disabling. United Kingdom clinical guidelines suggest that patients should be supported to self-manage in primary care settings. However, the processes and mechanisms that influence patient consultation decisions for joint pain are not comprehensively understood. We recruited participants (N = 22) from an existing longitudinal survey to take part in in-depth interviews and a diary study. We found that consultation decisions and illness actions were ongoing social processes. The need for and benefits of consulting were weighed against the value of consuming the time of a professional who was considered an expert. We suggest that how general practitioners manage consultations influences patient actions and is part of a broader process of defining the utility and moral worth of consulting. Recognizing these factors will improve self-management support and consultation outcomes.

'Why must I wait?' The performance of legitimacy in a hospital emergency department

This article examines the processes of negotiation that occur between patients and medical staff over accessing emergency medical resources. The field extracts are drawn from an ethnographic study of a UK emergency department (ED) in a large, inner city teaching hospital. The article focuses on the triage system for patient prioritisation as the first point of access to the ED. The processes of categorising patients for priority of treatment and care provide staff with the opportunities to maintain control over what defines the ED as a service, as types of work and as particular kinds of patients. Patients and relatives are implicated in this categorical work in the course of interactions with staff as they provide reasons and justifications for their attendance. Their success in legitimising their claim to treatment depends upon self-presentation and identity work that (re)produces individual responsibility as a dominant moral order. The extent to which people attending the ED can successfully perform as legitimate is shown to contribute to their placement into positive or negative staff-constituted patient categories, thus shaping their access to the resources of emergency medicine and their experience of care.

The drugs don't sell: DIY heart health and the over-the-counter statin experience

This paper draws on a study of over-the-counter statins to provide a critical account of the figure of the 'pharmaceutical consumer' as a key actor in the pharmaceuticalisation literature. A low dose statin, promising to reduce cardiovascular risk, was reclassified to allow sale in pharmacies in the UK in 2004. We analysed professional and policy debates about the new product, promotional and sales information, and interviews with consumers and potential consumers conducted between 2008 and 2011, to consider the different consumer identities invoked by these diverse actors. While policymakers constructed an image of 'the citizen-consumer' who would take responsibility for heart health through exercising the choice to purchase a drug that was effectively rationed on the NHS and medical professionals raised concerns about 'a flawed consumer' who was likely to misuse the product, both these groups assumed that there would be a market for the drug. By contrast, those who bought the product or potentially fell within its target market might appear as 'health consumers', seeking out and paying for different food and lifestyle products and services, including those targeting high cholesterol. However, they were reluctant 'pharmaceutical consumers' who either preferred to take medication on the advice of a doctor, or sought to minimize medicine use. In comparison to previous studies, our analysis builds understanding of individual consumers in a market, rather than collective action for access to drugs (or, less commonly, compensation for adverse effects). Where some theories of pharmaceuticalisation have presented consumers as creating pressure for expanding markets, our data suggests that sociologists should be cautious about assuming there will be demand for new pharmaceutical products, especially those aimed at prevention or asymptomatic conditions, even in burgeoning health markets.

Terminally ill patients as customers: the patient's perspective

BACKGROUND

Consumerism in health care defines patients as self-determined, rational customers. Yet, it is questionable whether vulnerable patients, such as the terminally ill, also fulfill these criteria. Vulnerable contexts and the patient's perspective on being a customer remain relatively unexplored. The present study addresses this research gap by analyzing terminally ill patients' views on being customers.

AIM

To explore the ways in which patients in palliative care refer to themselves as patients/customers, and how the patients' concepts of self-determination are related to their attitudes toward the patient/customer role.

DESIGN

Qualitative interviews were conducted. Data were analyzed in three steps: narrative analysis, thematic content analysis, and typology construction.

SETTING/PARTICIPANTS

Researchers recruited 25 patients via the Department of Palliative Care, University Medical Center Freiburg, Germany.

RESULTS

In many ways, palliative patients contradict the image of a self-determined customer. The palliative patient role is characterized by the concept of relational self-determination rather than an unrestricted self-determination. Self-attribution as a customer still occurs when positively associated with a person-centered, individualized treatment. Thus, the customer and patient role overlap within the palliative care setting because of the focus on the individual.

CONCLUSIONS

The idealized customer role cannot be arbitrarily applied to all medical fields. Palliative patients are dependent on the physician, regardless of whether the customer or patient role is preferred. Hence, self-determination must be understood in relational terms, and physicians must recognize their crucial role in promoting patients' self-determination in the context of shared decision-making.

'The onus is on me': primary care patient views of Medicare-funded team care in chronic disease management in Australia

BACKGROUND AND OBJECTIVE

This study investigated the views of primary care patients in receipt of Medicare-funded team care for chronic disease management (CDM) in Australia.

DESIGN

A qualitative study using a repeat in-depth interview design.

PARTICIPANTS AND SETTING

Twenty-three patients (17 female), aged 32-89, were recruited over a six-month period from two purposively selected general practices: one urban and one regional practice in Queensland, Australia.

DATA COLLECTION PROCEDURE

Semi-structured interviews were conducted with participants 6 months apart. An interview guide was used to ensure consistency of topics explored. Interviews were recorded and transcribed, and a thematic analysis was conducted.

RESULTS

Patients in this study viewed the combined contributions of a GP and other health professionals in team care as thorough and reassuring. In this case of Medicare-funded team care, patients also saw obligations within the structured care routine which cultivated a personal ethics of CDM. This was further influenced by how patients viewed their role in the health-care relationship. Aside from personal obligations, Medicare funding got patients engaged in team care by providing financial incentives. Indeed, this was a defining factor in seeing allied health professionals. However, team care was also preferential due to patients' valuations of costs and benefits.

CONCLUSION

Patients are likely to engage with a structured team care approach to CDM if there is a sense of personal obligation and sufficient financial incentive. The level of engagement in team care is likely to be optimized if patient expectations and preferences are considered in decisions.

Traditional medicines, collective negotiation, and representations of risk in Indian cancer care

Cancer is emerging as a key disease in India, but there has been virtually no research exploring understandings of cancer and practices of communication within oncology settings. This is despite the fact that the Indian context presents clinicians, patients, and family members with a range of unique challenges, including those related to disease awareness, interpersonal dynamics, and the use of traditional, complementary, and alternative medicines (TCAM). Drawing on a series of qualitative interviews with 22 Delhi-based oncology clinicians, in this article we examine clinicians' accounts of communication with their cancer patients. The interviews reveal the challenges of communication given cancer's relative novelty, cultural practices around collective negotiation, and rhetorical practices evident in advice-giving regarding TCAM. We conclude that with cancer set to become a major burden in India, research exploring competing forms of expertise, the politics of representation, and the nexus between traditional beliefs and techno-scientific development is urgently needed.

Empowerment and bariatric surgery: negotiations of credibility and control

Today obesity is understood as a chronic illness. Programs developed to deal with obesity often build on an explicit aim to "empower" patients to take increased responsibility for their health, in line with contemporary neoliberal discourses. There is little empirically based knowledge about this so-called empowering process. In this article we focus on how an empowering program for patients diagnosed as morbidly obese worked on individuals' identity. The program encompassed a course in lifestyle change, bariatric surgery, and aftercare. We conducted qualitative interviews with 9 individuals at different stages of their treatment process and applied discourse analysis to interpret their constructions and negotiations as they progressed through the program. We found that dimensions of control and credibility framed the respondents' identity work. Based on the findings we suggest that contemporary discourses of empowerment as practice might leave the participants "trapped" within the ambivalence of freedom and control.

Overcoming stigma: how young people position themselves as counselling service users

Increasing attention has been focused on adolescent help-seeking in relation to services aimed at promoting mental health and wellbeing. Much research reinforces the ubiquity of concerns about negative stigmatisation by peers as a barrier to young people accessing services. This paper draws on interviews conducted with young people, who completed a course of counselling in school, to investigate how they managed and negotiated this. Drawing on positioning theory from discourse analysis, young people's accounts are analysed with reference to the variety of positions they articulated and adopted. This demonstrates how they elaborated and reinforced virtuous problem-solver positions within broader discourses of individualisation and normalisation, and resisted positioning within a stigmatised mental illness discourse. Although focused on a small sample, the analysis offers potential insights into the ways other people may negotiate stigma concerns to access mental health resources, while also demonstrating the utility of positioning theory for understanding stigma and normalisation.

The illusion and the paradox of being autonomous, experiences from persons with spinal cord injury in their transition period from hospital to home

PURPOSE

To open a discourse on the concept of autonomy as a precursor for participation in individuals with Spinal Cord Injury (SCI) by exploring the experiences about their perceived autonomy in their transition period from hospital to home.

METHOD

Based on the 'grounded theory' approach; in-depth, semi structured interviews were conducted with 11 SCI-patients. A theoretical sampling strategy was used and the data was analysed according to the constant comparative method.

RESULTS

To capture this complexity of autonomy, the results have been structured in themes with regard to the self of the patient and his independency. The analysis showed four different typologies of how autonomy is perceived; (1) the active agent, (2) the active follower, (3) the passive follower and (4) the passive victim.

CONCLUSION

Rehabilitation professionals can help individuals in disconnecting their internalised ideal of independency to avoid the illusion of being autonomous and can gain insight in the patients' typology and empower patients to avoid the paradox of being autonomous. If the ultimate goal of rehabilitation is participation; empowering the patient to achieve a 'sense of agency' instead of autonomy is the central goal for rehabilitation professionals. Empowerment and agency are key topics for the patient to gain mastery over his own life.

Of time and troubles: patient involvement and the production of health care disparities

Patient involvement in care practice has many and diverse proponents. It is endorsed by health care institutions and promoted by community agencies representing people with illness. A vast literature documents the benefits of patient involvement and describes ways to enable it. This article contributes to a critical literature on patient involvement by documenting the work done by women with cancer in relation to care timelines and in responding to troubles with care. We highlight continuities and disjunctures between this work, and discourses of patient involvement as they manifest in documents circulating at an Ontario cancer centre. In making visible the social and material resources that underpin successful involvement, the study shows how initiatives that endorse and promote 'the involved patient' can function to exacerbate health care and social disparities. As well, the study extends analysis of the individualization and privatization of health by showing how contemporary discourses of involvement enlist patients to monitor and sustain not only their own health, but also the health care they receive.

Healthcare identities at the crossroads of service modernisation: the transfer of NHS clinicians to the independent sector?

Health policies increasingly support private businesses to take an active role in the organisation and delivery of public healthcare services. For the English NHS, this is exemplified by the introduction of Independent Sector Treatment Centres. A number of these facilities involve the wholesale secondment of NHS clinicians to the private sector which, we suggest, raises important questions about the identities of healthcare professionals accustomed to working in the public sector. Our paper investigates this transition highlighting three prominent discontinuities in clinical work: the ethos of private sector ownership, new lines of authority and fragmented relationships. Drawing on Giddens, we examine how clinicians experience and interpret these changes and how they keep their biographical 'narrative going'. The 'pioneers' interpreted the independent sector as an opportunity to re-invigorate their practice through new roles, relationships and higher quality care; the 'guardians' as an opportunity to replicate and protect the customs and standards of the NHS in the private sector; whilst the 'marooned' longed to return to the NHS. Our study illustrates how the sectoral context can shape healthcare identities, and how contemporary reforms aimed at promoting partnerships across public and private sectors can have profound implications for clinicians.

Valued identities and deficit identities: Wellness Recovery Action Planning and self-management in mental health

Wellness Recovery Action Planning (WRAP) is a self-management programme for people with mental illnesses developed by a mental health consumer, and rooted in the values of the 'recovery' movement. The WRAP is noteworthy for its construction of a health identity which is individualised, responsibilized, and grounded in an 'at risk' subjectivity; success with this programme requires development of an intensely focused health lifestyle. We draw on Bourdieu and Giddens to argue that what is being developed is a 'reflexive health habitus', which is not equally accessible to all social groups, and is in tension with WRAP's recovery-orientated aims. However, it is understandable that such a programme developed in mental health, because people with mental illness are highly stigmatized as 'a risk' and viewed as in need of risk management. By developing their own form of self-monitoring 'at risk' identity, mental health consumers are, paradoxically, able to construct themselves as ideal health citizens and no longer a risk, thus re-entering the moral community. We conclude by suggesting some changes to WRAP practice.

Mostly empty words--what the discourse of "choice" in health care does

PURPOSE

This paper has two purposes: one is to analyse how the policy of freedom of choice emerged and was formed in the Swedish health care discourse; the second is related to how free choice influences the discourse in health care and how subjects are formed within the field, i.e. what the language of choice in health care does.

DESIGN/METHODOLOGY/APPROACH

The research strategy is inspired by a combined theoretical framework borrowed from Michel Foucault's concepts of "discursive formation" and "subjectivization" completed with Judith Butler's concept of performativity.

FINDINGS

The language of "freedom of choice" calls to mind the rhetoric of promises, i.e. that the patient should be free and responsible, in his or her relation to health care. Since patients seem to be insufficiently informed and supported about the actual benefits of possibilities and limitations associated with the severely restricted reform of free choice, the statements concerning opportunities to make personal health decisions will lose their significance. The advocacy of discourses of freedom of choice seems therefore mostly like empty words, as they are producing weak patients instead of free and empowered people.

RESEARCH LIMITATIONS/IMPLICATIONS

As the reform was initiated in the beginning of 2000 it is rather fresh.

ORIGINALITY/VALUE

The paper produces insights into the rhetoric of political promises and the limitations of the reform dealing with freedom of choice in health care.

Role Transition and the Interaction of Relational and Social Identity: New Nursing Roles in the English NHS

Our study provides an analysis of role transition, examining how macro-level influences and micro-level practice interact in framing role transition, with a focus upon professional identity. Empirically, we examine the case of nurses in the English NHS, for whom government ‘modernization’ policy has opened up a new occupational position in the delivery of genetics services within a professional bureaucracy. We track the experiences of the nurses through their recruitment to, enactment of, and progress on from, the new genetics role over two years. Our qualitative interview-based study encompasses six comparative cases. Analysis draws upon two linked literatures — role and identity, and sociology of professions — to examine the tension between the identity expected by the profession and the role expected by government policy-makers. While policy encourages reconfiguration of roles and relationships to support the new, less-bounded role, concerns aligned to professional identity mean that inter-professional competition between doctors and nurses, and intra-professional competition within nursing itself, constrain the enactment of the new role. Through our empirical study, we develop literature on role transition through its application to a professionalized context, and sociology of professions literature, within which issues of identity are relatively neglected. Our study demonstrates that the emphasis of identity within a professional bureaucracy lies at the collective level.

"I like to be an informed person but..." negotiating responsibility for treatment decisions in cancer care

Social expectations surrounding sickness have undergone a transformation in Western welfare states. Emerging discourses about patients' roles and responsibilities do not however always map neatly onto patients' actions, experiences or desires. This paper emerges from a study in Ontario, Canada. Drawing on in-depth interviews with 5 women diagnosed with breast cancer we explore the activity and effort prompted for patients by the routine professional practice of outlining treatment options and encouraging patients to choose between them. We highlight research participants' complex responses to their responsibility for treatment decisions: their accepting, deflecting and reframing and their active negotiation of responsibility with professionals. The literature on treatment decision making typically characterizes people who resist taking an active role as overwhelmed, misinformed about the nature of treatment decisions, or more generally lacking capacity to participate. In this paper we suggest that patients' expressions of ambivalence about making treatment choices can be understood otherwise: as efforts to recast the identities and positions they and their physicians are assigned in the organization of cancer care. We also begin to map key features of this organization, particularly discourses of patient empowerment, and evidence-based medicine.

Genetic risks and healthy choices: creating citizen-consumers of genetic services through empowerment and facilitation

Genetic testing to identify susceptibility to a variety of common complex diseases is increasingly becoming available. In this article, focusing on the development of genetic susceptibility testing for diet-related disease, I examine the emergence of direct-to-the-consumer genetic testing services and the (re)configuration of healthcare provision, both within and outside the specialist genetics service, in the UK. I identify two key techniques within these practices: empowerment and facilitation. Using Foucauldian social theory, I show that empowerment and facilitation are being positioned as tools for the creation of citizen-consumers who will make appropriate dietary choices, based on the results of their genetic analysis. Through these techniques, individuals are transformed into properly entrepreneurial citizens who will, through judicious choices, act to maximise their 'vital capital' (their health) and the capital of the social body. I argue that the user of these services is not purely an economic figure, making rational choices as a consumer, but that her configuration as a citizen-consumer who avails herself of genetic information and services in a proper manner ensures that she is fit to contribute to the economic life of our present.

New labour and reform of the English NHS: user views and attitudes

BACKGROUND

The British National Health Service has undergone significant restructuring in recent years. In England this has taken a distinctive direction where the New Labour Government has embraced and intensified the influence of market principles towards its vision of a 'modernized' NHS. This has entailed the introduction of competition and incentives for providers of NHS care and the expansion of choice for patients.

OBJECTIVES

To explore how users of the NHS perceive and respond to the market reforms being implemented within the NHS. In addition, to examine the normative values held by NHS users in relation to welfare provision in the UK.

DESIGN AND SETTING

Qualitative interviews using a quota sample of 48 recent NHS users in South East England recruited from three local health economies.

RESULTS

Some NHS users are exhibiting an ambivalent or anxious response to aspects of market reform such as patient choice, the use of targets and markets and the increasing presence of the private sector within the state healthcare sector. This has resulted in a sense that current reforms, are distracting or preventing NHS staff from delivering quality of care and fail to embody the relationships of care that are felt to sustain the NHS as a progressive public institution.

CONCLUSION

The best way of delivering such values for patients is perceived to involve empowering frontline staffs who are deemed to embody the same values as service users, thus problematizing the current assumptions of reform frameworks that market-style incentives will necessarily gain public consent and support.

Perceived difficulties in managing ethical problems in family practice in Slovenia: cross-sectional study

AIM

To determine the prevalence of difficulties in managing ethical dilemmas in family practice.

METHODS

The study included a random sample of 259 family medicine physicians, representing 30% of the population of family physicians in Slovenia. Participants were given a self-administered questionnaire on perceived ethical dilemmas in their practice, with responses on a 5-point scale and a maximum score of 100. The main outcome measure was the percentage of family physicians reporting difficulties in solving perceived ethical dilemmas.

RESULTS

The response rate was 55%. Physicians reported having difficulties in solving ethical dilemmas often or very often (mean score+/-standard deviation, 56.1+/-12.1). The most difficult ethical issue included abandoned and unattended patients and patients with insufficient means of support (48.6%), followed by suspicion of physical abuse, sexual abuse, or other criminal behavior (40.9%), and use of limited health care resources (21.1%). Female physicians reported greater difficulties in solving ethical dilemmas than male physicians (57.7+/-10.6 vs 53.0+/-14.1, P=0.036, t test). Older physicians solved ethical issues more easily than younger ones (53.9+/-12.6 vs 58.2+/-11.2, P=0.043, t test). Specialists and residents in family medicine considered solving ethical dilemmas to be more difficult than general practitioners without specialization (57.3+/-11.6 vs 47.1+/-11.8, P=0.001, t test). Multivariate regression analysis of physician and practice characteristics did not yield any significant model to explain the differences in the perceived level of difficulties in solving ethical dilemmas.

CONCLUSION

Although managing ethical dilemmas is an important part of daily work of family physicians in Slovenia, it is perceived as a considerable burden in their work. Family physicians need more training in addressing and managing ethical issues.

Dependence and identity: nurses and chronic conditions in a primary care setting

PURPOSE

This paper aims to explore the ways in which practice nurses engage in identity work in the context of chronic disease management in primary care and assess the extent to which this is compatible with the identities promoted in government policy.

DESIGN/METHODOLOGY/APPROACH

The paper draws on qualitative interviews with nurses applying the concepts of "identity threat" and Hegel's Master-Slave dialectic to explore the implications of nurse-patient interdependence for identity in a policy context which aims to promote self-management and patient empowerment.

FINDINGS

The nurses in the study showed little sign of adapting their identities in line with government policies intended to empower health care "consumers". Instead, various aspects of identity work were identified which can be seen as helping to defend against identity threat and maintain and reproduce the traditional order.

PRACTICAL IMPLICATIONS

The paper provides information on barriers to self-management that are likely to inhibit the implementation of government policy.

ORIGINALITY/VALUE

Whilst much has been written on the extent to which patients are dependent on health professionals, the issue of professional dependence on patients has received much less attention. The paper hightlights how viewing the nurse-patient relationship in the context of a struggle for mastery related to identity represents a departure from traditional approaches and sheds light on hitherto unexplored barriers to self-management.

Identity, Contract and Enterprise in a Primary Care Setting: An English General Practice Case Study

This paper examines the responses of primary health care clinicians (doctors and nurses) to an invitation to enterprise contained in a new contract which offers financial rewards for meeting targets. We suggest that far from being swept along by a hegemonic enterprise discourse or having `no choice but to comply' (Cohen and Musson, 2000: 45), the engagement of our study participants in enterprising behaviours can be understood in terms of a more active process, albeit one characterized by new bureaucratic forms. Rather than riding roughshod over cherished traditional identities, part of the attraction of enterprise in our case study can be understood in terms of its role in assisting enterprising clinicians in managing the tensions inherent in these identities.