Monday, 30 August 2010

The NHS Direct helpline is dead. Long live NHS 111!

www.bbc.co.uk/news/uk-11120853. A shame - NHSD provided a reason to think about Freidson’s "lay referral system" again, this time in connection with ICTs (Freidson 1988).


No, you’re not.

Freidson made the point that we need to think about the temporal trajectory of sickness. This meant considering seriously what happens before we opt for a consultation with a medical expert. He noted decisions about whether to access professional healthcare are conventionally first made in our immediate kin/community context, looking at both social relationships and cultural themes as factors.

If ICTs, now a “mundane reality” (Nettleton 2005) for many in seeking out health-related information and advice, have impacted that context then the lay referral system and its two components (the extent to which lay culture is congruent with professional health culture and the cohesiveness and extension of the lay referral structure) may have to be amended.

For example, has the effect of more information availability through dominant providers such as NHS Direct aligned lay health culture more closely with the knowledge base underpinning professional health culture (an especially relevant question for those identified by Freidson as not sharing in that culture, namely the 'lower classes')? Secondly, with the option of finding condition-specific social networks online, those identified as relying on a loose and truncated lay referral structure to help make decisions (identified by Freidson as the 'middle classes'), may find such structures extended, if not more cohesive.

Ultimately, how will digital ICTs interact with other factors, such as the Government's aim to encourage more healthcare to take place in home settings, to change the proportion of referrals to professional medics, if at all?

Thursday, 26 August 2010

The opinions of Professor Field are not the same as evidence from the field

Healthy living is commonly seen as a rational choice on the part of individuals. Indeed, Prof Fields' outlook (click his name for a summary from the Herd blog) seems to be grounded in theories about the rational actor/self regarding individual.

Durkheim initiated a long tradition of sociological and anthropological opposition to the kind of assumptions underpinning Prof Fields’ views, with his examination of the social origins of individual thought.

We need to think about the influence of socio-cultural factors on perceptions, i.e. the norms and values associated with culture and reference groups. We also need to think about the organisation of social relationships, using social network analysis for example, to determine the effect that family and friends can have on decisionmaking.



If we do so, and as any parent can tell you, we will realise that behaviour is infrequently changed by more information or persuasive arguments in isolation (e.g. see Lewis way back in 1945: ‘Conduct, knowledge and acceptance of new values,’ in Journal of Social Issues).

Finally, here's the video referred to in the Herd blog for a great counter to Professor Field's outlook, focusing on social processes:

Saturday, 14 August 2010

Is remote healthcare remotely healthcare?

New fangled approaches in healthcare will always get some peoples’ backs up and the idea of a virtual medic is about as new fangled as it gets: http://www.express.co.uk/posts/view/190756/Web-Would-you-trust-a-virtual-medic-  Both patients and practitioners (http://www.bbc.co.uk/news/10285950) and somewhat inevitably insurance companies with competing premium member services have raised objections to mediated interactions where the purpose is diagnosis or advice. Nevertheless, NHS Direct (a bit of a misnomer given its callcentre and website operations essentially mediate the healthcare experience) has proven enormously popular in England – with 18 million visits to its website in 2009 and 5 million calls to its call centre.

Anecdotally, some of the strongest objections to the ‘re-mediation’ of healthcare come from Northern Ireland where NHS Direct isn’t available. The primary concern there isn’t necessarily about mediation, after all doctors there allocate time in the day to take phonecalls and even emails from patients, a situation also common in the US. It’s the idea that advice should be given by anonymous practitioners who have no idea of your medical history (moreover they are nurses, complain the doctors).

I have been speaking to some of those within the NHS who would like to get to the bottom of ‘resistance’ on the part of both patients and practitioners to more technology-enabled services. Many share a vision where interactions with health services ultimately become like interactions with banks: the 2020 Public Services Trust is doing some thinktank work on this front.

With the Northern Ireland example alone, it’s clear that a patchwork of values concerning healthcare exist and that’s before considering constituencies such as the poor where issues of access also come into play. Clearly, more work needs to be done to understand what lies behind those values and what the information needs and access issues of patients are. Ethnography can help on these fronts.