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Previous studies of service reconfiguration in healthcare have explored the influence of power on processes and outcomes. However, in these accounts the moral agency of managers is often underemphasised. This paper draws on the theoretical tools provided by the sociology of morality to help deepen understanding of the interaction between power and moral agency in service reconfiguration in healthcare. It presents results from a qualitative study of a pan-organisational service reconfiguration in the NHS in England, involving nineteen in-depth interviews with those leading the change and the analysis of twelve programme documents. We combine concepts of the moral background and epistemic governance to interpret participants' conviction that the service change was 'the right thing to do'. The paper shows how epistemic work carried out by service change regulations shaped the moral background within which participants worked. This, in turn, channelled their moral agency – specifically their commitment to patient care – in a way that also reflected central priorities. The paper adds to sociological understandings of service reconfiguration through considering the interaction of structure, agency and power, while also developing the concept of the moral background to show how power relations can influence moral beliefs. • Managers can show strong faith in uncertain evidence for healthcare service change. • The moral background explains this in a way which considers power and moral agency. • Confidence in evidence depends on background assumption of future as predictable. • Confidence also depends on premise that finances are not open to moral evaluation. • Service change regulations carry out epistemic work on background assumptions. [ABSTRACT FROM AUTHOR]

High quality primary care is a foundational element of effective health services. Internationally, primary care physicians (general practitioners (GPs), family doctors) are experiencing significant workload pressures. How non-patient-facing work contributes to these pressures and what constitutes this work is poorly understood and often unrecognised and undervalued by patients, policy makers, and even clinicians engaged in it. This paper examines non-patient-facing work ethnographically, informed by practice theory, the Listening Guide, and empirical ethics. Ethnographic observations (104 h), in-depth interviews (n = 16; 8 with GPs and 8 with other primary care staff) and reflexive workshops were conducted in two general practices in England. Our analysis shows that 'hidden work' was integral to direct patient care, involving diverse clinical practices such as: interpreting test results; crafting referrals; and accepting interruptions from clinical colleagues. We suggest the term 'hidden care work' more accurately reflects the care-ful nature of this work, which was laden with ambiguity and clinical uncertainty. Completing hidden care work outside of expected working hours was normalised, creating feelings of inefficiency, and exacerbating workload pressure. Pushing tasks forward into an imagined future (when conditions might allow its completion) commonly led to overspill into GPs' own time. GPs experienced tension between their desire to provide safe, continuous, 'caring' care and the desire to work a manageable day, in a context of increasing demand and burgeoning complexity. • The non-patient-facing work of general practitioners is often invisible or hidden. • Hidden work is associated with complexity and uncertainty. • Behind-the-scenes work is care work, just as direct work with patients is care work. • Doctors face tensions between completing tasks and working a manageable day. • Combining practice theory with the Listening Guide embraces multi-vocality. [ABSTRACT FROM AUTHOR]

Major service change in healthcare – whereby the distribution of services is reconfigured at a local or regional level - is often a contested, political and poorly understood set of processes. This paper contributes to the theoretical understanding of major service change by demonstrating the utility of interpreting health service reconfiguration as a biopolitical intervention. Such an approach orients the analytical focus towards an exploration of the spatial and the population – crucial factors in major service change. Drawing on a qualitative study from 2011–12 of major service change in the English NHS combining documentary analyses of historically relevant policy papers and contemporary policy documentation (n = 125) with semi-structured interviews (n = 20) we highlight how a particular 'geography of stroke' in London was created building upon multiple types of knowledge: medical, epidemiological, economic, demographic, managerial and organisational. These informed particular spatial practices of government providing legitimation for the significant political upheaval that accompanies NHS service reconfiguration by problematizing existing variation in outcomes and making these visible. We suggest that major service change may be analysed as a 'practice of security' – a way of redefining a case, conceiving of risks and dangers, and averting potential crises in the interests of the population. • Foucault's work on biopolitics is applied to analyse major service change. • The reconfiguration of stroke services in London is explored. • Empirical and theoretical implications are discussed. [ABSTRACT FROM AUTHOR]

Abstract Health systems around the world face financial pressures that can affect sustainability and patient outcomes, and there is a vast literature devoted to the allocation of scarce health care resources. Capital spending - for example on estates, equipment and information technology - is an important but often neglected area of this literature. This study explores the constraints on the allocation of capital budgets in health care, before addressing the question: what is the role of priority setting and rationing in responses to these constraints? The paper presents findings from interviews conducted with senior finance professionals in 30 National Health Service local provider organisations across England. Findings suggest a pervasive sense of impending crisis, with capital restrictions limiting investment in buildings, infrastructure and equipment. The paper applies a conceptual classification scheme from the classic rationing literature (the forms of rationing framework) and identifies widespread practices of 'selection', 'dilution' and 'delay', with 'denial' and 'termination' comparatively rare. Practices of 'deflection' and 'deterrence' are ascribed to national actors as a means of restricting the flow of capital resources to the system. The study suggests that there is little by way of tailored support for priority setting in capital spending, and a perception that decisions are often reactive and short term. It also suggests that wider system features and dynamics can preclude or constrain priority setting at the organisational level. The authors use these findings to suggest future conceptual development of the forms of rationing framework and make recommendations for research and practice in this area. Highlights • Respondents described capital budget deficits affecting quality and safety of care. • Most had adopted rationing and/or priority setting to help deal with this. • Service dilution, delay and selection were the most cited forms adopted. • Lack of tools and the system context impeded local decision-making. [ABSTRACT FROM AUTHOR]

The recent 50th anniversary of the 1967 Abortion Act provides the opportunity to revisit what has been termed the ‘remarkable authority’ this Act ascribes to doctors. This paper does so using as its starting point a seminal commentary on this question by the renowned medical sociologist Sally Macintyre, published in this journal in 1973 as ‘The Medical Profession and the 1967 Abortion Act in Britain’. We revisit themes from that paper through an analysis of the findings of interviews with 14 doctors who, throughout lengthy careers, have provided abortions and led the development of the abortion service in England and Wales. We contrast our findings with Macintyre's, and argue that our interviews highlight the shifting meaning of medical authority and medical professionalism. We show that those doctors most involved in providing abortions place moral value on this work; uphold the authority of women (not doctors) in abortion decision-making; view nurses and midwives as professional collaborators; and consider their professional and clinical judgement impeded by the present law. We conclude that medical sociologists have much to gain by taking abortion provision as a focus for the further exploration of the shifting meaning of medical authority. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has disproportionately impacted ethnic minorities in the global north, evidenced by higher rates of transmission, morbidity, and mortality relative to population sizes. Orthodox Jewish neighbourhoods in London had extremely high SARS-CoV-2 seroprevalence rates, reflecting patterns in Israel and the US. The aim of this paper is to examine how responsibilities over health protection are conveyed, and to what extent responsibility is sought by, and shared between, state services, and 'community' stakeholders or representative groups, and families in public health emergencies. The study investigates how public health and statutory services stakeholders, Orthodox Jewish communal custodians and households sought to enact health protection in London during the first year of the pandemic (March 2020–March 2021). Twenty-eight semi-structured interviews were conducted across these cohorts. Findings demonstrate that institutional relations – both their formation and at times fragmentation – were directly shaped by issues surrounding COVID-19 control measures. Exchanges around protective interventions (whether control measures, contact tracing technologies, or vaccines) reveal diverse and diverging attributions of responsibility and authority. The paper develops a framework of public health relations to understand negotiations between statutory services and minority groups over responsiveness and accountability in health protection. Disaggregating public health relations can help social scientists to critique who and what characterises institutional relationships with minority groups, and what ideas of responsibility and responsiveness are projected by differently-positioned stakeholders in health protection. • COVID-19 produced diverse responses and relations around health protection in London. •Pandemic preparedness can be enhanced by mapping possible partners in localities. •Establishing public health partnerships requires adequate resources. •Public health services cannot defer responsibility entirely to local partners. •Households are key constituents of public health relations. [ABSTRACT FROM AUTHOR]

Stories about disability are heavily shaped by the narratives offered by medicine and society. Those narratives enact an ‘anomalous’ body that is constructed as distant from the norm and therefore ‘damaged’ but also fixable. In this paper we explore how such narratives, and the practices they encompass, influence the stories disabled young people tell about their bodies and impairment. We do so by drawing on narrative qualitative interviews and visual practices carried out with seventeen disabled young people in a project funded by the Economic and Social Research Council that took place between 2011 and 2012 in the North East of England. The findings discussed here focus on how medical and societal responses to bodily difference become part of the stories disabled young people tell about their bodies, and influence the way they work with the body as something which remains ‘unfinished’ and therefore both fixable and flawed. Our conclusion is that a narrative of an unfinished body is produced, as young people manage their bodies as something that is integral to their emerging identity, but also as a potential threat that could undermine and give away their labour in making an ‘ordinary’ functioning body and life. The paper contributes to medical sociology and sociology of the body by producing new knowledge about how disabled embodiment is lived and framed by disabled young people in the context of ongoing attempts to change the body. [ABSTRACT FROM AUTHOR]

Abstract: Lay involvement in public health programmes occurs through formalised lay health worker (LHW) and other volunteer roles. Whether such participation should be supported, or indeed rewarded, by payment is a critical question. With reference to policy in England, UK, this paper argues how framing citizen involvement in health only as time freely given does not account for the complexities of practice, nor intrinsic motivations. The paper reports results on payment drawn from a study of approaches to support lay people in public health roles, conducted in England, 2007–9. The first phase of the study comprised a scoping review of 224 publications, three public hearings and a register of projects. Findings revealed the diversity of approaches to payment, but also the contested nature of the topic. The second phase investigated programme support matters in five case studies of public health projects, which were selected primarily to reflect role types. All five projects involved volunteers, with two utilising forms of payment to support engagement. Interviews were conducted with a sample of project staff, LHWs (paid and unpaid), external partners and service users. Drawing on both lay and professional perspectives, the paper explores how payment relates to social context as well as various motivations for giving, receiving or declining financial support. The findings show that personal costs are not always absorbed, and that there is a potential conflict between financial support, whether sessional payment or expenses, and welfare benefits. In identifying some of the advantages and disadvantages of payment, the paper highlights the complexity of an issue often addressed only superficially. It concludes that, in order to support citizen involvement, fairness and value should be considered alongside pragmatic matters of programme management; however policy conflicts need to be resolved to ensure that employment and welfare rights are maintained. [Copyright &y& Elsevier]

This paper contributes to the international literature examining design of inpatient settings for mental health care. Theoretically, it elaborates the connections between conceptual frameworks from different strands of literature relating to therapeutic landscapes, social control and the social construction of risk. It does so through a discussion of the substantive example of research to evaluate the design of a purpose built inpatient psychiatric health care facility, opened in 2010 as part of the National Health Service (NHS) in England. Findings are reported from interviews or discussion groups with staff, patients and their family and friends. This paper demonstrates a strong, and often critical awareness among members of staff and other participants about how responsibilities for risk governance of ‘persons’ are exercised through ‘technical safety’ measures and the implications for therapeutic settings. Our participants often emphasised how responsibility for technical safety was being invested in the physical infrastructure of certain ‘places’ within the hospital where risks are seen to be ‘located’. This illuminates how the spatial dimensions of social constructions of risk are incorporated into understandings about therapeutic landscapes. There were also more subtle implications, partly relating to ‘Panopticist’ theories about how the institution uses technical safety to supervise its own mechanisms, through the observation of staff behaviour as well as patients and visitors. Furthermore, staff seemed to feel that in relying on technical safety measures they were, to a degree, divesting themselves of human responsibility for risks they are required to manage. However, their critical assessment showed their concerns about how this might conflict with a more therapeutic approach and they contemplated ways that they might be able to engage more effectively with patients without the imposition of technical safety measures. These findings advance our thinking about the construction of therapeutic landscapes in theory and in practice. [Copyright &y& Elsevier]

This paper reports on research framed by theories of therapeutic landscapes and the ways that the social, physical and symbolic dimensions of landscapes relate to wellbeing and healing. We focus especially on the question of how attributes of therapeutic landscapes are constructed in different ways according to the variable perspectives of individuals and groups. Through an ethnographic case study in a psychiatric hospital in the North of England we explore the perceived significance for wellbeing of ‘smoking spaces’ (where tobacco smoking is practiced in ways that may, or may not be officially sanctioned). We interpret our findings in light of literature on how smoking spaces are linked to the socio-geographical power relations that determine how smoking is organised within the hospital and how this is understood by different groups using the hospital building. We draw on qualitative research findings from discussion groups, observations, and interviews with patients, carers and staff. These focused on their views about the building design and setting of the new psychiatric hospital in relation to their wellbeing, and issues relating to smoking spaces emerged as important for many participants. Creating and managing smoking spaces as a public health measure in psychiatric hospitals is shown to be a controversial issue involving conflicting aims for health and wellbeing of patients and staff. Our findings indicate that although from a physical health perspective, smoking is detrimental, the spaces in which patients and staff smoke have social and psychological significance, providing a forum for the creation of social capital and resistance to institutional control. While the findings relate to one case study setting, the paper illustrates issues of wider relevance and contributes to an international literature concerning the tensions between perceived psychological and psychosocial benefits of smoking vs. physical harm that smoking is likely to cause. We consider the implications for hospital design and the model of care. [Copyright &y& Elsevier]

Abstract: Excessive alcohol consumption among young people in England regularly features in national media and has been a focus of recent academic research and government policy. Though the majority of young people do not regularly drink excessively, heavy sessional drinking – ‘binge’ drinking – is associated with negative health and social consequences for those who do. Alcohol-related health problems in young people are not spread consistently across England, however, and while there are significant intra-regional differences, northern regions fare worse overall than those in the south. This paper draws on an 18-month project which explored differences in the physical, social and regulatory environments (highlighted by previous research as influential) in two locations with contrasting alcohol harm profiles. The paper focuses on the lives of 15–16 year olds and examines potential differences that influence behaviour at this crucial age; and in particular issues that might presage risky and/or harmful drinking in young adulthood. The study examines evidence from young people themselves (activity diaries and interviews); stakeholder interviews; and observation analysis. The study finds social practices in the two areas to be largely similar; moreover, the collectivised and social nature of alcohol consumption suggests sources of influence from a wider context, beyond immediate family and friendship groups. However these social practices were acted out in locations with very different physical characteristics, in particular these related to the availability of non-alcohol focused leisure activities and the spatial arrangement/visibility of adult drinking culture. [Copyright &y& Elsevier]

Abstract: Pelvic radiotherapy creates physical effects and psychological responses that negatively affect the sexual health of women and couples, yet these sexual consequences are not frequently researched or clinically assessed. This focused ethnographic study explored factors that influence the clinical assessment of treatment-induced female sexual difficulties after pelvic radiotherapy within routine medical follow-up. Participant observation of follow-up clinics (n = 69) and in-depth interviews with 24 women, 5 partners and 20 health professionals were undertaken at two cancer centres in the South East of England from 2005 to 2006. Thematic analysis of interview transcripts resulted in five emergent themes, two of which are explored in detail within this paper. A social constructionist approach to human sexuality was used to explore representations of female sexuality in oncology follow-up constructed by clinicians, women and their partners. Yet neither social constructionist nor biomedical (the predominant model in medical follow-up) perspectives on human sexuality provided an adequate interpretation of these study findings. This paper argues that the comprehensive study and practice of sexual rehabilitation in oncology requires a synthesis of both biomedical and social constructionist perspectives in order to capture the complex, subjective and embodied nature of the female sexual response in both health and illness. [Copyright &y& Elsevier]

Abstract: This paper explores the notion of genetic responsibility, i.e. the responsibility to know and manage one’s own genome for oneself and the sake of others, focusing particularly on responsibilities to family and kin. It also considers wider ideas about the emergence of new forms of biological subjectivities with which the concept of genetic responsibility is associated. The paper draws on a UK-based study concerned with lay constructions of familial hypercholesterolaemia (FH), a treatable inherited form of high cholesterol, which involved qualitative interviews with 31 people with the condition recruited through a specialist outpatient clinic. The paper is an attempt to open out discussions about the significance of genetic responsibility and biological subjectivity. I argue that in this study, FH was not associated with a notable family narrative of illness or a strongly defined specific disease community, and no clear sense emerged of obligations to kin or others derived through genetic risks or genetic connections. While responsibilities concerned with the welfare of oneself and one’s existing offspring were enunciated, obligations to other potential or actual kin, e.g. to tell and encourage kin to manage their risks, were much less clearly defined. Drawing on these findings, I start to address questions about the pervasiveness of genetic responsibility and genetic identity and the contexts in which they might be significant. [Copyright &y& Elsevier]

Sight impairment is experienced by approximately 253 million people worldwide, including people of all generations, at all life course stages. Caught between past and present embodiments of the world, people often express feelings of loss with the onset of sight impairment. This paper examines the role of nonhuman nature encounters as a contingent resource amongst individuals navigating these emotional transitions. It responds to recent calls to attend to the life course in both critical disability studies and the growing body of work linking nonhuman nature relations to human wellbeing. The paper draws on findings from a qualitative study that combined in-depth narrative interviews with in situ go-along interviews to explore how 31 people with sight impairment in England describe and experience a sense of wellbeing (or otherwise) with nature across their everyday lives and life trajectories. The data were analysed using inductive narrative thematic analysis. While nonhuman nature encounters were valued by many participants in promoting a sense of freedom, relatedness, pleasurable sensory immersion, opportunities for exploration and 'skilling up', this paper cautions against generalised or overly Romantic tropes of what nonhuman nature can 'do' through key sight loss junctures, and for whom. It highlights the value of providing timely and sensitive social scaffolding and nurturing creativity to open up meaningful opportunities to engage with nonhuman nature and to counter feelings of loss exacerbated by identity-limiting life course narratives and disability stereotypes. Informed by the stories shared by participants to chart and situate their experiences of sight loss, we call for a new identity politics within and beyond the growing movement to 'connect' people to nonhuman nature for wellbeing; a politics that affirms diverse forms of more-than-human embodiment, recognising how and why such relations may weave into – and indeed out of – people's varied, interdependent life course trajectories. • Disabling life course norms can exacerbate feelings of loss with sight impairment. • Care is needed in generalising benefits of nature through transitions of sight loss. • Social scaffolding and creativity can enable supportive nonhuman encounters. • A more inclusive identity politics is needed in nature-wellbeing policy & practice. [ABSTRACT FROM AUTHOR]

This paper examines how people living in two socially contrasting areas of Stockton on Tees, North East England experience, explain, and understand the stark health inequalities in their town. Participants displayed opinions that fluctuated between a variety of converging and contrasting explanations. Three years of ethnographic observation in both areas (2014–2017) generated explanations which initially focused closely on behavioural and individualised factors, whilst 118 qualitative interviews subsequently revealed more nuanced justifications, which prioritised more structural, material and psychosocial influences. Findings indicate that inequalities in healthcare, including access, the importance of judgemental attitudes, and perceived place stigma, would then be offered as explanations for the stark gap in spatial inequalities in the area. Notions of fatalism, linked to (a lack of) choice, control, and fear of the future, were common reasons given for inequalities across all participants. We conclude by arguing for a prioritisation of listening to, and working to understand, the experiences of communities experiencing the brunt of health inequalities; especially important at a time of austerity. [ABSTRACT FROM AUTHOR]

Housing is a significant determinant of health and substandard housing is a public health issue. East London has long had a shortage of social and affordable housing, worsened in recent years by a combination of stressors. In one of East London's most deprived boroughs, Newham, changes brought about by the 2011 Localism Act and the unique demands of being the host Olympic borough in 2012 have brought considerable pressures to bear on social infrastructure. This paper examines how these pressures were experienced by local residents via their narratives of social housing and health. The data reported here are from a qualitative study comprising two waves of data collection. Narrative family interviews and go-along interviews were conducted with 40 Newham residents at wave one and 28 at wave two. A narrative analysis with a Bakhtinian interpretation was undertaken. This revealed that residents framed experiences of social housing in terms of an inherent system-level ideology based on notions of need and waiting. A particularly striking feature of this ideology was the extent to which descriptions of ill health and impairment were implicated in constructions of housing need; participants directly attributed a range of health complaints to their housing predicaments, including stress, depression, cancer scares, panic attacks and loss of sleep. Understanding the contested ideology of social housing can illuminate both the dynamic processes of social exclusion and the ways in which its subjects seek to resist it. [ABSTRACT FROM AUTHOR]

Recent decades have witnessed a significant rise in the use and ‘misuse’ of pharmaceutical medicines. Without significant behavioural change, the adverse health and environmental impacts resulting from medicine misuse will be most felt by today's young people. Yet despite real concerns surrounding pharmaceutical sustainability, insights into the ways that understandings of, and expectations to take medicines are communicated to, and taken up by young people remain limited. This paper draws on research focused around everyday home and school settings, to examine how understandings and norms relating to medicine use become embedded within the lives of young people. Between May 2014–January 2015, fifty students (aged 11–14) from one secondary school in England participated in focus groups and forty-three in interviews. Two focus groups were held with parents (n = 10). Findings demonstrate that attitudes towards medicine use were bound up with notions of parental responsibility, risk, peer governance and social acceptability, labour-related expectations, and processes of regulation within the school. Indeed, it was clear that medication use was often a compromised solution in response to wider structural pressures and demands and that such thinking was embedded at an early stage in the life course. The study found that few opportunities arose for open and informed discussion relating to responsible medicine use. Such circumstances demonstrate that any attempts to change medicine-related attitudes and behaviours should be considered within the wider social and structural contexts that govern their use. [ABSTRACT FROM AUTHOR]

This paper investigates how the concepts of clinical specialisation and evidence influence the jurisdictional power of doctors, nurses and therapists involved in stroke care in Sweden, England and Poland. How stroke care has become a distinct specialism across Europe and the role that evidence has played in this development are critically analysed. Five qualitative case studies were undertaken across the three countries, consisting of 119 semi-structured interviews with a range of healthcare workers. The informants were purposively selected and their perspectives of evidence-based practice (EBP) within stroke care were explored. The data were analysed through thematic content analysis. The two key themes that emerged from the data were the health professionals' degrees of EBP and specialisation. The results illustrate how the two concepts of clinical specialisation and evidence are interrelated and work together to influence the different professions' degree of professional jurisdiction. It is concluded that doctors' professional dominance gives them full jurisdiction in stroke care and that nurses' and therapists' degrees of jurisdiction is dependent on their ability to specialise. [ABSTRACT FROM AUTHOR]

Since the earliest days of the HIV/AIDS epidemic, talking about the virus has been a key way affected communities have challenged the fear and discrimination directed against them and pressed for urgent medical and political attention. Today, HIV/AIDS is one of the most prolifically and intimately documented of all health conditions, with entrenched infrastructures, practices and technologies – what Vinh-Kim Nguyen has dubbed ‘confessional technologies’ – aimed at encouraging those affected to share their experiences. Among these technologies, we argue, is the semi-structured interview: the principal methodology used in qualitative social science research focused on patient experiences. Taking the performative nature of the research interview as a talking technology seriously has epistemological implications not merely for how we interpret interview data, but also for how we understand the role of research interviews in the enactment of ‘life with HIV’. This paper focuses on one crucial aspect of this enactment: the contemporary ‘normalisation’ of HIV as ‘just another’ chronic condition – a process taking place at the level of individual subjectivities, social identities, clinical practices and global health policy, and of which social science research is a vital part. Through an analysis of 76 interviews conducted in London (2009–10), we examine tensions in the experiential narratives of individuals living with HIV in which life with the virus is framed as ‘normal’, yet where this ‘normality’ is beset with contradictions and ambiguities. Rather than viewing these as a reflection of resistances to or failures of the enactment of HIV as ‘normal’, we argue that, insofar as these contradictions are generated by the research interview as a distinct ‘talking technology’, they emerge as crucial to the normative (re)production of what counts as ‘living with HIV’ (in the UK) and are an inherent part of the broader performative ‘normalisation’ of the virus. [ABSTRACT FROM AUTHOR]

Embodied health movements work on the boundary between lay and expert knowledge. Consumer groups, depending on their goals, may increase or decrease pharmaceuticalization. This paper reports a small case study about the retrospective evaluation of a specific second line treatment for type 2 diabetes by an existing patient involvement group. The group is part of a research collaboration between academia and the health service in England, and shares some characteristics of embodied health movements. We used the case study to explore whether an institutionally funded non activist patient group can make a more balanced contribution to drug licensing decisions than that made by either access-oriented or injury-oriented consumer groups, without being co-opted by an institutional agenda. The questions we wished to address were how this group evaluated existing mechanisms for licensing drugs; how they balanced scientific and lay knowledge; how they made their decisions; and how they viewed their experiences as panel members. The five panel members were interviewed before and after the panel discussion in July 2013. They were critical of current licensing processes, and used their own embodied experiences of medicines to evaluate expert knowledge. Their decisions on the panel were informed either by a balancing of benefits and harms, or by trust in experts. The case study suggests that such a group may have the potential both to balance the pro-pharmaceuticalization impact of access-oriented groups and to influence forms of pharmaceutical governance. [ABSTRACT FROM AUTHOR]

The paper investigates whether, how and in what circumstances boundary blurring or boundary maintenance is productive or destructive of sense in collaborative research based on a case study involving researchers from two universities and two principal organisational stakeholders in a local healthcare system in England between 2009 and 2012. Adopting a narrative method, using meeting observation, document analysis and interviews, we describe two key sets of activities in the evolution of collaboration, which allows us to tackle the question at two levels. Studying the production of documents and their use as boundary objects in project management meetings, we show how these were used to enable cooperation by establishing a truce between worldviews, giving participants a better feel for the game and a clearer perception of its stakes. Studying how the partnership expanded to take in other organisations besides the two formal partners, we show how the project accommodated pre-existing organisational interests but thereby sacrificed its experimental ethos. In showing how actors needed to subvert their experimental script to enact collaborative partnership, we argue for understanding and evaluating the latter as the co-produced outcome of disputes and co-orientations towards a practical ideal, not as an organisational format for knowledge co-production. [ABSTRACT FROM AUTHOR]

Healthcare decision-makers have always faced the challenge of allocating finite resources, but the global economic downturn places extra pressure on health systems to meet rising demands. The National Institute for Health and Care Excellence (NICE) and UK government have therefore called on commissioners to consider opportunities for ‘disinvestment’— the cessation or restriction of health-care practices, and subsequent shift of resources to higher value care. However, there are no clear guidelines on how to approach disinvestment, and little is known about how this is tackled in practice. This paper presents results from a study that used ethnographic methods to investigate how disinvestment is understood and enacted. Eight routine local-level commissioning meetings where resource allocation decisions were discussed were observed over one year in two demographically contrasting regions of England. 28 interviews accompanied observations, conducted with purposefully-sampled professionals who were involved in, or potentially impacted by, disinvestments. Analysis of interviews/meeting recordings was undertaken using constant comparison methods, complemented by observational field notes. We found variation in informants' reported definitions of disinvestment, and an absence of disinvestment decision-making in observed meetings. Observations and interviews showed evidence of practical and ideological barriers to disinvestment, including an absence of tools and capacity, difficulties in collaboration and communication, a reluctance to engage in explicit rationing, and a perceived lack of central/political support. These findings support the need for the development of methods to encourage and guide disinvestment, including a clear definition of what ‘disinvestment’ entails. Crucially, disinvestment needs to be a collaborative effort, involving health-care providers and commissioners in decision-making processes. [ABSTRACT FROM AUTHOR]

Many public health systems in high- and middle-income countries are under increasing financial pressures as a result of ageing populations, a rise in chronic and non-communicable diseases and shrinking public resources. At the same time the rise in patient mobility and concomitant market in medical tourism provides opportunities for additional income. This is especially the case where public sector hospitals have a reputation as global centres of excellence. Yet, this requires public sector entrepreneurship which, given the unique features of the public sector, means a change to professional culture. This paper examines how and under what conditions public sector entrepreneurship develops, drawing on the example of international patients in the UK NHS. It reports on a subset of data from a wider study of UK medical tourism, and explores inward flows and NHS responses through the lens of public entrepreneurship. Interviews in the English NHS were conducted with managers of Foundation Trusts with interest in international patient work. Data is from seven Foundation Trusts, based on indepth, semi-structured interviews with a range of NHS managers, and three other key stakeholders ( n = 16). Interviews were analysed using a framework on entrepreneurship developed from academic literature. Empirical findings showed that Trust managers were actively pursuing a strategy of expanding international patient activity. Respondents emphasised that this was in the context of the current financial climate for the NHS. International patients were seen as a possible route to ameliorating pressure on stretched NHS resources. The analysis of interviews revealed that public entrepreneurial behaviour requires an organisational managerial or political context in order to develop, such as currently in the UK. Public sector workers engaged in this process develop entrepreneurship – melding political, commercial and stakeholder insights – as a coping mechanism to health system constraints. [ABSTRACT FROM AUTHOR]

Governments world-wide have attempted to use market mechanisms and privatisation to increase the quality and/or reduce the cost of healthcare. England's Health and Social Care Act 2012 is an attempt to promote privatisation through marketisation in the National Health Service (NHS). While the health policy literature tends to assume that privatisation follows from private-sector entry points, we argue that this is more likely if firms expect to make a profit. This paper examines the link between privatisation and marketisation in England drawing on 32 semi-structured interviews with private-sector and public-sector respondents, campaigners, and other experts conducted 6–10 months after the implementation of the 2012 Act. By generating a theoretical framework on the conditions of profitability we seek a better understanding of the conditions under which marketisation leads to privatisation. We find that significant barriers to profit-making remain after the reforms, including a top-down squeeze on prices, uncertainty in market rules, state dominance of funding and provision, and failures to depoliticise the market. These factors restrict private-sector involvement by frustrating profit-making. Where profits are made they are through reduced unit costs and high volumes by a longstanding incumbent in a particular market segment. This, however, restricts marketisation by reinforcing entry barriers. [ABSTRACT FROM AUTHOR]

Abstract: Clinical practice guidelines produced by NICE – the National Institute for Health and Care Excellence – are seen as key mechanisms to regulate and standardise UK healthcare practice, but their development is known to be problematic, and their adoption and uptake variable. Examining what a guideline or health policy means to different audiences, and how it means something to those communities, provides new insight about interpretive discourses. In this paper we present a micro-analysis of the response of healthcare professionals to publication of a single NICE guideline in 2009 which proposed a re-organisation of professional services for chronic non-specific low back pain. Adopting an interpretive approach, we seek to understand both the meaning of the guideline and the socio-political events associated with it. Drawing on archived policy documents related to the development and publication of the guideline, texts published in professional journals and on web-sites, and semi-structured interview data from professionals associated with the debate, we identify a key discourse that positions the management of chronic non-specific low back pain within physician jurisdiction. We examine the emergence of this discourse through policy-related symbolic artifacts taking the form of specific languages, objects and acts. This discourse effectively resisted and displaced the service reorganisation proposed by the guideline and, in so doing, ensured medical hegemony within practice and professional organisations concerned with the management of non-specific low back pain. [Copyright &y& Elsevier]

Abstract: Much has been written on the beneficial, restorative qualities of ‘natural’ (non-built) rural or urban ‘green’ space, including woodland, in promoting mental and physical health when accessed for leisure, sport and education. In contrast, with the exception of rural health studies, there is relatively little debate about the health benefits of ‘green space’ as work place, especially in woodland and forests. In the developed world, this apparent gap in the literature may be partly due to an assumption of the forest work place as inherently healthy, and also the invisibility of a tiny percentage of the workforce now employed in forestry. However, in the UK and parts of Europe over recent years there has been a small, though significant, increase in opportunities to train and work in woodlands using traditional, sustainable management such as coppicing, and an exploration of health issues of woodland work is timely. This paper reports on findings from a secondary narrative analysis of oral history interviews selected from two phases of the Woodland Recollections Project and newsletters written by local people historically and currently engaged in coppicing and woodland work in North West England. Perceptions of healthy working in green space are examined by applying key concepts of Attention Restoration Theory (ART). Findings suggest that woodland work environments involve many counter-restorative factors that can render the ‘green idyll’ detrimental to health and wellbeing. To benefit from restorative elements requires drawing on a high level of specialist skills that empower individuals to manage and maintain healthy working practices in these diverse and challenging environments. [Copyright &y& Elsevier]

Abstract: The paper discusses the possibilities technology provides for (re-)shaping healthcare professionals. Drawing upon critical studies of technology and the sociology of professionals, we present findings from a longitudinal study into the introduction of the Electronic Prescription Service (EPS) in Community Pharmacies in England conducted between June 2009 and July 2011. Our case illustrates the conditions that allow technology to shape healthcare professionals and the potential consequences of such shaping. The data collected, which consisted of qualitative interviews and document analysis, and their analysis rests on predictions of future directions and developments of the pharmacy profession through EPS. Specifically, we show that technology has the potential to shape fundamental aspects of pharmacy work such as its nature and values, professional roles, the degree of power professionals can exercise, their jurisdictions and professional boundaries. Drawing upon these changes and on their implications, we argue that the introduction of technology in a healthcare setting does not determine consequences but opens up a field in which processes of de-professionalisation and re-professionalisation occur simultaneously. Their implications for healthcare professionals in the future, remains an open, yet worth exploring, question for the present. [Copyright &y& Elsevier]

Abstract: This paper aims to examine the relationship between parental socio-economic status (SES) and adolescent substance use. The central question posed in the title is approached in two stages. First, theoretical and empirical research in this area is reviewed. Second, data from an ongoing longitudinal study of young people in England (the Peterborough Adolescent and Young Adult Development Study – PADS+) are used to highlight the nature of this relationship in one city. Results from discrete-time event history analyses show that when examining what predicts initiation of substance use, familial and demographic factors emerge as important predictors, but SES does not appear to be relevant. The concluding discussion focuses on whether support is found for hypotheses derived from the existing literature and implications for future research. [Copyright &y& Elsevier]

Abstract: Assisted conception involving donor insemination challenges cultural idioms of parenthood and family; there is now a growing body of work exploring how women and couples negotiate becoming a family in this way. But sperm donation also raises questions on the more intimate levels of sex, sexuality and sexual bodies, and these have received little sustained attention in the literature. Lesbian couples in the UK increasingly negotiate access to medicalised donor insemination, but many also conceive in informal arrangements with donors where they themselves negotiate proximity and contact with donors when retrieving donor sperm. I explore in this paper how lesbian couples manage and perceive sperm donations, how they seek to negotiate their intimate, sexual and bodily overtones, and how the medical and non-medical settings enable them to do this in different ways. I draw on empirical data from an interview study conducted from 2006 to 2009 in England and Wales comprising 25 lesbian couples. I suggest that sperm donation raises dilemmas of intimacy for lesbian couples, and that couples try to resolve such dilemmas by carefully and intentionally choreographing donation events through managing patterns of movement and action. The different institutional, medical and regulatory frameworks governing clinical and non-clinical sperm donation shape that management in significant and different ways. I argue that sperm donation choreographies enable couples to negotiate the private, sexual and intimate tensions surrounding sperm donations, and also the subjectivity of the sperm donor. [Copyright &y& Elsevier]

Abstract: How far does ethnicity/culture/religion mediate couples’ responses to genetic risk? This paper examines the responses of 51 British Pakistani couples referred to a genetics clinic in southern England to counselling about recurrence risks for genetic problems in children. It is based on fieldwork conducted between 2000 and 2004 that combined participant observation of genetics consultations with interviews in respondents’ homes. Interviews were conducted with 62 adults in connection with these 51 cases, of which 32 were followed through two or more clinical consultations and 12 through more than one pregnancy. Risk responses were categorized as: taking the risk; postponing; exploring risk management or dismissing the risk as irrelevant to current circumstances. Responses were cross-referenced for associations with the severity of the condition, number of affected and unaffected children, availability of a prenatal test, age, gender, and migration history. I found that most couples were initially risk-takers who already had an unaffected child or children. Couples caring for living children with severe conditions were more likely to postpone. However, the risk responses of 15 couples changed over time, most towards and some away from risk management, reflecting changes in couples’ appreciation of the severity of the condition and their subsequent reproductive experiences. The study highlights the diversity and dynamism of responses within one ethnic group and challenges stereotypes about cultural and religious responses to genetic risk. [Copyright &y& Elsevier]

Abstract: This paper seeks to make sense of the sleeping practices of people who are recovering from heroin use. It brings together two hitherto unrelated literatures: the sociology of sleep and studies on heroin use and recovery. Conceptual resources developed within the sociology of sleep are deployed to facilitate the analysis of interview data generated as part of a qualitative investigation into the everyday lives of recovering heroin users living in England. Twenty one men and 19 women were interviewed with 37 of the 40 being interviewed twice, giving a corpus of 77 interviews. Without exception all the participants in the research experienced extensive sleeping problems that were not only exacerbated by the pharmacological effects of heroin, but were made worse by the way of life that accompanied their using. Irregular and anarchic sleeping practices mirrored the study participants’ disrupted and difficult lives. Attempts to establish sleep routines, and normative sleeping patterns, constitutes an important marker of recovery, but after years, and for some decades, of chaotic, intermittent and irregular sleeping, cultivating sleep presents a series of difficult challenges. Their embodied biographies of heroin use constrain the promotion of sleep, and attempts to develop rituals and routines to restore sleeping patterns are confounded by the involuntary aspects of sleep and their recalcitrant bodies. These findings are significant because not only is the quality of sleep critical to health outcomes but it also forms an important but hitherto relatively overlooked aspect of recovery from heroin use. [Copyright &y& Elsevier]

Abstract: Increasingly policy for long term condition management is focussing on new technologies. Telecare is viewed as a means of making services more responsive, equitable, cost and clinically-effective and able to play a central part in mediating between service users, professionals, and service providers. It has also been identified as helping to establish patient self-management for long term conditions. In this paper we consider the social practices of the work of telecare integration and incorporation for patients, their interactions with professionals and the synergy or otherwise with policy makers’ expectations for how patients approach, use and interact with services. The research took place in England and in Wales and involved qualitative interviews with 31 individuals. Our research suggests that, telecare services provide both an adequate substitution for traditional services and additional benefits such as minimising the need to travel and the added reassurance of regular external surveillance. However, the nature of patient work involved is ‘low level’ rather than requiring higher level interpretation of readings and decision making commensurate with realising a policy vision of more independent and responsible self –managers. Indeed a paradox of the reliance and acceptance of telecare is the creation of new relationships and dependencies rather than the diminution of reliance envisaged by policy. The illumination of practices around telecare provides evidence for policy makers and others to adjust the predictions and presumptions about how telecare might enable and promote more effective long term condition management. [Copyright &y& Elsevier]

Abstract: As a form of ‘active transport’, cycling has been encouraged as a route to improving population health. However, in many high-income countries, despite being widely seen as a ‘healthy’ choice, few people do cycle for transport. Further, where cycling is rare, it is not a choice made equally across the population. In London, for instance, cycling is disproportionately an activity of affluent, White, men. This paper takes London as a case study to explore why the meanings of cycling might resonate differently across urban, gendered, ethnic and class identities. Drawing on qualitative interview data with 78 individuals, we suggest first that the relative visibility of cycling when few do it means that it is publicly gendered in a way that more normalised modes of transport are not; conversely, the very invisibility of Black and Asian cyclists reduces their opportunities to see cycling as a candidate mode of transport. Second, following Bourdieu, we argue that the affinities different population groups have for cycling may reflect the locally constituted ‘accomplishments’ contained in cycling. In London, cycling represents the archetypal efficient mode for autonomous individuals to travel in ways that maximise their future-health gain, and minimise wasted time and dependence on others. However, it relies on the cultivation of a particular ‘assertive’ style to defend against the risks of road danger and aggression. While the identities of some professional (largely White) men and women could be bolstered by cycling, the aesthetic and symbolic goals of cycling were less appealing to those with other class, gendered and ethnic identities. [Copyright &y& Elsevier]

Community initiatives aiming to reduce health inequalities are increasingly common in health policy. Though diverse many such initiatives aim to support residents of disadvantaged places to exercise greater collective control over decisions/actions that affect their lives - which research suggests is an important determinant of health – and some seek to achieve this by giving residents control over a budget. Informed by theoretical work in which community capabilities for collective control are conceptualised as different forms of power, and applying a relational lens, this paper presents findings on the potential role of money as a mechanism to enhance these capabilities from an on-going evaluation of a major place-based initiative being implemented in 150 neighbourhoods across England:The Big Local (BL). The research involved semi-structured interviews with 116 diverse stakeholders, including residents and participant observation in a diverse sample of 10 BL areas. We took a thematic constant comparative approach to the analysis of data from across the sites. The findings suggest that the money enabled the development of capabilities for collective control in these communities primarily by enhancing connectivity amongst residents and with external stakeholders. However, residents had to engage in significant 'relational work' to achieve these benefits and tensions around the money could hinder communities' 'power to act'. Greater social connectivity has been shown to directly affect individual and population health by increasing social cohesion and reducing loneliness. Additionally, supporting enhanced collective control of residents in these disadvantaged communities has the potential to improve population health and reduce health inequalities. • Supporting communities in gaining collective control has potential to reduce health inequities. • Disadvantaged communities with control over money, can develop 'powers' to improve where they live. • Communities in ' total ' collective control of budgets could benefit in symbolic and monetary ways. • Local initiatives require varied relational work in order to achieve positive community benefits. • Local resident led initiatives need to recognize, the exercise of relational work in their design. [ABSTRACT FROM AUTHOR]

This paper determines the association of neighbourhood ethnic density on adolescent mental health and its interplay with ethnic minority status and neighbourhood deprivation. 4145 cross-sectional responses to the 2009–2011 UK Household Longitudinal Study (UKHLS) youth self-completion questionnaire for youths aged 10–15 living in England were combined with household responses to the household UKHLS interview and 2011 Census data. Regression models were used to predict a Strengths and Difficulties Questionnaire (SDQ) score (range 0–40) with higher values indicating worse mental health. Ethnic density was operationalised using two distinct measures: co-ethnic density and diversity index. There was no difference in the mental health of ethnic minority youths by whether they lived in neighbourhoods of differing levels of ethnic density or neighbourhood deprivation. White British youths had poorer mental health when living in deprived neighbourhoods where their ethnic group was the vast majority. The difference compared to all other neighbourhoods was two points on the SDQ score. Interventions should seek to encourage adolescents living in white-working class neighbourhoods to explore ethnic diversity to determine whether it improves their mental health. • Youths in deprived neighbourhoods tend to live in ethnically diverse areas. • Youths living in less ethnically diverse neighbourhoods report poorer mental health. • White British youths report poor mental health in monoethnic, deprived neighbourhoods. [ABSTRACT FROM AUTHOR]

Vulnerability is a problematic label routinely applied to people with dementia, yet their situated experiences of vulnerability have not been prioritised or documented. Drawing on empirical data collected using a novel methodology - walking interviews with 15 people with dementia living in Southern England, followed by a sit-down interview that included a nominated family member - this paper advances understanding of how vulnerability is experienced and dealt with by people with dementia when outdoors, and at times shared with family carers. Data were analysed using abductive techniques; a thematic coding framework was created from the dataset, in addition to the application of critical theories of vulnerability and disability. We found that vulnerability is characterised by a sense of 'ontological vulnerability' for the person diagnosed with the condition - that is, an awareness of failing knowledge about oneself or the 'rules' of outdoor life, which individuals experienced emotionally and dealt with civically. People with dementia attempted to manage risks and anxieties, often doing this independently so as not to burden family members. These findings highlight how people with dementia experience and deal with vulnerability when outdoors, which others need to acknowledge and support to enable people with dementia and their families to work though these challenges, in a family-orientated way when risk planning. • When outdoors, people with dementia showed awareness of vulnerabilities exposed. • People with dementia may attempt to hide or mask their feelings of vulnerability. • Ontological vulnerability is relational and maybe shared with family members. [ABSTRACT FROM AUTHOR]