Search

Metaphors are inescapable in human discourse. Policy researchers have suggested that the use of particular metaphors by those implementing policy changes both influences perceptions of underlying reality and determines what solutions seem possible, and that exploring 'practice languages' is important in understanding how policy is enacted. This paper contributes to the literature exploring the generative nature of metaphors in policy implementation, demonstrating their role in not just describing the world, but also framing it, determining what is seen/unseen, and what solutions seem possible. The metaphor 'care pathway' is ubiquitous and institutionalised in healthcare. We build upon existing work critiquing its use in care delivery, and explore its use in health care commissioning, using evidence from the recent reorganisation of the English NHS. We show that the pathways metaphor is ubiquitous, but not necessarily straightforward. Conceptualising health care planning as 'designing a pathway' may make the task more difficult, suggesting a limited range of approaches and solutions. We offer an alternative metaphor: the service map. We discuss how approaches to care design might be altered by using this different metaphor, and explore what it might offer. We argue not for a barren language devoid of metaphors, but for their more conscious use. [ABSTRACT FROM AUTHOR]

The new General Medical Services contract was introduced into general practice in the UK in 2004, and it links pay to performance far more than in the past. As a result, accurate data collection about patients and the care that they receive is now not only important for good patient care but also to prove that targets are being met. The use of electronic records and information technology has thus become much more sophisticated. This article reports the results from an ethnographic study of the early stages of the new contract in two general practices. As expected, electronic data collection had increased in importance in both practices, with consequences both for clinician–patient interactions and for the structures and processes in the practices, as uniform data collection instruments are put in place that privilege ‘hard’ biomedical data that can be easily coded above ‘softer’, more patient-centred information. Roles and responsibilities had been changed to reflect the needs of the new systems, and new software applications allowed increased surveillance of both doctors’ and nurses’ performance; both of these had an impact on patterns of authority in our study practices. Furthermore, the structural changes that were found acted to embed the new ways of working, ensuring their reproduction in the future. In spite of these effects, we found little opposition to or critical reflection on the changes, and the doctors in our study continued to view their improved computer systems as neutral recording devices. The implication of these findings is discussed. [ABSTRACT FROM AUTHOR]