An ethnographic study of cardiovascular disease prevention : the social organisation of measures, knowledge, interventions and tensions in English general practice

This thesis is about different ways of knowing about people's health, and about what happens when these different knowledges intersect at the frontline of general practice - when people (patients) consult with healthcare professionals. Starting with the accounts of patients, I use institutional ethnography (Smith, 2005b) to explore how patients' (and healthcare professionals') knowledge and practices are socially organised. Within healthcare services, policymakers are coordinating activities to prevent cardiovascular disease, based on knowledge of population health from vast epidemiological datasets such as the Global Burden of Disease project. A suite of 'lifestyle' and pharmaceutical interventions are promoted by policymakers as evidence-based approaches to preventing cardiovascular disease (including heart attacks and strokes) within the population. The flagship Health Check programme aims to prompt people to make changes to their diet and exercise habits, and identify some who will benefit from additional interventions to reduce their risk. However, interviews with patients, observation of preventive care in practice, and the concerns of some general practitioners suggest that cardiovascular disease prevention is not as simple or unproblematic as it first appears; patients' knowledge of their own health needs is often at odds with the preventive care provided. I show how patients look for a discussion with healthcare professionals about how they can best implement preventive approaches, but find that they are given standardised 'automated' responses which do not take account of their own individual circumstances or preferences. Despite prominent notions of 'shared decision-making' and patient involvement written into clinical guidelines, and despite healthcare professionals striving to provide 'patient centred care', tensions persist between an institutional knowledge of prevention and a local, experienced knowledge of what is required to improve health. This thesis explores these tensions, their impact, and how both HCPs' and patients' activities are coordinated remotely from the frontline of general practice.