ACERCA DE LA IMPUTACIÓN NECESARIA

The introduction of an “epistemic object” to each participating primary care team in the second phase of this empirical study revealed that their likely object-oriented activities were different from one another despite surface similarities, as illustrated in chapter 7. In this chapter this initial finding from the second research phase will be subjected to further analysis through the theoretical framework of activity theory, in order to account for those emergent differences in activity in relation to the same partially-given (epistemic) object. The findings from this closer analysis of the data offer an explanation for the apparent similarities, but paradoxical differences, in each team’s activity: activities were different across the three teams because the object was constituted differently through the activity of each team. Since activity and context are conceptualised as mutually constitutive in activity theory, this suggests a way of accounting for diversity in the practice or activity of primary care teams which will be discussed in subsequent chapters. In the meantime, the purpose of this chapter is to account for the differences in activity between the three participating teams.

The chapter begins with further analysis of the “internal category differences” identified from the initial analysis of each team’s account of their (epistemic) object-oriented activity in chapter 7. Each of these will each be considered in turn, in relation to their role as mediating artefacts of each participating primary care team’s activity. The “absolute differences” in activities identified in chapter 7 will then be re-considered briefly in light of this exercise. Finally, the way the epistemic object was mutually contested and constituted differently within the three primary care teams, conceptualised as activity systems, will be re-considered through analysis of internal activity system tensions or contradictions.

Through this closer analysis of the data, the linkages between primary care teams as activity systems and other related activity systems will be indicated, which provides a necessary step in order to address the research questions posed here.

Introduction: interpreting differences through activity theory

The three accounts of activity presented in chapter 7 demonstrated an everyday aspect of primary care practice which was clearly both complex and complicated in terms of the collective aim and the necessary organising in order to bring that aim to fruition. The partially given object was identified as being broadly similar across the three teams (the elderly lady’s problem generated broad agreement about likely assessment, diagnosis and treatment). However, each team’s account of their ensuing likely activity related to this apparently common object was different from that of the others.

In chapter 5, the mediated, collective nature of activity which incorporates cultural and historical attributes, was discussed at length. The key concept of mediation was discussed in relation to the philosophical “concept of the ideal”, through which meaning could be understood to be attributed to objects (Illyenkov, 1977; Bakhurst, 1997). Using this theoretical concept, analysis of the mediating artefacts employed within each primary care team or activity system, will show that the object was not constituted the same way despite initial similarities, but was in fact contested and mutually constituted differently through collective team activity (Blackler and Regan, 2006b).

In the next section, things identified as mutual mediating artefacts in the activity of each team will be analysed further to account for the differences in activity between the three participating primary care teams. These objects, termed “internal category differences” in the initial analysis presented in chapter 7, included the “the hospital”, “the ambulance service” and “the rapid response team”, which will now be discussed in turn in relation to the activity of each primary care team.

Mutual mediating artefacts of activity: “the hospital”

Each primary care team mentioned “the hospital” in their collective account of activity and in general discussion during the first research phase. During the second phase, through the “epistemic object” exercise, each team’s account suggested that the activity surrounding the care of the elderly lady in the example might well involve an admission to “hospital”. This arose in discussion sooner in two out of three teams and bears further examination: members of the Harebell and Rowan teams mentioned hospital admission

very early in their collective accounts, which might be thought to indicate similar activity in these two teams. Meanwhile Primrose participants gave a different account of likely activity including the place of the hospital in their narrative, which provided a complex picture of inter-related issues, of which potential hospital admission was only one.

Through fieldwork and reviewing documentation gathered during this research, the complexity of the term “hospital” in relation to the three participating teams became obvious. Although from a distal, acontextual perspective the phrase “hospital admission” may appear to be the same, in fact this is not the case. The term “hospital” carries a variety of meanings, as demonstrated by the following definition:

An institution providing medical or psychiatric care and treatment of patients. Such care may be residential (in-patient), including the care of patients for a whole day and their return home at night (day care). Out-patient services include consultation with specialists by prior appointment, X-rays, laboratory tests, physiotherapy, and accident and emergency services for those requiring urgent care. Most health districts have a district general hospital (DGH), which provides sufficient basic services for the population of the district. Some larger hospitals have resources that are more highly specialized, to meet the needs of a wider population, providing so-called regional or supraregional (national) services. Such hospitals often provide training for medical students (teaching or university hospitals) and for postgraduate education. Some smaller hospitals – known as community hospitals – may be staffed by general practitioners and are intended for people for whom home care is not practicable on social grounds.

(Concise Medical Dictionary, 2007)

If this multiple definition were being followed, two main types of hospital seemed to have mediated the teams’ activities at first glance: two could be classed as “DGHs”, whilst the third could be classed as a “community hospital”. But like so many other terms in the social world, “hospital” is a contested concept and its meaning tends to differ depending on context. As the data presented here will show, the medical dictionary definition proved inadequate when analysing “the hospital” as a mediating artefact of teams’ activities in this research.

In order to gain some insight into the apparently similar but actually different activities of the three participating primary care teams, the place of “the hospital” as a mediating artefact of the likely collective activity of each primary care team will be considered within the teams’ accounts of activity, beginning with the Rowan team.

The hospital within the activity of the Rowan team

The activity of the Rowan team in relation to the epistemic object exercise was very quickly identified as being mediated by the presence of the community hospital as part of this extended primary care team:

Rowan, 2nd stage group interview, epistemic object exercise, 2006:

P1: I suppose the basic thing with the assessment is first of all whether they [team members responding to the call portrayed in the epistemic object exercise] think that person is at risk. If they think they’re [the patient] at risk in the environment, then they would probably look to get them out of that… And that would basically be, well practically most people would arrange admission to hospital – I mean, in theory they should be able to offer social service input at that stage, but rarely that would happen and would be that immediately, and if the patient was at risk, then usually it would be hospital admission for physical assessment first of all and then possibly psychiatric assessment as well.

INT: And where would you – which hospital would she be admitted to? P1: [community hospital name] usually.

INT: And which type of admission would that be? P1: It’s an “acute”.

INT: GP beds? P1: Yeah.

The decision to admit to hospital here reflected the difficulty of accessing adequate home care support through the inter-linked activity system of the local council social work department as it was organised locally. But it also reflected the place of the community hospital within the primary care team. As the data presented in this chapter and chapter 9 will show, the description of “community hospital” within the definition of hospitals on page 169 does not adequately reflect the breadth of activity related to the

community hospital within the Rowan team. A better insight may be offered by the following definition of a community hospital, all aspects of which were present in the Rowan community hospital:

A local hospital, unit or centre providing an appropriate range and format of accessible health care facilities and resources. These will include inpatient and may include outpatient, diagnostic, day care, primary care and outreach services for patients provided by multidisciplinary teams. Medical care is normally led by general practitioners in liaison with consultant, nursing and paramedical colleagues [now called Allied Health Professionals] as necessary. Consultant long-stay beds, primary care nurse-led and midwife services may also be incorporated.

(Ritchie, 1996 p.11)

Community hospitals also routinely dealt with admissions for complex problems, such as that presented by the hypothetical patient in the “epistemic object” exercise, which would be dealt with by the specialty of general practice (Temple, 2002).

The explanation of one participant during an initial research phase discussion about the nature of the work of the local primary care team indicated that the community hospital was an important mediating artefact of local clinicians’ working practice:

Rowan, participant 5, 2005 [GP previously practising in city area]:

INT: So your type of Practice - with the inpatient work at the community hospital and…all of those things - are there other Practices that you know of…that do similar types of role?

P: Not really, no. I mean there are some, there are other GP surgeries who have some responsibility with community hospitals… [but] the amount of work that you’re involved in the community hospital - there are not many, as far as I’m aware, there aren’t many Practices that do that… to the extent that we do. But I mean I’m not saying it’s completely unique, I know that there are definitely other Practices who have the extended role of looking after inpatients. [Place name] would be an example not far from here and there would be others, presumably in the Highlands.

INT: And what difference does that make to your...working, this extended role?… What are the actual practical implications of that for you?

P: [Pause] That you always feel you should be somewhere else. [Laughter] That’s probably the practical implication but, I think it, I mean - on the positive side it provides you with variety, there’s no doubt about that and I think it also provides you with a bit of support in that if you [pause] feel that something is just outside the remit of [“normal”] general practice you can admit the patient to the hospital quite often for investigation or treatment, and I think actually that’s sometimes a supportrather than - some people might see it as an extra burden -

but actually it takes a lot of the load off some of your clinical decisions. So I think that’s a benefit, and a definite practical implication of seeing a patient here in the surgery - if you think that it might be something that’s maybe that little bit more serious, it can, certainly base line investigations can be done at the hospital very easily. And so a chest x-ray, a full blood count - if they’ve got chest pain you can exclude a heart attack much more easily than you could in the ordinary GP setting.

Routinely collected data show that this community hospital had amongst the highest activity figures in Scotland (http://www.isdscotland.org/isd/4434.html), which would appear to support this participant’s view that it was slightly different from other areas where the primary care team includes a community hospital. There was little doubt from the various accounts gathered in this research that the hospital met a locally perceived need, particularly in view of the geographical positioning and history of the locality. (These issues will be discussed in more detail in chapters 9 and 10).

The local population had never known any other approach to healthcare services, and all the practitioners within the area seemed committed to this model of service:

Rowan, participant 5, 2005:

INT: …in terms of where you are here in [Rowan], is the hospital a necessary resource for you here?

P: For this area? INT: Yeah.

P: Ithink it is and I think you’ll find most of the doctors here will say the same thing. We think it is very much a necessity and because of the geography, the distance, the time that it takes to get to a bigger centre - when you think [about] that, it’s sometimes a necessity.

This integral position of the hospital within the local extended primary care team was confirmed by other participants, who explained the extent of integration between the inter-organisational elements of the primary care team, but also the way in which services were being realigned to reflect contemporary healthcare issues without compromising the level of importance attached to this crucial clinical facility:

Rowan, participant 3, 2005:

P: I don’t know what you know about the Practice and what we’re doing and where we’re going, but we’ve got a big commitment – we’re a community hospital Practice, we’re an intermediate care Practice… We’re in the process of building a new hospital in fact which is just up the hill… The hospital dominates a lot of what we do and… very soon the hospital will be us. Because at the moment, you come along here to the Practice and you’re only seeing a third of what we do. Out there we’ve got community hospital practice [GP beds], we’ve got long term care of the elderly beds, we’ve got an A&E unit, we’ve got a maternity unit. We do police surgeon work, so this [gestures to the building where the interview is taking place] is the bitthat is recognisable as a Practice to everybody else. I suppose the way I can put it across to you is that if you came back to see us in a year and you walked into the hospital, and you, you’d say at Reception “Where’s the Practice?” they’d say “You’re in it”. And that’s how we view it…

This heightened sense of the centrality of the community hospital in local team activity was perceived very positively by the Rowan team, but this did not mean that there were no changes taking place within their view of the way services were organised. Whilst many other areas were trying to focus on what they could do to develop their range of services delivered in primary care, in line with government policy (such as those already provided here through the mediating means of the community hospital), the Rowan

team were reconsidering their provision of what might be regarded as core general practice or primary care, common to most general practices and primary care teams:

Rowan, participant 12, 2005:

INT: So the hospital is really quite central to what you do here?

P: Ehm, possibly too much. I think that’s been among the major criticisms in the past – to some extent, it has been difficult to make as many gains on the primary care side as I would like to have seen, and to that extent I think the new GMS contract [2003] has helped because that has refocused a lot of effort on the primary care side [routine general practice]. Also we’ve been involved with, in the Primary Care Collaborative...and that was quite a positive move in terms of focusing on the primary care side of things and – I mean, I don’t think it’s been harmful in the sense that the work we’ve done on the hospital side has questioned a lot of automatic assumptions about what can be done in the community hospital, and the links we’ve built with some of the more forward- thinking consultants, I think have helped that. But I think it’s probably gone about as far as it can go… and I think we do need to refocus, particularly in light of demographic change, about the increasing number of the elderly and this kind of thing. We have to refocus services on providing services in the community and not in hospital beds, but we’re quite well placed to do that now really. We’ve brought back [to the community hospital] quite a lot of stuff that some people think would have to go to a District General and shown that it can be done… locally, and I think we now maybe need to move to towards looking at community services, and as I say, most of these are pretty well on track, so that hopefully, in future, the hospital will not be where everything revolves around, it will be in the Resource Centre for the area… I think that because we have quite a large team there’s quite a lot that can be decided here – it’s one of the big advantages of the extended primary care because you have the hospital resource there, and people involved on that side, and the community services and the AHPs and so on, and there is quite a lot that can be done. It is quite complex because people have different ideas and not everybody agrees...but it does give you the possibility if you can get people to agree and work together on developing services in a particular way.

As this participant indicated, even within primary care teams of an apparently similar nature, this particular team had pushed the extent of their practice as far as possible in order to deal with more serious problems. This had resulted in a distinctive form of practice locally which might be regarded as unwise or even unsafe amongst other clinicians who did not understand the clinical challenges posed by the geographical and topographical location of the team. Again, the issue of labels masking actual activity was raised by participants to illustrate this point:

Rowan, participant 3, 2005:

P: The trouble with intermediate care is that …I’ve read things in…something like “GP” or “Pulse” - …“we do intermediate care”, in the comics [vernacular for the GP popular non-academic press]and you know, intermediate care down