Making connections: healthcare as a case study in the social organisation of work

The division of labour has been a central preoccupation since the earliest days of sociology, and considered key to an understanding of wider societal structures. Both Durkheim and Marx shared Saint-Simon's basic assumption that the most fundamental aspect of human existence was the absolute necessity to produce the means of subsistence (Lee and Newby 1983). They recognised that the starting point for understanding a given society was the way in which it organised the totality of activity necessary to existence, although they interpreted this in different ways. Weber, unlike Durkheim and Marx, did not produce over-arching social theories, but for him, too, the social organisation of work was a key concern. These early works set the agenda for, and provided a stimulus to, successive generations of scholars. Healthcare work has emerged as a particularly popular case for the study of the world of work and occupations. In fact, we would argue that the modern healthcare system is the most exciting setting in which to study work and organisations. It is a dynamic, technologically-rich environment, which incorporates interfaces between the public, private and voluntary sectors and entails a complex division of labour comprising professions, occupations, unwaged caregivers, managers and technicians. As such, it provides a natural laboratory for the exploration of many classic sociological problems and the identification of new lines of analysis. In recent years widespread concerns over cost-containment on both sides of the Atlantic have led to the introduction of new modes of organisational governance in healthcare systems. These have had a profound impact on the social organisation of work, changing the sites of provision, increasing labour intensification, challenging traditional lines of demarcation and prompting the development of new roles and modes of working. Such changes have been buttressed by new ideologies of citizenship which are redefining orthodox professional client relationships and explicitly acknowledging the contribution of lay health work. In addition, the introduction of new medical technologies has changed the working environment for many healthcare workers, leading to shifts in the division of labour and changes to working practice. This has presented new challenges to the development of skills and, in some instances, has been seen as an attack on professional autonomy and clinical judgement. Given the rapidity of change in the healthcare sector, this monograph provides an opportunity to produce an international snap-shot of the current state of play. The papers here describe different dimensions of current health trends in the UK, North and South America, Australia, Canada, Finland and the Netherlands. Bringing them together in this collection highlights convergence and divergence across national and international contexts, and points to new research directions and developments. There is a strong tradition of studies of health service organisation and delivery within medical sociology. In a recent review undertaken for the silver anniversary special issue of Sociology of Health and Illness, Griffiths (2003) argues that a concern with the social organisation of healthcare could be said to be implicit in every paper ever published in the journal. Whilst acknowledging the value of individual contributors, she observes that papers in this area ‘sometimes fail to build on earlier research’ but argues that ‘when read together they offer a valuable picture of a complex range of healthcare settings and their social organisation’ (2003: 155). A further strength of devoting a monograph to this topic is that it enables such connections to be made more readily and facilitates the establishment of links with developments within the wider field of sociological endeavour. Whilst the roots of the issues considered in the papers included in this edition can be traced to the classic concerns of the sociology of the division of labour, the authors have augmented their contribution to medical sociology by looking to cognate areas of study such as organisational sociology, sociology of scientific knowledge and studies of technically-mediated collaborative work. Our aim in this introduction is to trace some of these connections. Despite their very different theoretical destinations, both Durkheim and Marx take as the starting point for their analyses the totality of activities that are necessary in a particular society. At the macro-level, such an approach recognises the importance of all forms of work, whether it is paid or unpaid, carried out in the private, public or voluntary sector (Freidson 1978). It focuses attention on how various occupations form, the organisation and structure of their work, how this division of labour changes over time and the principal drivers for such change. At the micro-level, it highlights the need to study the relationship between the bundles of activities that constitute the technical division of labour and the social roles which comprise the moral division of labour in a system of work. Whilst the particular contributions of occupations themselves may often be presented in essentialist terms, every occupation has a history which may be described in terms of changes in bundles of activities, in the values given them and in the total system of which the occupation is a part (Hughes 1984). Beyond its obvious applicability to the complex division of labour that characterises the paid work of service providers, the adoption of this kind of theoretical lens is particularly pertinent to the healthcare context where the patient and significant others are participants in the work of maintaining health and managing illness. Medical sociologists have drawn attention to self-care activities and expertise developed through the experience of living with a chronic disease or disability, and some have made the case for inclusion of the client in the division of labour as essential for understanding healthcare work (Stacey 1981, Strauss et al. 1985). Work in this area has also directed attention to the invisible caring work that takes place in the domestic sphere. This is particularly pertinent to an understanding of healthcare where the division of labour in the family has been translated into and reinforced through the division of labour in the public domain (Stacey 1981, Gamarnikow 1978, 1991). The gendered nature of caring work is seen by many as a key to understanding the relative status of nursing and other carers in the health services division of labour, the historical shifts in the sites of care between the private and the public sphere, and the associated redistribution of work and redefinition of activities that this has occasioned. In contrast to the utilitarian approach of economics, a further contribution of sociology to the study of work is the emphasis which is placed on its inherently social character. Durkheim pointed optimistically to the function of the division of labour in creating social solidarity, whilst Marx underlined the alienated qualities of work under capitalist systems of production, and Weber warned of the dispiriting effects of rationalisation processes on the meaning of work and bureaucratic forms of control constraining the free will of the individual. All in their different ways identify the division of labour as the most powerful mobiliser of persons and draw attention to the importance of work for the creation of collective and individual identities. The healthcare system has been a particularly fruitful site for the exploration of the activities and culture of a wide range of occupational groups and the processes through which individuals are enrolled into such communities of practice (Becker et al. 1961, Olesen and Whittaker 1968, Mumford 1981, and of such social provides a point of which individuals meaning of their work and although occupations in the strength and of such an on the of has been particularly valuable in the of social roles in an division of the to draw attention to the existence of work which occupational identities. 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