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 1970, Dingwall 1977, Atkinson 1981, Melia 1987, Haas and Shaffir 1987). Membership of such social groupings provides a point of reference from which individuals make meaning of their work and manage identity, although occupations vary in the strength and duration of such an association. Hughes' writing on the 'drama of work' has been particularly valuable in signalling the centrality of social roles in an overall division of labour. He coined the term 'dirty work' to draw attention to the existence of work which threatens occupational identities. There is ample evidence of the applicability of this idea in the healthcare context, with several classic studies of medical sociology linking to this theme (Emerson and Pollner 1976, Jeffrery 1979, Dingwall and Murray 1983, Mizrahi 1986, Brown 1989, Allen 2001). For Hughes, work was a central criterion by which people were judged and by which they judged themselves. He argues that even in the lowest occupations people develop collective pretensions to give their work and thus themselves value in the eyes of each other and outsiders. An enduring metaphor that has shaped studies of the social organisation of work which has been particularly influential in the study of healthcare is that of the biological organism. Its influence can be traced back to Durkheim, who looked to Darwinian theory to develop an understanding of the evolution and development of the division of labour. In developing this line of thought, Durkheim was heavily influenced by Spencer, and Spencer's understanding of the basic laws of human social organisation (see Turner 1984). Durkheim draws on the observations of Darwin that the struggle between organisms is a function of their similarity. The chances of conflict diminish as the species become more distinct from each other. According to Durkheim, people submit to the same law. In the same city different occupations can co-exist without being obliged mutually to destroy one another because they pursue different objects. The closer functions come to one another, he argues, then the greater the risk of conflict. Orthodox accounts of Durkheim's work have tended to downplay the importance he placed on competition as a driver for change in systems of work, yet a careful reading reveals striking similarities between his writings and those of the Chicago School in which the world of work was treated as an analogue to the City's urban ecology (Dingwall 1983). The most influential recent exposition of social ecological theory is Abbott's The System of Professions (1988). Clearly located in fieldwork study and heavily influenced by the work of Hughes' students (Freidson, Bucher, Strauss), his work is a self-conscious attempt to develop a framework which addresses what he perceives to be the main weaknesses in the sociology of the professions: their failure to study the basic conditions and control of the content of work. Placing interprofessional battles at the heart of his work, Abbott is concerned with the evolution and inter-relationships of professions and the ways in which they control their jurisdiction1. Given that their fortunes are interdependent, a profession's success reflects as much the situations of its competitors and the system structure as it does its own efforts. Abbott draws attention to the larger social forces that impact on the system of work. Most consequential for the creation of new tasks and the destruction of others are changes in technology and organisation, but he also points to the effects of changing social values which require the creation of new forms of legitimacy. Abbott parts company with early sociologists of the division of labour, in that for him history is not a simple pattern of trends and development but a complex mass of contingent forces of social ecology. His concern with legitimacy, however, links his work to the parallel development of the new institutionalism in the sociology of organisations (Powell and DiMaggio 1991). This approach places considerable emphasis on the way in which organisations are required to adopt certain forms and processes less as a matter of technical rationality or increased efficiency than as a means of meeting the expectations of significant actors in the environment. Ecological imperatives are as much cultural as economic. Arguably, for example, most health professionals and the organisations in which they work are no more or less attentive to patients than they ever were; they are however now required to document and demonstrate this in elaborate ways in order to be treated as legitimate by governments, insurers, courts and other members of the societal networks in which they are embedded. A failure to comply with these cultural expectations has economic consequences in the erosion of resources. In one sense, a potential limitation of Abbott's thesis for the study of healthcare work is its restriction to the system of professions, rather than work of all forms2. Nonetheless, the contemporary system of healthcare represents an interesting case through which to explore his central thesis. As Freidson (1970) has shown us, health service provision has been defined to a considerable extent by the 'professional dominance' of medicine which historically has exerted significant control over this system of work. The evolution and workplace construction of the boundary with medical practitioners and other occupational groups has been a popular focus of concern within medical sociology, and, given the dynamic nature of the division of labour within health care settings, is likely to remain so. Indeed we are now witnessing the emergence of new areas of sociological interest with the development of international health policies designed to make inroads into medical autonomy. Abbott argues that no profession that fails to deliver a service can stand indefinitely against competitors. As state intervention into the healthcare arena on both sides of the Atlantic increases, the stage is set for testing how far a profession can continue to deliver a service in the face of decreasing legitimacy. The relationship between the professions, the state and citizens in shaping the social organisation of work in society was central to Durkheim's thinking (Durkheim 1957). He envisaged a special role for professions as secondary groupings which mediated between the state and the individual. According to Durkheim '. . . it is out of this conflict of social forces that individual liberties are born' (1957: 63). The working out of such tensions in different contexts has been a key concern in the study of health care work ranging from Parson's classic work on the sick role as a mechanism of social control through to more recent work on the rise of surveillance medicine (e.g.Armstrong 2005, Samson 2005). This theme has recently received attention with the introduction of new systems of organisational governance in response to the rising health costs and concerns about service quality. The use of national service frameworks, best practice guidelines and evidence-based practice are being promoted as a means for enhancing provision. Such developments present some fundamental challenges to the traditional ecology of knowledge in healthcare. At one level, these developments raise the spectre of Weber's so-called 'iron cage'3 of bureaucracy and systems of hyper-rationality. At another, recent studies reported in this collection reveal there is ample opportunity for health professionals to resist such efforts to control and standardise their work. One of Hughes' legacies most evident in studies of healthcare systems is the attention he drew to systems of work at the micro-level. For him the division of labour implied interaction; he regarded it to be a poor term for the differentiation of function in social life as a whole, because it emphasised division rather than integration. For this reason, he did not study any one occupation, as he was more interested in their inter-relationships. Hughes' writings are characteristically fragmented, however, and the clearest articulation of this overall approach came from Freidson (1976). Criticising Smith and Durkheim for paying little attention to the concrete substance of the concept of the division of labour, Freidson argues that the ultimate reality of the division of labour lies in the social interaction of its participants. Among the individuals on the factory shop floor, or on the hospital ward, and among the groups engaged in negotiating legislation and formal plans for controlling work, there are boundaries set on what will be considered legitimate to negotiate, how the negotiation will take place, and what bargains can be struck. Some are unselfconscious and taken for granted, some are specifically understood as scientifically incontrovertible necessity, and others as legitimate laws, rules and regulations, and practices . . . [I]n the everyday world from which we abstract conceptions of the division of labor, it seems accurate to see the division of labor as a process of social interaction in the course of which the participants are continuously engaged in attempting to define, establish, maintain and renew the tasks they perform and the relationship with others which their tasks presuppose (Freidson 1976: 311). One of the attractions of healthcare as a site for the study of work is its characteristically complex division of labour. Traditionally, hospital wards and multidisciplinary team meetings (Griffiths 1998, 2001) have proved to be rich locales for the examination of the division of labour in action. It is perhaps significant that the negotiated order perspective arose from a workplace study of a psychiatric hospital (Strauss et al. 1964). Studies of this kind drew attention to the situated character of work roles and the mismatch between formal organisational plans and workplace jurisdictions (Abbott 1988) arising from the need to respond to context-specific contingencies. Healthcare settings revealed themselves to be an arena for the playing out of inter- and intra-occupational differences and have yielded fascinating materials through which to study occupational identity and boundary work. Healthcare providers are increasingly expected to co-ordinate their contribution with that of the patient and their unwaged caregivers, who bring different kinds of knowledge and expertise to the interaction, and challenge professional power (Pilnick 1998, Allen 2000). technology has also had a profound impact on organisational in healthcare work, meaning that as as interaction, interaction is a field of Studies in the field of collaborative work have not for understanding of new technologies but also for the ways in which they are in practice and 2000). One of the of healthcare work is that it is people work and this is consequential for its social organisation and practice. 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