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Title: Information, self-management and common sense : an ethnography of NHS mental healthcare as an accountable bureaucracy
Author: Armstrong, Neil
Awarding Body: University of Oxford
Current Institution: University of Oxford
Date of Award: 2016
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This thesis presents mental healthcare as an 'accountable bureaucracy.' I find a resemblance between clinical expertise and the ethos of the office. Accountable clinicians must produce documentation of disinterested, standardised, justifiable decisions. What staff members consider to be good clinical practice emerges as being good, accountable bureaucratic practice. My fieldwork investigates an attempt to promote patient 'empowerment.' I use the term empowerment to refer to a set of interlocking clinical goals that pertain to increased patient input to decision-making, more equal clinical relationships, and a wider reconfiguring of services. Patient empowerment is thought of as correcting inappropriate and outdated paternalism in healthcare, leading to better quality care, improved outcomes and reduced costs. I argue that patient empowerment and accountability are contradictory, in such a way that thin conceptions of empowerment may be compatible with accountability, but thicker conceptions are not. Contradictions between empowerment and accountability exist at the level of basic concepts, clinical style, documentary practices, and clinical relationships. In typical care, accountability is primary, and much of what clinicians consider to be empowering is ignored or excluded. To deliver routinized care, clinicians simplify, and think in terms of reified mental disorders. As they require standardised knowledge about patients, clinicians become adept at 'routinized intimacy.' Attempts to promote empowerment face serious obstacles. Thinner conceptions of empowerment are bureaucratically less problematic, but unsatisfying to many clinicians. Thicker versions of empowerment make care harder to document, control, justify and standardise, and risk escalates. My findings shed light on an under-acknowledged but important contradiction. I contribute to anthropological literature on accountability, ignorance and uncertainty, professional knowledge and ethics, responsibility and patient self-care, and mental healthcare as a source of disempowerment.
Supervisor: Hsu, Elisabeth Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available