Crossing the first border: returning to the Academy from the ‘real world’
On embarking on doctoral research (eleven years, two children and one mortgage after my Masters degree) I had relatively few concerns about the disciplinary borders that I have since transgressed. After all, I had already blithely switched disciplines years before as an undergraduate (settling on a Joint Honours in Philosophy and Literature) and again for my MSc (in Social Policy and Planning). Crossing the border to academia was the more daunting challenge. I was working in a senior position in the NHS at the time, charged with developing a programme of integrated health and social care, intended to improve the organisation of services for people with multiple health problems, despite a context of ever-decreasing funding, and concerns about local hospital services.
The ‘real world’ problems that integrated care seeks to address are complex and enduring, not just managerial issues but genuine social, political, and economic concerns. From within my professional world, the best practice guides of health think tanks and policy directives pointed to integrated care (the bringing together of services, budgets and organisations) as a solution to optimise the quality of care, improve patient outcomes, prevent hospital admissions and so save money. Assumptions that these results were achievable underpinned large scale financial and service plans, and yet, empirical research failed to demonstrate delivery of the policy promise.
I found this state of affairs professionally troubling, and deeply intriguing. The need to think differently about these issues became the basis of my doctoral research, which I have pursued on a part-time basis whilst retaining my part-time NHS position. On entering the Academy, the challenges of inhabiting these multiple positions became apparent. Not only was I intent on taking an alternative epistemological position to that underpinning much of the relevant health services research by thinking differently about integrated care, not as an intervention but as a social practice, I was deliberating inhabiting the boundaries between medicine and social science. Boundaries are awkward places to be, but can be exhilarating when shared with supervisors adept not only at inhabiting uncomfortable positions but also at forging new knowledge from these places.
Approaching the object of study
The study of the practice and experience of integrated care connects to political debates about the role of a publicly funded health service and a means-tested system of social care; economic debates about the relationship between the wider economy and levels of public spending; medical debates about how to manage multi-morbidity and frailty, and social and cultural questions about how to live in the UK in the 21st century. To study this, I needed to embrace ambiguity, maintaining open-ended inquiries, whilst developing a sufficiently focused approach to define an object of study. In resolving this tension, I construct my object of study as a case. I read extensively about case studies. I read lots of case studies. I aspire to ‘do’ ethnography. I read lots about ethnography. I read lots of ethnographies. I do qualitative research training, de-construct the concept of data. I am in danger of inserting quotation marks around every word of every sentence I write. I undergo the ritual of the NHS ethics committee; I have no idea what to wear to (what felt like) the hearing. ‘A suit!’ my supervisor advises.
Having discovered the notion of a field, I start my fieldwork. This is a multi-layered experience, entailing the development of a dual life, both participant-observer and NHS manager. The suit jacket comes off but the NHS badge stays on when I hang around in clinics and drive round the streets, observing nurses, doctors, OTs, and physios. I pore over policy documents, simultaneously checking what needs to be included in the management plans I am producing in my ‘day-job’ and critically analysing the discourse of efficiency and control. I spend days in the homes of the people who are affected by these policies, I deal with the emotional realities of long-term ethnography, immersed in others’ lives. I dig out my black suit to attend a funeral. I keep a reflexive journal. I develop an understanding of narrative and start to write the stories of the people and places. Back in the Academy I attend my upgrade viva. ‘No! Not a suit!’ my supervisor warns. Narratives, discourses, places, practices, these are the objects of my study, rendered in texts, represented in photographs and audio files. How do I theorise about these? How can I understand how they all co-exist, hang together as they do? How do I talk about my research with others?
Switching the theoretical lens
An interdisciplinary research group, and interdisciplinary modes of training, provide me not just with multiple ways of viewing my research object, as an object displayed in a museum case can be viewed from different angles, but of contrasting the different realities of this object. Thanks to Mol, I am able to conceive of the research object as having multiple realities. Integrated care is a discourse in policy documents, and a practice in the field, and an intervention when framed by evaluators. I slowly build a multi-stage process of analysis, initially tracking back and forth between empirically inductive analysis of fieldwork and discourse analysis of storylines. The interdisciplinary ability of linguistic ethnography to place, trace and analyse situated encounters and texts provides an analytic framework that connects the individuals, networks and institutions encountered in my research. Practice theory enables me to trace the routines and inter-connected bundles of ‘doings and sayings’ that constitute this notion of integrated care. A turn to the spatial opens up further interpretative possibilities, and, grounds me ontologically as I problematise ideas of context and place. I am able to build a theoretical understanding of the disconnections and tensions I have detected between the lived experience, the practice and the policy intentions. I am convinced that without this interdisciplinary approach it will not be possible to move forward on the issues that integrated care is intended to address.
Inhabiting new ways of knowing
The thing with crossing borders is that it’s not always possible to go back. Even if it is possible, the original habitat can be rendered hostile by the transformation engendered by the journey abroad. Crossing the border to academia and developing a theoretical approach that (at least partially) explains my object of study, does not provide the kind of answers that can be easily transported back again. My dilemma now, having thought differently about integrated care, is how to re-enter the ‘real world’ and contribute to the debate raging around us about the latest NHS crisis? Moreover, thinking differently about this research object creates a shift in thinking that needs to be accommodated in the next stage of learning and practice; an interdisciplinary habitus is being developed that will shape my future journeys, wherever they will go.
Gemma Hughes is a PhD candidate in the Nuffield Department of Primary Care Health Services at the University of Oxford