Health and social care for people with severe mental health problems: an ethnographic study.

Abstract

In the study reported in this thesis sociological theories were used to underpin an investigation into the organisation and delivery of community mental health care. Set against a background of accelerating change in the wider, macro-level, system of mental health work ethnographic data were first generated relating to the meso-level organisation of interagency services in two contrasting study sites. In each site interviews, observations and documentary analysis were also used to generate data relating to the micro-level care delivered to three exemplar service user case study subjects over a four to five month period. Macro-level public services modernisation was triggering sustained upheaval at the meso-level at which local services were planned, commissioned and provided. Complex structural, historical and people-related factors combined together to both help and hinder efforts to reconstitute local systems of work. Case study data were drawn on to examine the micro-level roles and responsibilities of paid and unpaid workers and the unfolding of complex service user trajectories, as these were played out in the two contrasting meso-level contexts. Findings exemplify the degree to which roles are realised in specific, interactive, workplaces. The work of psychiatrists, social workers, nurses, clinical psychologists, general practitioners, pharmacists, health and social care assistants and unpaid lay carers and service users was found to be highly sensitive to local particularities and to the 'lines of impact' running between macro, meso and micro-levels. Features with consequences for the work of particular groups included: team composition and history relative resource availabilities and arrangements for the funding of particular types of work progress on the agreement of formal policies and procedures spatial and temporal organisational factors the localised exercise of occupational jurisdictional authority differentiations and non-differentiations of roles and responsibilities made by recipients of services and personal factors, including individual practitioners' levels of knowledge and skill