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Emboydingpolicymaking2016

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Emboydingpolicymaking2016

  1. 1. Embodying policy-making in mental health: the implementation of Partners in Recovery Jennifer Smith-Merrya,b and James Gillespieb,c a Faculty of Health Sciences, University of Sydney, Lidcombe, NSW, Australia; b Menzies Centre for Health Policy, University of Sydney, Lidcombe, NSW, Australia; c School of Public Health, University of Sydney, Sydney, NSW, Australia ABSTRACT This paper starts from the premise that embodied knowledge is critical to understanding health policy implementation. We explore this notion through a qualitative investigation of the way that knowledge has functioned in the implementation of an Australian mental health policy, Partners in Recovery (PIR). Analysis uses the theoretical lens of interpretive policy analysis and the ‘embodied, inscribed, enacted’ knowledge schema developed by Freeman and Sturdy [(2014a). Introduction: Knowledge in policy – embodied, inscribed, enacted. In R. Freeman & S. Sturdy (Eds.), Knowledge in policy: Embodied, inscribed, enacted (pp. 1–19). Bristol: Policy Press]. Our analysis reveals a policy problem centred around difficulties of coordination where the inscribed solution lies in individuals who must implement the PIR program in local areas. Our interviews with PIR consortium members and stakeholders show that this implementation happens through the enactment of embodied knowledge. However this implementation is not straightforward and we point to difficulties arising from the centrality of embodied processes in implementation, related to the localisation of systems knowledge in individuals and structural devaluation of certain types of knowledge over others. ARTICLE HISTORY Received 13 November 2015 Accepted 23 March 2016 KEYWORDS Mental health; embodied knowledge; health services; health policy; Australia; interpretive policy analysis Introduction A reflection on embodied knowledge is important for understanding consumer accounts of health and illness and it is this aspect of experiential knowledge which is considered primarily in health sociology. However, a consideration of the embodied knowledge of practitioners and policy-makers is critical to understanding the practices of the health system that create the administrative regimes consumers experience in their healthcare encounters. For that reason, we focus in this paper on the micro practices of policy and identify the way embodied knowledge is enacted by those that implement policy through their day to day work. We use as a case study Partners in Recovery (PIR), an Aus- tralian Federal Government policy implemented in local healthcare regions in order to coordinate services for people with severe and complex mental ill-health. We begin by © 2016 Informa UK Limited, trading as Taylor & Francis Group CONTACT Jennifer Smith-Merry Jennifer.smith-merrry@sydney.edu.au Faculty of Health Sciences, University of Sydney, PO Box 170, Lidcombe, NSW 1825, Australia HEALTH SOCIOLOGY REVIEW, 2016 VOL. 25, NO. 2, 187–201 http://dx.doi.org/10.1080/14461242.2016.1171120 Downloadedby[UniversityofSydneyLibrary]at19:0726July2016
  2. 2. introducing the PIR program and then introduce the theoretical approaches through which we interpret the data. Background: the PIR program Throughout the 1990s and 2000s, Australian mental health care was repeatedly character- ised as in ‘disarray’, with multiple reports documenting problems (Rosenberg, Hickie, & Mendoza, 2009; Whiteford, 1992), particularly in coordination which had led to disorgan- isation and fragmentation of services (Banfield et al., 2012). To understand the system, one must be literate in its funding arrangements, different accountabilities, alliances and com- petitive providers, and for an individual experiencing mental ill-health, particularly those whose lives are made more difficult by comorbid illnesses and social needs, the system is almost impossible to navigate. However, successive policies have had little success in creat- ing a cohesive system which allows those with mental ill-health to easily access the services they need (Whiteford et al., 2014). PIR was a 2012 initiative of the Gillard Labor government aimed at a national, but decentralised solution to these coordination problems, enacted in local regions (for a more in-depth understanding of the PIR program refer to: Brophy, Hodges, Halloran, Grigg, & Swift, 2014; Smith-Merry, Gillespie, Hancock, & Yen, 2015). Government announcements launching or promoting PIR articulated the health and social support systems for mental ill-health as riddled by ‘gaps’, ‘cracks’, wrong turns and disconnection through which individuals must ‘battle’ (Butler, 2012): One of the most consistent themes fed back to the Australian Government is that care for the most vulnerable people with severe and persistent mental illness is not adequately integrated or coordinated, and people with complex needs often fall through the resulting gaps. (Depart- ment of Health and Ageing [DoHA], 2012b, p. 10) The potential PIR client1 was also seen as the source of the problem with their ‘complex needs’, propensity to ‘fall through the gaps’, and ‘disconnection’ (DoHA, 2012a; PIR oper- ational guidelines 2013). They were also seen as prone to ‘extensive reliance’ on multiple services (Department of Health [DoH], 2014b). The policy problem was therefore a problem with two parts. One was the fractured mental health system. The other was those with ‘severe and persistent mental illness’ (DoH, 2014b). Both of these problems actually related to people, their embodied actions and their interactions with systems of organisation for the implementation of mental health policies. A healthcare system is, at a micro level, made up of the interactions between people who have different embodied knowledge of the system and therefore act on a policy in different ways (Flood & Fennell, 1995). The solution proposed by PIR was a system based on coordination and collaborative working. The Commonwealth government contracted with lead agencies in 48 Medicare Local (primary care) regions across Australia in 2013 to run PIR. These agencies then formed consortia of non-government organisations already working in health and social care. The program hinged on the activities of a new work role, the support facilitator (SF) whose purpose was to meet with individual consumers, identify their needs and then locate services which could meet these needs (Smith-Merry et al., 2015; Urbis, 2015). Alongside those working at the ‘consortium’ level, the SF role was also expected to link 188 J. SMITH-MERRY AND J. GILLESPIE Downloadedby[UniversityofSydneyLibrary]at19:0726July2016
  3. 3. up the system and foster better communication and collaboration (Smith-Merry et al., 2015). The program consciously referenced recovery, which is the concept that individuals diagnosed with mental ill-health have a reasonable expectation of living a meaningful life with or without the symptoms of mental ill-health (Anthony, 1993). However, despite this inclusion of the concept in the program name, recovery ideals and common recovery ‘tools’ of practice did not underpin the program (Smith-Merry, Freeman, & Sturdy, 2011) except when local implementation teams chose to include them. Theorising local-level knowledge in health policy practice Standard accounts of policy-making, such as the popular ‘policy cycle’ framework, promote a mechanistic and sequential interpretation of policy processes at only a macro level (e.g. Althaus, Bridgman, & Davis, 2013). However, policy-making cannot be fully understood without a consideration of its day-to-day implementation (Colebatch, 2005) and the work of the individuals who are involved in that implementation – work that is ‘discursive, embodied, embedded, radically contingent [and] deeply interactional’ (Gheradi, 2011, p. 58). Exploring policy at this micro level leads to an understanding of the way that policy shapes local practice in healthcare settings and how seemingly rational health policies can become irrational through implementation. Interpretive policy analysis and micro level policy practices Interpretive policy analysis (IPA) is a theoretical approach to policy-making which seeks to understand how policy is interpreted and put to use in practice, and is therefore useful in understanding the micro social and embodied practices of policy implementation. IPA emerged as a challenge to positivist accounts of policy-making (Palumbo & Calista, 1990; Torgerson, 1986; Yanow, 1990, 1993), developing out of, and alongside, organisational sociology (Wilkinson, 2011) with which it shares a focus on context-driven organisational processes and ideologies as determinants of practice-based actions (Flood & Fennell, 1995). IPA brings together this organisational level understanding with a focus on the micro interactions of those involved in implementation, which has been an approach largely missing from a sociology of health and illness (important exceptions are discussed below) (Davies in Collyer, 2012). Bourdieu has also been important in the development of IPA practice, particularly his conceptualisation of ‘field’ and ‘habitus’ which place impor- tance on the ‘empirical reality’ of a setting (in this case the organisation, or policy field) and the embodied actions of agents in those settings (Bourdieu, 1990; Gheradi, 2011, p. 45). Yanow (1993, p. 41), a key protagonist of IPA, writes that policy implementation pro- blems relate to difficulties of interpretation of policy meaning, and so an interpretive approach ‘calls on us to ask: what does a policy mean; to whom … does it have meaning; and how do various interpretations of meaning affect policy implementation?’ This permits an empirical focus on how the individual interprets new policy knowledge, given their existing embodied and social situation, and the policy implementation that results. This is integrally an embodied process and attention is focused on the work that bodies do, including the thought processes and bodily practices that develop in HEALTH SOCIOLOGY REVIEW 189 Downloadedby[UniversityofSydneyLibrary]at19:0726July2016
  4. 4. relation to policy. In this paper we use an IPA-inspired theoretical approach towards understanding knowledge in practice, developed by Freeman and Sturdy (2014a), in order to draw out the types of knowledge used in the implementation of PIR as a new policy entering an existing policy community. The overt focus on embodied knowledge in this schema has been highlighted elsewhere (Maybin, 2014) and makes it particularly applicable to the discussion in this paper. Embodied, enacted, inscribed: a framework for understanding knowledge in practice Freeman and Sturdy’s (2014a) knowledge schema separates knowledge into that which is embodied, enacted and inscribed. The schema draws on both organisational sociology and the sociology of knowledge, particularly in the use of these fields by scholars of manage- ment (e.g. Blackler, 1995; Fourcade, 2010; Lam, 2000; Nonaka, 1994). Freeman and Sturdy rely heavily on Lam’s (2000) description of the different interconnected types of knowl- edge as embrained, embodied, encoded and embedded. Lam’s work in turn developed out of the work of Collins (1993) who focused on five types of knowledge: embrained, embodied, encultured, embedded and encoded. Each revisioning of this knowledge scheme has retained a focus on the importance of embodiment as a key form of knowl- edge. Embodiment in this context links the body inextricably with thought, or ‘the mind’. Freeman and Sturdy quote the sociologist Dorothy Smith at length to describe their understanding of embodiment: Body … [is] the site of consciousness, mind, thought, subjectivity and agency as particular people’s local doings. By pulling mind back into body, phenomena of mind and discourse – ideology, beliefs, concepts, theory, ideas and so on are recognized as themselves the doings of actual people situated in particular local sites at particular times. (Smith in Freeman & Sturdy, 2014a, p. 203) This focus on the body in policy-making and implementation is important because, outside of an IPA approach, policy-making is largely presented as a disembodied process in which the actions of individuals are denied in favour of a focus on the macro policy narrative. This is even the case in health sociology which has tended to view policy and practice design and implementation as an abstract process whose actions only impact on the bodies of consumers (e.g. Bunton, 2001; Greaves, Oliffe, Ponic, Kelly, & Bottorf, 2010; Richardson, 2010). Important exceptions to this are work by Newnham (2014) on midwifery practice in relation to Australian maternity policy and the work by Long, Forsyth, Iedema, and Carroll (2006) on multi-disciplinary health- care teams, which ends with a call for a greater academic focus on the embodied interper- sonal relationships involved in health care. For Freeman and Sturdy (2014a), embodied knowledge is that which is ‘held by human actors and employed and expressed by them as they go about their activities in the world’ (p. 8). They use this category ‘to direct attention to the importance of embodied human beings in the distribution, movement and mobilisation of knowledge’ (p. 9), and include what might be elsewhere described as experiential or tacit knowledge. Embodied knowledge can be verbalised but can also be so embodied that it is difficult to describe and can be known only through action and interaction. 190 J. SMITH-MERRY AND J. GILLESPIE Downloadedby[UniversityofSydneyLibrary]at19:0726July2016
  5. 5. Scholars who have utilised Freeman and Sturdy’s schema (e.g. Freitas, 2014; Maybin, 2014) focus on individuals doing policy through the everyday practices of their work by taking the inscribed knowledge of the policy document and changing their work in relation to the policy. This is a process of changing knowledge into know-how. This under- standing of embodiment builds from the work of Polanyi (e.g. in Svabo, 2009; Yanow, 2003) and extends embodiment to an interiorisation of tools of practice. In this case, the meaning of ‘tool’ extends beyond physical tools to encompass mechanistic ways of doing that become essential to a role, for example, the multi-disciplinary team meeting in healthcare practice. While some embodied acts are separate from thought, in that they are felt so deeply that they cannot be verbalised or described to another (instinctual knowledge), other types of embodiment include processes that are understood and con- sciously practiced and, in turn, can be expressed to others through doing and meeting. In health sociology, those who work on embodiment primarily focus on the subjective experience of receiving care. This takes a number of different approaches, for example, work on the conflict between internal individual understandings of the lived or social body, and its treatment within a bio-medically focussed healthcare system (e.g. Turner, 1992). Other examples include work which focuses on the disruption to the understanding of the self as a result of ill-health (e.g. Bendelow, 2000; Kelly & Field, 1996), or emotion and bodily performance of illness or pain (e.g. Freund, 1990). The application of Freeman and Sturdy’s schema to health practice does not deny these aspects of embodi- ment but rather extends this focus by highlighting the embodied aspects of implemen- tation of health policy in practice settings. Knowing cannot be separated from doing and for Freeman and Sturdy (2014a) enacted knowledge is embodied and inscribed knowledge when put into action. While knowledge that is embodied might be learned discursively, once embodied it may become non-discur- sive and exists at an instinctual level (Gheradi, 2011). This means that for this knowledge to be observable and transmitted to others it needs to be enacted. Only through enactment can it be shared and ‘give rise to new knowledge’ in the form of further embodiment or inscription (Freeman & Sturdy, 2014a, p. 12). Examples of this type of knowledge are com- mittee meetings, conferences, performances and training (Smith-Merry, 2014, p. 24). Social relations shape the way that enactment takes place, with different settings allowing different forms of embodied knowledge to be enacted. For example, the embodied knowl- edge enacted in a public forum is different to the embodied knowledge that can be enacted in a clinical setting. While embodied knowledge is primarily non-discursive, enacted knowledge can be both discursive and non-discursive and transmitted both through words and actions (e.g. demonstration of equipment or use of data management software for consumer records). Inscribed knowledge is that which is ‘inscribed in artefacts: it may be written down in texts, or represented in pictures and diagrams; or it may be incorporated into instruments, tools and machines’ (Freeman & Sturdy, 2014a, p. 10). Examples of this type of knowledge are formal policy documents and guidelines, but also non-formal documents such as emails or ‘tools’ which capture knowledge, such as surveys or databases. This brings to the fore materiality, and policy and practice documents are useful materials of policy prac- tice because they exist in a more readily recognisable form and are easier to transmit than embodied or enacted forms of knowledge. As Smith-Merry (2014, p. 29) comments, ‘inscription makes knowledge portable’. Inscribed knowledge must be enacted to be HEALTH SOCIOLOGY REVIEW 191 Downloadedby[UniversityofSydneyLibrary]at19:0726July2016
  6. 6. used. An example of this is the policy document. Policy documents are created through embodied actors in enacted settings, but they cannot result in any further policy work unless they are enacted and their goals embodied by individuals (Freeman & Maybin, 2011). Each of these knowledge ‘types’ are taken into consideration in our analysis of the PIR program as it has been implemented in practice in Western Sydney. Method The data we report here derives from qualitative analysis of key documents and interview data collected through our evaluation of the implementation of PIR in two regions in Western Sydney. Ethics approval was gained from the University of Sydney Human Research Ethics Committee (approval number 2013/678). The aim of the qualitative data collection was to understand the extent to which system coordination is improving in the context of PIR, and interview questions related to the day to day operation of the program from the perspective of those working within PIR and relevant stakeholders. For example, we asked participants what knowledge they drew on in PIR related work, who they interacted with, what barriers existed to their work and what facilitated it. The interview data derives from interviews with 43 individuals involved in the implementation of PIR in the two regions in our study. This included respondents from the PIR lead agencies (the consortia) (4 in total); SFs and team leaders (TLs – these are SFs with greater coordination responsibility) (15 in total); and stakeholders (24 in total) who have engaged with PIR. All participants were aged over 18 and equal numbers of men and women participated in the interviews although the latter was not part of our sampling criteria. Interviews were conducted in person in the respondent’s place of work and were recorded and transcribed verbatim. In our results, respondents have been identified by their role in the system and a numerical identifier. We also collated official documents produced by the government to explain and guide the implementation of PIR. These comprised: media releases (Butler, 2012), DoHA PIR Funding Guidelines (2012) which explained PIR and called for the creation of consortia to tender to operate PIR in different regions; the PIR Funding application form (2012) which was filled in by prospective consortia; PIR Operational Guidelines (2013) to guide operation for successful consortia; the DoH PIR website (2014a); DoHA Factsheets (2012); and the Federal Government Budget Statement (2013) committing ongoing funding to PIR. All interviews and documents were thematically analysed utilising the basic analysis approach outlined by Braun and Clarke (2006). This approach fits well with an interpre- tive analysis approach. Results have been structured to develop a picture of the use of embodied, enacted and inscribed knowledge in the PIR implementation. Quotations are used where possible to more clearly translate the meaning of the data to the reader (Gill & Colebatch, 2006). Results and discussion We begin with a discussion of inscribed knowledge and actor responsibilities identified in the program implementation documents, and the forms of embodiment inscribed for 192 J. SMITH-MERRY AND J. GILLESPIE Downloadedby[UniversityofSydneyLibrary]at19:0726July2016
  7. 7. these actors. We then turn our attention to the embodied knowledge of SFs and consor- tium members, how this was transmitted to the wider mental health sector and how the PIR program was then understood by stakeholders. Inscription of the PIR approach Government documents about PIR focused on its scope and how those individual roles identified as implementing the program should do so in a system characterised by com- petition and fragmentation. Documents focused on success through ‘collective ownership’ and ‘partnership building’ (DoHA, 2012a, pp. 6, 24) with ‘PIR organisations … [bringing] sectors, services and supports together to promote collective ownership by all partners’ (DoHA, 2012b, p. 5). Policy directives were transmitted to individuals involved in the PIR implementation through inscription in documents and training and through the del- egation of the SF and ‘consortium member’ role as the core implementation roles. Inscribed individual actor responsibilities The PIR guidelines inscribed a particular type of embodiment and enactment for consor- tium members and SFs. The job of the PIR consortium members was to develop collab- oration by creating new ways of working and ‘joining up’ sectors as the ‘mechanism to drive collaboration’ (DoHA, 2012b, p. 6). The functions of the SFs included work to meet consumer needs and the development of ‘pathways and networks between the sectors, services and supports needed by the target group’ (DoHA, 2012b, pp. 4–5). Exemplifying the interconnectedness of embodiment, enactment and inscription the personal qualities needed by SFs and consortium members were explicitly described through their inscription in the PIR Guidelines. The guidelines stated that ‘In undertaking their roles effectively, PIR organisations and their staff (including Support Facilitators) will need to … be confident … communicate … negotiate … analyse … share [and] engage’ including ‘with people who have often been difficult to work with’ (DoHA, 2012a, p. 7). SFs were told that in order to successfully implement PIR they must ‘possess personal qualities such as humane concern, empathy with both the client issues and service provi- der experience, imagination, hope and optimism’. Consortium members were to be responsible for: building shared goals; shared knowledge; mutual respect; frequent, timely and problem solving/ solution-focused communication; and fostering connectivity and collective owner- ship/responsibility to ensure the needs of PIR clients in the region are met. (DoHA, 2012b, p. 6) Those implementing PIR therefore had to first embody the qualities of PIR to be able to model and transmit its goals to the program stakeholders. Consortium members and the enactment of inscribed knowledge The inscribed knowledge of the new program was transferred to newly recruited SFs and consortium members through documents, training and meetings. ‘Documents themselves do nothing’ (Freeman & Sturdy, 2014a, p. 205) and for the words written in documents to be put to use they must be enacted within contexts where that knowledge has relevance HEALTH SOCIOLOGY REVIEW 193 Downloadedby[UniversityofSydneyLibrary]at19:0726July2016
  8. 8. and use. Collins (1993) also writes that it is difficult to learn simply from inscribed knowl- edge and, while documents might set the boundaries around what should be done, it is much less productive to spread understanding of a program of work via documents than via enactment through discussion or doing. Consortium members came to under- stand PIR through meetings where the documents were discussed and negotiation took place over who would take on the directives and carry out the work (Consortium 1; Con- sortium 2). However this knowledge was not adopted in an uncomplicated way and con- sortium members spoke about the importance of their own previous knowledge and the knowledge of others in helping them form their own understanding of PIR practice (Con- sortium 2; Consortium 3). The embodied and enacted expertise of SFs SFs highlighted the importance of knowledge gained through their previous positions or personal experience in the enactment of their role (SF2; SF7; SF8). To this, they added knowledge from their everyday interactions in doing the work of PIR, coming to understand the role as they practiced it, thereby gradually building up their embodied knowledge of the role (Smith-Merry et al., 2015). This newly embo- died SF knowledge was then taken out by SFs into each interaction that they had with others around the work of PIR. Our previous research reporting the specific experiences of SFs in implementing the program has shown that the SFs themselves felt that they were building the program through their work by creating connections in every interaction with the sector. They were both ‘educating’ the sector about PIR and making future connections for referrals to build the PIR program and reach new clients (Smith-Merry et al., 2015). In the words of one SF collaboration for PIR was seen to be about ‘Communication. If you show up at my door and not tell me who you are, how can we collaborate? How can we gain trust?’(SF8). Another spoke about the importance of building relationships based on communication ‘so that it’s not just them sending a referral into a black hole. It’s [having] a two-way relationship and they have someone that they know that they can talk to about it’ (TL1). As these quotations show SFs believed that they drove the collaborative goals of PIR through communicating freely and sharing infor- mation about relevant services in the community (TL1; TL2; SF3; SF6; SF7; SF10). Sta- keholder accounts held meetings and interpersonal connections as primary in system collaboration for the PIR intervention (Stakeholder 12, Stakeholder 9, Stakeholder 10; Stakeholder 15; Stakeholder 16). Personal connections were seen to transmit PIR goals and ways of working and ‘strike up a relationship’ that could then be drawn on further as needed (Stakeholder 9). This is demonstrated in the following quotation which highlights the importance of visiting other workplaces, meeting and interacting as enacted processes for facilitating the work of PIR: I’d put money on the reason that Partners in Recovery in the [named region] get referrals is because they went out and they sourced referrals and they met with people and they dis- cussed – like they came to us and really, really wanted to get involved and link. They come to one of our meetings every week … You’ve got a guy or someone from PIR ringing you, PIR ringing up saying ‘hey, you know, my name – I’m from PIR, I’d like to come and meet with your team’. (Stakeholder 10) 194 J. SMITH-MERRY AND J. GILLESPIE Downloadedby[UniversityofSydneyLibrary]at19:0726July2016
  9. 9. For stakeholders (Stakeholder 1; Stakeholder 16), the inscribed knowledge of emails and brochures did not promote adequate understanding of the program, whereas an enact- ment of embodied knowledge allowed the type of back and forth questioning through which understanding could be clarified. Connections were said to be easier in organis- ations which were collectively described as ‘well connected’ through strong interpersonal connections (Stakeholder 8; Stakeholder 16; SF6; TL4). The ‘well-connected’ organisation is strong because of the collective embodied knowledge of their members, which is readily enacted with others. The enactment of embodied knowledge through meeting Embodied knowledge must be enacted for it to be passed on to others (Freeman & Sturdy, 2014a) and PIR workers primarily enacted their knowledge by connecting to the sector through group-based meetings and forums. As one participant commented, if their organ- isation wanted to find out about PIR then they sent someone to the relevant meetings (Sta- keholder 15). Eighteen respondents stated that PIR knowledge was enacted primarily through the involvement of SFs in interagency forums which brought together individuals from different agencies or organisations around a particular topic (e.g. hoarding and squalor or housing) and allowed members of the groups to seek advice or share their experiences of what works (Stakeholder 6; Stakeholder 13; SF3). Several stakeholders also spoke about finding out about the program when PIR staff came to their organisation and conducted training or an ‘in-service’ on PIR for an organisation (Stakeholder 17; Sta- keholder 12; Stakeholder 13). These meetings and training opportunities are examples of forums where knowledge is enacted either formally, through training, or informally through sharing personal embodied knowledge in order to implement and expand the work of PIR. Schön (1983) relates that embodied knowledge is known through doing, which he describes as ‘knowing in action’, and reflecting on this doing: ‘reflecting in action’ and ‘reflecting on action’. Others learn from this experience through the telling or observing of this embodied knowledge in a context where the observer is able to relate closely to the experience (Smith-Merry, 2012). This process of knowledge transfer took place in the SF interactions with others in meetings. Meetings were only successful if the SFs enacted their knowledge in the right ways. As recognised in the program documentation mentioned above, the embodiment of particu- lar personal qualities by SFs and consortium members was seen to both facilitate and hinder collaboration. Key positive attributes for collaboration were described as flexibility and a ‘willingness’ or ‘effort’ made to connect (Stakeholder 9; Stakeholder 10; Stakeholder 16). This was contrasted with a bad ‘attitude’, inflexibility or silence (Stakeholder 3; Sta- keholder 12; Stakeholder 10; Stakeholder 1; Consortium 2; Stakeholder 11; Stakeholder 16) which would stall communication. Appropriate interpersonal communication was also therefore a strong factor in the enactment of knowledge in order to build the program. Collaboration based on the enactment of consumer knowledge You go and walk with a client, think about how their mornings are going to be spent every day … It’s a really important part of addressing someone’s sense of being themself and belonging. (SF9) HEALTH SOCIOLOGY REVIEW 195 Downloadedby[UniversityofSydneyLibrary]at19:0726July2016
  10. 10. SF work practices also developed through their understanding of the system from their clients’ perspectives (SF4; SF6; SF7; SF8; SF9; TL1; TL2). The quotation above shows the way that SFs literally walked the same path as the clients that they worked with in order to understand their experiences. Embodied consumer knowledge was also important in the spread of PIR into local mental health and social care systems. This happened in two ways. Firstly, direct meetings took place between PIR and other services to meet client needs (Stakeholder 6; SF7; SF9). Repeated meetings gradually developed an inter-reliance amongst services where familiarity meant that natural referral paths developed (Stake- holder 14; Stakeholder 16; Stakeholder 17). Secondly, the embodied knowledge of consu- mers also helped interpret the system for practitioners (Stakeholder 2; Stakeholder 11; Stakeholder 14; SF9; SF4; SF8). This example represents this process: … you have an individual and then because of that individual you might then talk to four or five different services. That I suppose opens up those conversations to further working. (TL1) In this example, the daily embodied practices of both PIR workers and stakeholders were changed through responding to their understanding of the embodied needs of their clients. Here the clients enacted their embodied knowledge and the workers learned from this and re-embodied the knowledge on their own terms. Their experience of that knowledge could never be the same as the PIR consumers themselves, but nevertheless they were able to take on aspects of this knowledge to shape their own practice (their know-how). Indeed this is a key aim for recovery-oriented practice, where the practitioner changes their own practice in relation to their client’s experiences (Smith-Merry et al., 2011). This use of the embo- died knowledge of mental health consumers has also been an important tool in the devel- opment of recovery-oriented policy (Smith-Merry, 2012). At a macro level, the system was at least in part coming to know itself through clients relating their experiences with what had worked. Rather than PIR joining up services for clients, the clients created maps for the system to know itself by and thereby made those working within the system more amenable to collaboration. Conflicting forms of embodied knowledge SFs reported instances where they were made aware by health clinicians that they had the ‘wrong’ types of embodied knowledge and expertise. Several SFs stated that they were not taken seriously without clinical qualifications and had even been asked for their qualifica- tions (SF1; TL2). The SF role is a brokerage role rather than a clinical role but those working in clinical settings expected that anyone working with consumers with mental health problems should have health-related qualifications (Smith-Merry et al., 2015). Long et al. (2006) have shown how the work of healthcare practitioners working in multi-disciplinary teams is made problematic by a conflict between different forms of expertise at the boundaries of professions. They point to embodied changes amongst those workers pushing up against these boundaries and the ‘complex, in situ enactments of specific bodies and practices’ which develop as a result. SFs internalised criticism of the knowledge base to their work, which upset them and destabilised their positions (SF5; SF3; TL1). Those difficult structural attributes of the system which PIR was meant to fix were also, probably not surprisingly, the hurdles which stymied their work. The most significant 196 J. SMITH-MERRY AND J. GILLESPIE Downloadedby[UniversityofSydneyLibrary]at19:0726July2016
  11. 11. implementation problem related to the siloed nature of the system (Consortium 1; Stake- holder 9) which engendered different ways of working, and even understanding, mental ill-health. As one respondent commented, PIR’s ‘model of working is a recovery model. Whereas community health is a medical model and that’s more or less what we want as well’ (Stakeholder 1). Stakeholders spoke about the need for a culture or ‘common’ ground for understanding in order to enable collaboration and had actively sought out partners who shared this (Stakeholder 5; Stakeholder 8; Stakeholder 14; Stakeholder 15). Several respondents spoke directly about the difficulty of collaborating while speaking different languages: … collaborating with other services, especially ones that are doing clinical, and you’re doing a recovery oriented … that collaboration process is an ‘interesting’ one. (Consortium 1) You know clinical services are coming from a clinical vein, NGOs are coming from psycho- social support. (Consortium 2) These respondents were pointing out that partnership and collaboration is easy when all partners share the same language or paradigmatic view of the problem. When the opposite is true, communication stalls and with it program implementation. The enactment of embodied knowledge is difficult when there is not a common set of shared understandings or experiences to work from. As Wynne (1991) writes, expertise is only relevant when it exists in a setting that is recognised as such. The instability of embodied knowledge While embodied knowledge was that which was most heavily relied upon in the implementation of PIR, this was seen as unreliable due to difficulties in enacting this knowledge beyond the individual. One respondent spoke about the difficulties they encountered when they had to rely on an individual SF to ‘do their bit’ with a client and they failed to act (Stakeholder 13). Reliance on personal connections was seen as pro- blematic in the context of high staff turnover because the embodied knowledge an individ- ual had of PIR was lost to the organisation when they moved on. When staff left, the connections made needed to be built up again, sometimes from scratch, which took time (Stakeholder 3; Consortium 4; Stakeholder 10; Stakeholder 1). This problem with embodied knowledge has also been identified in work by Maybin (2014) who pointed out the problem of interdependence in team-based working when members of the team leave and their knowledge leaves with them. While, as discussed above, ‘one on one’ con- nections were productive, they therefore needed to be sustained beyond the individual level (Stakeholder 9). Interagency forums were seen as an antidote to this, allowing knowl- edge to be translated in such a way that when an individual left the knowledge kept going through the collective knowledge of the group (Stakeholder 14). Conclusion Our discussion has provided an account of the implementation of health policy through the lens of Freeman and Sturdy’s (2014a) embodied, enacted and inscribed knowledge schema. Freeman and Maybin (2011) write that government is ‘unthinkable’ without documents, but it is also unknowable. Health policy documents and guidelines (should) provide a structure and limit for implementation and a delegation of responsibility for HEALTH SOCIOLOGY REVIEW 197 Downloadedby[UniversityofSydneyLibrary]at19:0726July2016
  12. 12. practice (Althaus et al., 2013). In line with this, we can see that the guidelines written to implement the PIR program created new roles within the mental health system – the SF and the consortium member – and inscribed a particular type of embodiment and set of actions they were expected to perform. Inscribed knowledge, however, is meaningless unless it is enacted in relevant ways (Freeman & Sturdy, 2014a). The inscribed knowledge of PIR was enacted via meetings and training. In these settings it was merged into the existing action and knowledge ‘repertoires’ of those who filled the SF and consortium member roles (Smith-Merry, 2012) thereby giving ‘rise to new knowledge’ (Freeman & Sturdy, 2014a, p. 12). This new embodied knowledge could then be taken out by SFs into the sector to further develop the work of PIR. The embodied knowledge of SFs was thus the know-how related to PIR operation, but contextualised within their own existing knowledge and history of interactions with the mental health system. Freeman and Sturdy (2014b, p. 203) write that ‘embodiment is a key facet even of the most rarified forms of expertise’. The expertise the SFs brought to their work was highly connected to the individual relationships built up with others in the sector and was thus deeply contextually dependent and created and situated in their work within PIR. It was an expertise build on ongoing interactions, unlike professions which have a public identity and an associated expertise that is separate from themselves as individuals and their organisational affiliations (Collins & Evans, 2002). Our data has shown that SFs created their own networks and then implemented the PIR policy through those networks by per- forming PIR goals again and again via their interactions in meetings, forums and other face-to-face settings including collaborative care to meet client needs. Fourcade (2010) has commented that attending and performing at meetings is an embodied practice, however Freeman and Sturdy’s schema visualises meeting as the enactment of embodied knowledge. It is where embodied knowledge, personal to the individual, becomes social and transmitted to others. While successful in enacting the goals of PIR within traditional mental health and social care systems, we have commented elsewhere that PIR has had significantly more difficulty in engaging more widely (Smith-Merry et al., 2015). Our interviews with SFs and stake- holders have pointed to an instability of embodied knowledge. A localisation of knowledge to the individual level (without strong overarching system-wide written directives from Government) can mean that knowledge is more easily lost when it is not collectively owned. Collective ownership in this case was effected by communication at interagency meetings and SF forums. However, the expertise of the PIR workers was not valued in those settings where the embodied knowledge of health clinicians dominated. This fits with Colebatch’s (2005, p. 21) idea that ‘policy work is concerned with constituting a regime of practice which is congruent with the activities of existing players (whose con- cerns are legitimated by their standing as “stakeholders”)’. For embodied knowledge to be enacted successfully in this case there needed to be a shared understanding to work from and, despite the lofty aims of the PIR program, the entrenched siloed, disconnected and fragmented nature of the health and social care sectors which PIR was put in place to address, still restricted this from occurring. Health sociology has only very rarely turned its attention to the embodied work that practitioners do (Davies in Collyer, 2012). Existing work in health sociology focusing on the embodied knowledge of practitioners has been concentrated mainly in the context of the work of practitioners with patients. In those contexts, embodied knowledge 198 J. SMITH-MERRY AND J. GILLESPIE Downloadedby[UniversityofSydneyLibrary]at19:0726July2016
  13. 13. may be visualised much more clearly because of the physicality of the work involved, such as in Fine’s (2014) work on the embodied physical care-giving practices of those working in aged care. Embodiment is more difficult to conceptualise in settings where embodiment is not overtly physical but is instead enacted through meetings and communicative events. Our analysis has shown that for those wanting to understand the subtle interactions of embodied knowledge in health policy practice, a characterisation of knowledge as embo- died, enacted and inscribed knowledge (Freeman & Sturdy, 2014a) may be of assistance in revealing the multidimensionality of practice-based knowledge. We encourage further work on embodied knowledge and practice in health sociology using this analytical tool. Note 1. We acknowledge the contested nature of terminology around individuals who experience mental ill-health and the inability for one term to capture every individual’s experience of ill-health and their interactions with the health care system. Here we use the terms consumer and client interchangeably. Consumer is the term most used by peak consumer-led bodies in Australia (e.g. by the National Mental Health Consumer and Carer Forum) and client is used in the PIR program guidelines. Acknowledgements We acknowledge the assistance of Ivy Yen who worked as a research assistant on this project and collected the interview data used in this paper. The authors declare that that they do not have finan- cial interest or envisage any benefit arising from the direct applications of this research. The funding bodies have not seen or approved this research and place no limitations on its publication. Disclosure statement No potential conflict of interest was reported by the authors. Funding This work was supported by funding from New Horizons and Wentwest for whom we are evaluat- ing Partners in Recovery. ORCID Jennifer Smith-Merry http://orcid.org/0000-0002-6705-2652 James Gillespie http://orcid.org/0000-0002-0355-4178 References Althaus, C., Bridgman, P., & Davis, G. (Eds.). (2013). The Australian policy handbook (5th ed.). Crows Nest: Allen and Unwin. Anthony, W. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16(4), 11–23. Banfield, M., Gardner, K., Yen, L., McRae, I., Gillespie, J., & Wells, R. (2012). Coordination of care in Australian mental health policy. Australian Health Review, 36(2), 153–157. Bendelow, G. (2000). Pain and gender. Harlow: Prentice Hall. HEALTH SOCIOLOGY REVIEW 199 Downloadedby[UniversityofSydneyLibrary]at19:0726July2016
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