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,
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
up the system and foster better communication and collaboration (Smith-Merry et al.,
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,
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
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
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
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
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.
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
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
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
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
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
HEALTH SOCIOLOGY REVIEW 195
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;
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
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
… 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).
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
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
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.
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.
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.
No potential conﬂict of interest was reported by the authors.
This work was supported by funding from New Horizons and Wentwest for whom we are evaluat-
ing Partners in Recovery.
Jennifer Smith-Merry http://orcid.org/0000-0002-6705-2652
James Gillespie http://orcid.org/0000-0002-0355-4178
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