Categorisation and micro‐rationing: access to care in a French emergency department

Abstract

This paper describes how the categorisation of patients by staff in a French emergency department (ED) leads to the micro-rationing of care. Although ED staff are reluctant to acknowledge it, they refuse to treat many would-be patients at the reception stage, and advise them to go to other care settings (such as general practitioners' premises or social dispensaries).The study analyses the judgmental categories staff use to decide patients' eligibility for care, paying particular attention to their clinical, organisational, moral and social dimensions. Staff ration care at the point of service delivery but they soften the harshness of the rationing by making a positive discrimination in favour of those seen to be in real need. Data from observations and interviews are used to analyse the tensions between the different models of`local justice' employed by doctors.

Understanding interdepartmental and organizational work in the emergency department: An ethnographic approach

“…The role of emergency staff as ''gatekeepers'' of the hospital, controlling the entry of patients into the hospital, makes the ED an ideal location to observe, in real time, the process of health rationing (Vassy, 2001). An even firmer indicator of the potential importance of exploring interdepartmental relations ethnographically concerns patient throughput.…”

How Triage Nurses Use Discretion: a Literature Review

“…They evaluated patients' appropriateness by judging whether their conditions matches the ED's purpose of treating the acutely ill, which is a finding that resonates with the broader literature on how ED personnel interpret and judge patients (Dingwall & Murray, 1983;Dodier & Camus, 1998;Hughes, 1989;Jeffery, 1979;Mannon, 1976;Roth, 1972;Vassy, 2001). Nurses also relied on behavioural cues, time factors and other assumptions to judge the believability of patients' complaints.…”

Models of Health Care Rationing

“…They must be rationing. For some of the ways in which they are rationing, see Vassy (2001). 4 The essentially political nature of rationing is also (strongly) emphasized by Light and Hughes.…”