Health States of Exception: unsafe non‐care and the (inadvertent) production of ‘bare life’ in complex care transitions

Abstract

This paper draws on the work of Giorgio Agamben to understand how the social organisation of care transitions can reduce people to their ‘bare’ life thereby making harmful and degrading treatment seemingly legitimate. The findings of a 2‐year ethnographic study show how some people experience hospital discharge as undignified, inhumane and unsafe process, expressed through their lack of involvement in care planning, delayed discharge from hospital and poorly coordinated care. Our analysis explores how these experiences stem from the way patients are constituted as ‘unknown’ and ‘ineligible’ subjects and, in turn, how professionals become ‘not responsible’ for their care. The result being that the person is reduced to their ‘bare’ life with limited value within the care system. We suggest that the social production of ‘bare life’ is an inadvertent consequence of reconciling and aligning multiple disciplines within a complex care system.

An ethnographic study comparing approaches to inter-professional knowledge sharing and learning in discharge planning and care transitions

“…Through the preliminary stages of data collection, our focus narrowed onto a number of empirically induced issues, one of which was to understand the relative contribution of different interventions to interprofessional knowledge sharing and learning. A range of other themes were developed from the extensive body of empirical data which are not reported in this paper (Bishop and Waring, 2019;Waring et al, 2015Waring et al, , 2016Waring and Bishop, 2019).…”

“…A growing demand for urgent care at the hospital "front door" creates pressure at the "backdoor" to discharge patients, but a lack of integration with community health and social care sectors often makes the timely and safe transition of care difficult to realise (Coleman and Berenson, 2004). In the UK, there has been mounting attention to the breakdowns in care that lead to patients being sent home too early or without the necessary care to support recovery (Healthwatch, 2015;Waring and Bishop, 2019). International research suggests that as many as 20 per cent of patients experience sub-optimal or unsafe care during or after discharge, resulting in prolonged recovery, re-admission and long-term harm (Aase et al, 2017;Coleman and Berenson, 2004;Enderlin et al, 2013;Atkins and Kansagara, 2016).…”

How latent patterns of interprofessional working may lead to delays in discharge from hospital of older people living with frailty – ‘Patient more confused than usual?’

“…Our observations showed how professional lenses or ‘gazes’ (Foucault, 1975) view the patient from many different angles according to their disciplinary or professional criteria, segmenting the patient and redefining their needs (Mol, 2003). As Waring and Bishop (2020) suggest, these different perspectives struggle and compete with each other at the point of discharge, often failing to bring them together to form a holistic understanding of patient situation and develop patient-centred, co-ordinated discharge plans (Waring and Bishop, 2020). They argue that bureaucratic practices – such as we observed in this study – serve to compound this problem of segmentation by transforming complex patient needs into ticks on checklists or descriptors on drop-down menus, with algorithms determining whether or not patients are eligible for particular services and allocating responsibilities to specific staff or organisations.…”

“…Second, we propose that the introduction of new electronic forms avoids standardisation and bureaucratisation. These carry with them the risk of further patient segmentation and the reduction of patients to units of need, required to conform with a range of criteria such as the eligibility to services (Waring and Bishop, 2020). Where possible, communication systems should allow for personal communication between professionals and the exchange of narrative information rather than of ‘factoids’ or lists of tick boxes in standardised forms.…”

Approaches to improving patient safety in integrated care: a scoping review

“…Open access involves different practitioners, teams, organisations and systems. 9 Integrated care provides health and care professionals with knowledge of an individual person's diverse care needs through shared information systems, enabling service providers to minimise gaps in treatment and care and address conflicts or duplication in care plans. This creates an environment that supports safety practices including proactive care through timely identification and enhanced management of risk.…”