Accepted Manuscript

Gatekeepers in the healthcare sector: Knowledge and Bourdieu's concept of field

Fran M. Collyer, Associate Professor, Karen F. Willis, Professor,Associate Dean,

Learning & Teaching, Sophie Lewis, Dr

PII: S0277-9536(17)30364-7
DOI: 10.1016/j.socscimed.2017.06.004
Reference: SSM 11268

To appear in: Social Science & Medicine

Received Date: 7 December 2016

Revised Date: 26 May 2017
Accepted Date: 1 June 2017

Please cite this article as: Collyer, F.M., Willis, K.F., Lewis, S., Gatekeepers in the healthcare
sector: Knowledge and Bourdieu's concept of field, Social Science & Medicine (2017), doi: 10.1016/
j.socscimed.2017.06.004.

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Title: Gatekeepers in the Healthcare Sector: Knowledge and Bourdieu’s Concept of Field

a b a
Authors: Fran M. Collyer ; Karen F. Willis and Sophie Lewis .

a. University of Sydney
b. Australian Catholic University

Corresponding Author: Associate Professor Fran M. Collyer

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Addresses and Affiliations:

Associate Professor Fran M. Collyer

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Department of Sociology and Social Policy
RC Mills A26
University of Sydney

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Sydney, NSW, 2006
Australia
T +61 2 9351 2653
Fran.Collyer@sydney.edu.au

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Professor Karen F. Willis
Associate Dean, Learning & Teaching
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Faculty of Health Sciences
Australian Catholic University
Street Address: Level 5, 250 Victoria Parade, Fitzroy, Vic, 3065
Postal Address: Locked Bag 4115, Fitzroy, Vic, 3065
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T +61 3 9953 3566

karen.willis@acu.edu.au
W http://acu.edu.au
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Dr Sophie Lewis
School of Social Sciences | Faculty of Arts and Social Sciences
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UNSW Australia | Sydney | Australia 2052

E: sophie.lewis@unsw.edu.au | P: +61 2 9385 0542
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Gatekeepers in the Healthcare Sector: Knowledge and Bourdieu’s Concept of Field

Abstract

Choice is an imperative for patients in the Australian healthcare system. The complexity of

this healthcare ‘maze’, however, means that successfully navigating and making choices

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depends not only on the decisions of patients, but also other key players in the healthcare

sector. Utilising Bourdieu’s concepts of capital, habitus and field, we analyse the role of

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gatekeepers (i.e., those who control access to resources, services and knowledge) in shaping

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patients’ experiences of healthcare, and producing opportunities to enable or constrain their

choices. Indepth interviews were conducted with 41 gatekeepers (GPs, specialists, nurses,

hospital administrators and policymakers), exploring how they acquire and use knowledge

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within the healthcare system. Our findings reveal a hierarchy of knowledges and power within
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the healthcare field which determines the forms of knowledge that are legitimate and can

operate as capital within this complex and dynamic arena. As a consequence, forms of
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knowledge which can operate as capital, are unequally distributed and strategically controlled,

ensuring democratic 'reform' remains difficult and 'choices' limited to those beneficial to
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private medicine.
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Keywords
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Australia; gatekeeper; healthcare; Bourdieu; field; capital; knowledge; choice.

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Introduction

Choice is a core value in the Australian healthcare system. Patients are encouraged to

‘choose’ whether to buy private health insurance, whether to use private or public healthcare

services, who to consult about health conditions, and what health goods and services to

consume, including surgical procedures, over-the-counter medications and complementary

therapies. Yet sociologically, choice is a problematic notion. Recognising that choice has

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become an imperative in health systems which demand patients become ‘active’ consumers

of health, there is a growing interest in how choices are structured and constrained within the

healthcare system, and concern over this differential capacity to choose (Harley et al., 2011;

Collyer et al., 2015a).

The notion of choice also co-exists uneasily with the complexity of healthcare systems such

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as those found in Australia, where there is a dynamic policy, market and consumer

environment and a composite of public and private providers and facilities. This complexity

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makes a healthcare system more a maze than a ‘system’ (Collyer et al., 2015a), and

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successfully navigating the maze requires more than a map and a compass for a patient.

Their success depends, in part, on the quality and quantity of resources that individuals

possess prior to, or can amass during, their journey through the maze. Equally important is

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the very context of the healthcare system: how it is organised, the accessibility, cost and
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appropriateness of its services, the information available and whether this is adequate to

assist patients to find services that meet their medical, and many social and cultural needs.
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Within the healthcare 'maze', multiple decisions are made, not just by patients, but by health-
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workers and policymakers, including about how services should be provided, organised and
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funded, and by whom. This aspect of choice has been less researched. The sociology of

knowledge and the sociology of science have begun to open up decision-making processes in
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areas of social life such as the laboratory (e.g., Camic et al., 2011; Latour and Woolgar, 1979),

but have yet to make a significant impact in the study of the organisation of healthcare. Where
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we do find studies of decision-making in the social sciences, the term ‘gatekeeper’ has, since
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the 1970s, increasingly been used to describe the key actors and groups involved in this

activity. The term has become ubiquitous in fields such as research methods (e.g., Crowhurst,

2013), media/communications (e.g., Soroka, 2012) and network analysis (e.g., Marks et al.,

2013), to indicate individuals with a key role and set of specified tasks. In the medical

sociology literature, where it appears less frequently, the notion of a gatekeeper is generally

reserved for the GP (a general practitioner or community-based doctor) (e.g., Segar et al.,

2013), although there are a few examples where it has been used for doctors in hospital

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settings (e.g., Mizrachi et al., 2005); other health-workers such as pharmacists (Chiarello,

2013); and non-health-workers, such as parents where their child is the patient (Dimond,

2014) and medical receptionists (Vassy, 2001; Hammond et al., 2013).

In naming the GP or other actor as a ‘gatekeeper’, the idea is to suggest a figure with a

significant social role to control access to resources. This may involve the screening of

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individuals seeking entry and allowing only some to pass ‘beyond the gate’. The gatekeeper is

often, particularly in the research methods literature, an under-theorised and abstract figure,

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overly rational (Crowhurst, 2013) and in Marxist or political economy analyses of healthcare,

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an agent rather than actor. For example, in private healthcare systems, such as the United

States, the gatekeeper is conceived as an ‘agent of capital’, for they act to limit the legal and

financial responsibilities of corporations such as health insurance companies or Health

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Maintenance Organisations (e.g., Budrys, 1993). In this context, the gatekeeper can only be
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self-interested and profit-oriented, and where a decision is in the patient’s interest, it is

coincidental (Collyer, 2015:50). In state-run health systems, with health-workers on fixed

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salaries regardless of patient turnover, or in countries (such as Australia or Canada) with

state-funded insurance systems and laws that are effective in prohibiting the payment of
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financial incentives to refer patients to particular businesses/services; the gatekeeper is more

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likely to be referred to as an 'agent of the capitalist state' (e.g., Bíró, 2013), for they assist the

state to control public outlays for diagnostic tests, specialists and hospitals - because patients
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are only subsidised for these costs when they have been referred by a GP or other registered

health-worker (Collyer et al., 2015b). In the latter context, the gatekeeper may or may not be
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acting in their own financial self-interest, but there are nevertheless assumptions they are
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responding to system imperatives, they have very limited roles, and little interest is shown in

the individuals who ‘play’ these roles. Indeed, even in the broader literature, instead of

examining those who ‘monitor the gate’, the focus is on those who are ‘outside the gate’

(Budrys, 2013:356). The gatekeeper is rarely portrayed as a fully social being with their own

motivations and capacities for action. The gatekeeper responds only as directed by the

demands of the system: ‘demands’ narrowly focused on organisational profits or budget

efficiencies.

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An argument can clearly be made for re-working the concept of the gatekeeper to enable

greater sociological insight into rarely investigated aspects of the healthcare system, where

decision-making fundamentally shapes both patient care and the operation of the system.

One of the current limitations in the gatekeeping literature is its focus on the entry point to

healthcare, rather than the many other potential gatekeeping processes that take place

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throughout healthcare provision (Chiarello, 2013:320). For example, decisions about who

should receive care and of what kind, but also how services should be organised and

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financed. This would require looking not just at doctors but other significant individuals,

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organisations and institutions. Moreover, the re-working and expansion of the concept should

entail a more thorough sociological approach in which gatekeeping is conceived as a fully

social process, a complex of actions that go beyond the filtering of individuals, and indeed

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beyond the concept of healthcare rationing, where decisions are made about what services
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will be funded. Such a broad range of tasks cannot be performed by rationally calculating

robots, but must emanate from social actors in situ, in key positions with access to relevant
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knowledge and a capacity to act on this knowledge. As a sociological concept, gatekeeping

needs to be conceived not as the performance of a role, but a process which produces the
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possibilities for action. For the healthcare field, gatekeeping is one of the more important
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ways in which pathways or structures are created, maintained and modified over generational

time, and these guide, enable and constrain the ‘choices’ of patients, health-workers and
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policymakers about possible therapies, providers and services.

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Employing this extended understanding of the gatekeeper, we can inquire more deeply into
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the human processes that configure and organise the healthcare system, and into the myriad

of ways in which the choices and decisions of participants (whether patient, doctor or policy

maker) might be circumscribed. If, as De Maio (2010:93-4) argues, healthcare systems reflect

the dominant values of the society and are ‘…outcomes of political struggle; they reflect the

end result of competition between complex forces', then we need to understand the

connections between the organisation of the system and the decision-making and actions of

the key actors within it.

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Our focus is therefore on gatekeeping, and the gatekeepers of the healthcare system. On

those actors who, in the main, are knowledgeable, highly competent, and caring, and yet

contribute to a system which does not always operate most effectively for the patients for

whom it is supposedly designed, nor most efficiently for the government that must manage

the healthcare budget. Thus we ask questions about the kinds of knowledge produced within

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the healthcare field, how knowledge is controlled within the field, the kinds of knowledge

available to gatekeepers, and the extent to which their knowledge and positions within the

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field may allow or restrict their capacity to build effective pathways within the system and

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assist patients with their healthcare choices. To address such questions, we designed an

empirical study of gatekeepers and their practices in the Australian healthcare sector. We

employ the concepts of Bourdieu - particularly his notion of the field - to map the various

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actors and relations of power within the field, and examine gatekeeping in action. This study
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is described in the next section, followed by a discussion of Bourdieu's concepts and then

findings from the project.

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The Study
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The gatekeeper study is part of a larger research program which aims to investigate the way

patients navigate the healthcare system in Australia. Both the gatekeeper study and its
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companion, the patient study (reported elsewhere, e.g., Willis et al., 2016), focused on a

series of research sites to ensure the inclusion of individuals from low and high socio-
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economic areas, metropolitan, regional and remote areas, across three Australian states and
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one territory. After approval from the Human Ethics Committee (HEC) at the University of

Sydney, (and the various authorities with responsibility for ethical conduct in the public

hospital system in the three states and one territory), participants were selected using internet

searches of appropriate sites (such as hospitals and general practices) through theoretical

sampling, and invited to participate. Between 2014 and 2015 we interviewed 41 individuals for

the gatekeeper study, and these included GPs and nurses in private and public general

practices and hospitals, specialists in both private and public practice, clinical directors,

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managers and CEOs in private and public hospitals, consumer and professional association

representatives, senior managers in Medicare Locals/Primary Health Networks, executive

managers in various health departments, and policy experts in research institutes and

universities. All participants gave their informed consent verbally and in writing according to

the requirements of HEC.

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All in-depth, semi-structured interviews with the gatekeepers were conducted by the first

author, transcribed and analysed using the techniques of thematic analysis. Due to the

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sensitive nature of some of the material discussed, pseudonyms are used to protect identity,

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and neither the institution or geographic location of the participant are revealed. Descriptors

are provided to give an indication of context, for example, 'GP, metropolitan public hospital'.

Bourdieu and Gatekeeping

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Bourdieu’s method of analysis, plus his concepts of capital, habitus and field, can be utilised
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in conjunction with a more sociological notion of the gatekeeper to effectively analyse some of

the less well-known aspects of social action within the healthcare sector. Bourdieu’s sociology
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serves as an important corrective to schemas where actors have unlimited capacity for choice
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and reflexivity (e.g., Giddens, 1991), instead offering a glimpse into a world where choice is

bounded (Williams, 1995:588). Bourdieu’s insights into the differing health knowledges of the
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various social classes is well known (e.g., Blaxter, 1990; Bourdieu, 1978), but can be

extended to other actors, for instance, gatekeepers, where we can ask questions about the
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knowledge these actors accrue and utilise, and how their knowledge and practices are
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constrained and shaped within the healthcare system.

For this it is crucial to take into account Bourdieu’s concept of the field, which provides an

explanation of these constraints through emphasising the dynamic relationships that give rise

to social action within a given social space. Any social action can be understood by identifying

the relations and structures of domination in that particular field (Bourdieu, 1993:72). Given

that, by definition, all fields are sites of struggle, and are constituted by a set of relations

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between a range of positions that reproduce the field itself (Bourdieu, 1993:35); analysis

should proceed by identifying the key actors and the relations between the positions in which

these actors stand. In the healthcare field, key actors include individuals (e.g., medical

doctors, government ministers), groups (e.g., activists, lobbyists), organisations (e.g.,

specialist colleges, pharmaceutical companies, professional associations) and institutions

(e.g., universities, medical schools). There are also key historically formed relations between

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officials, managers and professionals in government, industry, the community, hospitals and

the health insurance sector. These relations, in conjunction with the structures of the field,

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have ‘the potential to alter the nature and future direction of that field’ (Rhynas, 2005:181).

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We can get a sense of these relationships by examining the hierarchies of a given field. In the

healthcare field, as with all fields, there is an hierarchy of ideas and practices, a constant

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struggle to appropriate the ‘sayings of the tribe’ (doxa) and acquire ‘the power the group
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exercises over itself’ (Bourdieu, 1990:110; Brown et al., 2008:1049). The healthcare field in

Australia (and increasingly in all other parts of the world), differs from other fields (such as the
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field of art, or the field of science), in that its struggles centre around the ‘medical model of

illness’: a discourse that became dominant in the 20th century and insists that all disease has
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an identifiable biological cause and can be treated without taking social life into account;
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defines health as an absence of pathology; and emphasises curative medicine (Willis and

Elmer, 2007:24-26). The inculcation of this discourse by all persons, whether patients,
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practitioners or policy-makers, and its institutionalisation into the very structures of the system,

ensure that alternative forms of therapy and understandings of illness struggle to operate as
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legitimate forms of capital in the field, for, unlike orthodox medicine, they fail to be treated as
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‘social facts’. The healthcare field is consequently a site of contestation between groups,

organisations and institutions that on the one hand perpetuate the notion of health and

healthcare as value-free and largely independent of the social, and on the other, oppose this

doxa. A second feature of the healthcare field is that it is fundamentally capitalist, for

biomedicine arose historically in cohort with Western capitalism (Doyal and Pennell 1983),

and is provided amidst a complexity of relations between the private and public sectors, and

an on-going tension between the treatment of health and healthcare as a commodity versus a

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right of citizenship. These two points of tension mean that the various actors in the field hold

contrasting ideas about (1) whether the root causes of ill-health are best located in the biology

of the human organism or the social context, and (2) the extent to which services should be

made available as commodities through the capitalist market. Such conflicting values,

practices and forms of organisation makes this sector distinctive, and in Bourdieu's terms are

both reflections of, and assist to constitute, divergent structures of power: economic versus

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cultural.

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A Bourdieusian perspective, then, situates gatekeepers as decision-makers within a dynamic

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and uniquely structured field, with differential access to the specific kinds of capital that can

be accrued and wielded within the field, driven by different interests and value systems,

encouraged to compete - and sometimes collaborate - but always as actors rather than mere

agents.
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Most studies employing Bourdieu focus on knowledge as a hidden component of social action.
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In the everyday world, we 'know without knowing' the right thing to do (Jenkins, 1992, in

Williams, 1995:583). However, if we are to explore the practices of gatekeepers, their

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decisions and the resources they draw upon, our focus needs to include the practices that
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Bourdieu did not emphasise: those which involve more conscious reflection on their stocks of

knowledge, on the strategic weighing up of alternative possibilities, where actors draw deeply
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on the forms of knowledge available to them. In this we can appeal to Bourdieu’s 'logic of

practice', for it tells us that actors locate their practices not only in their own interests, but in
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their 'own experience of reality (i.e., their practical logic)' (Williams, 1995:582). In other words,
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the gatekeepers have decision-making practices that, as a result of their experience (habitus)

and position within the field, may be strategic, involving knowledge about the ‘rules of the

game’.

In the sections below, we draw on our empirical material to demonstrate how gatekeeping in

the healthcare field is structured around struggles over the form of capital that has currency in

this field (i.e., over what constitutes health and what should constitute good healthcare), and

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over how this is best delivered (i.e., by which speciality and whether in the private or public

sectors). We begin with participants' insights into the kinds of knowledge essential to those

working in healthcare, and how this is unevenly distributed in the mixed public/private sector

field and thus makes ineffective the actions of certain gatekeepers. Moving onto other areas

of the health system, gatekeepers with different kinds of habitus - and different positions in

the field - potentially come into conflict as they work from their knowledge base to design

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treatment regimes or programs of service delivery. Participants reveal how 'negotiations'

produce solutions that favour the field's dominant forms of capital. Our final section examines

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some of the ways knowledge is controlled in the field, restricting opportunities for challenging

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the status quo and improving services.

System Knowledge: An Essential Form of Capital

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Participants were encouraged to speak freely and generally about their views of the

healthcare system, its strengths and weaknesses. Many spontaneously raised concerns
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about the dearth of knowledge in the system and how this results in fragmentation and a lack

of coordination across an already complex system. We encouraged participants to tell us

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about their information sources and the kind of information they believed to be important in
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the health sector. Some regarded patients as the ones with insufficient knowledge, and often

the knowledge they referred to has been described elsewhere as 'health literacy'; but other
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forms of knowledge included ‘system knowledge’, that is, knowledge about the healthcare

system itself (for further explanation of this, see Willis et al., 2016). However our
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gatekeepers indicated that system knowledge is also lacking among many health-workers,
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particularly GPs, who require this if they are to find appropriate services and specialists for

their patients:

'GPs are quite demoralised. They struggle sending patients to us. They complain they

don't know which psychiatrist to send patients to, we don't know how to match them,

we don't know...' [Here the psychiatrist pauses, and then admits:] 'I used to have a

network, I used to know who the providers were and …– I'm old fashioned, I believe in

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relationships and I'd have my relationships with certain providers and I knew who was

good for which sort of patients. But that got lost when the bureaucracy changed and I

can't be bothered now trying to re-establish it all' [Liam, psychiatrist, private practice,

high SES area].

'... we have doctors who work in our system who have very deep and narrow

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knowledge around things but have absolutely minimal knowledge in all sorts of other

areas, and yet we entrust them to do things' [Matthew, senior bureaucrat in a state

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health department].

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In both the above cases, the gatekeeping process appears to be hindered by inadequate

access to the appropriate kinds of social capital (e.g., from social networks) that could assist

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with building system knowledge. Doctors in small country towns, and those who have
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worked in a practice for a long time, seem to have more knowledge about the area, better

networks, and an ability to find appropriate services and specialists for their patients:
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'I usually refer people to local specialists... Because I know them. I know they're good,
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and it's easier for the patient too than going to [the city]. When you've been in an area a
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long time you know who to refer to really, and you know your patients. You know

without them telling you if they can [afford to go private or must go public]' [Jarrod, GP,
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regional town, mixed SES].

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System knowledge is not simply information about local services and specialists. In
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Bourdieu’s terms, system knowledge is knowledge about the field, but also an understanding

of the ‘rules of the game’ (Bourdieu, 1984:471). This form of knowledge can be seen in

operation when GPs advocate for their patients, which they tend to do when there is an

urgent need for them to be seen and the waiting lists are long. It is particularly apparent

when the need might be ‘social’ rather than ‘medical’, and the GP needs to be mindful of the

etiquette or legitimate ways of behaving in the healthcare field. This 'mindfulness' can be

understood in Bourdieu's terms as stemming from the habitus, within which the individual's

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experiences become embodied, and out of which various kinds of capital are formed

(Bourdieu 1993:86). Engaging with capital, the gatekeepers have the resources essential to

make choices and act appropriately and effectively. The operation of habitus and capital is

evident in the case of a GP who discussed a case of an Aboriginal woman who needed an

ophthalmologist, and was visiting her daughter in the city. Concerned that the woman would

return to her remote community without seeing the public specialist if the waiting time was

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too long, the GP pressured the public clinic to see her urgently:

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‘I think most health services are okay with that. As long as you don’t abuse it, if you call

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up for every single one of your patients, say, for an endoscopy and you say it’s urgent

and it’s not it makes people unhappy. It’s also not very fair either... I think there are

limits to how much. I think we should always advocate but I suppose I can’t force

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people’s hands into doing things’ [Padriac, GP, metropolitan public hospital clinic].
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Not all health-workers have the same opportunities or capacities to accrue and utilise system
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knowledge. Much depends on their position within the field. In a healthcare system where

most GPs work in private practices, GPs may be quite isolated with little interaction with other
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GPs:
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'I wouldn’t say [the lack of system knowledge is] limited to people who trained
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overseas. I mean I trained in the system here and I had no idea about the system. You

don’t get trained in it. You get trained around the biomedical model of disease and
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disease processes, and you know everything about just the patient in front of you. You
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don’t understand the context in which you work... The context in [a big city] is very

different to [a regional town]. And most GPs don’t understand that and nor can they I

don’t think, because the number of organisations involved and who does what

changes so quickly and we've grown it so much' [Matthew, senior bureaucrat in State

health department, former GP].

Although trained primarily in biomedical diagnosis and treatment, and rarely given the

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opportunity to develop the analytical skills essential for understanding the politics and

operation of the private/public healthcare 'maze', GPs working in group, rather than solo

practices may develop some measure of system knowledge. Group practices are more likely

to have regular meetings for all reception staff, doctors and other health-workers, where

information is exchanged about the availability and quality of services in the area. In several

of the practices we visited, we were told that reception staff gather important information in

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their 'chats' with patients, particularly about experiences with local specialists, the quality of

those interactions, how much services cost, and what languages are spoken. This

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information is sometimes made available on the organisation's computer system to assist

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GPs with referrals.

There have also been more systematic efforts to address the lack of system knowledge in

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the Australian context. Medicare Locals, re-named Primary Health Networks by the incoming
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Federal government, are one such endeavour. These Commonwealth-funded organisations

run educational programs and information sessions for the GPs in their area, and seek to
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build networks of GPs, specialists and allied health-workers. Another initiative is the adoption

across several Australian State health departments of a web-based, commercial tool called
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HealthPathways (developed in Canterbury, New Zealand). This seeks to offer information

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about 'best practice' procedures and standard treatment guidelines for various illnesses. In

many jurisdictions it also seeks to improve referral practices by offering information about
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services in the local area. One participant, Pierre, indicated that the program has to be

tailored for each area, making it an expensive, long and difficult process:
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‘Best practice is just that. Best practice. It might change slightly from country to country,

but… to localise them absolutely is a nightmare. That’s the difficult part’ [Pierre, CEO,

Medicare Local/Primary Health Network, mixed SES area].

The 'nightmare' for the gatekeepers in this case stems from the field itself, with its

fundamental tensions around the medical model and its private/public sectors. Behind the

HealthPathways software is the biomedical model of healthcare, an abstraction built on

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assumptions about the irrelevance of social context to treatment regime. Thus, in tailoring

'best practice' to local conditions, gatekeepers must take into account 'social' factors. For

example, patients might be offered the choice of an extended chemical therapy regime, or a

less efficacious but less time-consuming surgical treatment. Patients from a remote

community may be less able to spend six weeks or longer away from their employment

and/or support networks, and such factors must be taken into account in making the 'best'

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decision.

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Moreover, the provision of local referral information is equally problematic, because while it

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is possible to compile lists of local service providers at a local community practice, data has

not been systematically gathered at a regional or state level that will address 'system' needs,

that is, about which options will prove less costly for patients, more profitable for private

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businesses, or optimal from a government planning and budgetary perspective. Nor, as we
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shall argue below, is such data likely to be gathered.
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Gatekeepers and Negotiations Over Capital

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'System knowledge' is a fundamental requirement for all organisations, particularly large

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bureaucratic organisations such as hospitals. One of our participants pointed to the uneven

spread of this kind of knowledge among staff. He told us that he has to keep a close eye on
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decisions made by staff to transfer patients to or from other departments or hospitals:

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‘The problem with the way it is, is that sometimes, … surgeons or the clinicians are
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very happy to accept and they ignore little things, like whether [the hospital has] a bed

to put a patient in' [Thomas, Director of Clinical Services, major public hospital].

The organisation of hospitals, particularly public hospitals where patient care is a team

responsibility, provide various opportunities for accessing or developing useful forms of

knowledge. In these organisations, individuals with dissimilar backgrounds and knowledges

are organised into networks to achieve better (and more efficiently produced) health

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outcomes. Participants in our study spoke of situations where individuals from many

specialities come together to discuss patient care, discharges or transfers, each bringing a

different kind of knowledge and perspective:

‘Whoever the expert, so to speak, if it was a clinical, or non-clinical, in our group we

would listen to that perspective and the reasoning behind that. We would... ask why is

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it done that way, or why are you saying we can’t have that. Or are you saying it’s just

too expensive to save that person’s life, whatever the example may be. Then we could

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put forward our point of view. Listen if he doesn’t get that he’s going to die now, do

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you want that on our head or is it worth spending $10,000 or $100,000 whatever. Then

we look at are there alternatives, and then we both - from both sides, clinical and non-

clinical start saying. "All right, we realise that this is potentially what we need, can we

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do it another way? Are there other options, without spending $100,000?"' [Ashak,
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General Manager, large metropolitan public hospital, mixed SES area].
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In these meetings, some formal and pre-arranged, and others accidental and informal,

knowledge is often inter-disciplinary. Wendy, a hospital nurse, indicated that there are often
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disagreements in team meetings. For instance the doctor may have decided the patient can
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be discharged, but the physiotherapist disagrees:

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‘… the doctor’s focussing, say, on the knee, and decides it is now working properly,

whereas the physio is looking at the way that person’s walking, standing… and how is
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this patient going to be safe when they go home. See, that’s what the physiotherapists
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are looking at. They’re looking at the patient going home, are they going to be safe to

walk up and down the stairs? Are they going to be safe to get in and out of bed? Are

they going to be safe to transfer to the toilet? They’re the things they’re looking at. The

doctor just goes, “Oh, the knee’s better, that’s good. Go”. It doesn’t always work out

that way’ [Wendy, Registered Nurse, public country hospital, mixed SES area].

Other members of the team also look at the patient from a different perspective and see

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different needs. For instance:

‘...the occupational therapist is thinking about, one, safety in the home, what

equipment’s going to be needed for that person to get home. Then she’s got to work

with the physios because the physios will be looking at that patient going, “Is that

person safe in the home with their mobility?” … So, they’ve got to come together to

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make sure this patient has the right equipment. And then you’ve got the social worker

who’ll come along … they’re looking at the social situation, the family situation. Is this

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patient able to get home even with all of this? Is this person going to go home and fail?’

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[Wendy, Registered Nurse, public country hospital, mixed SES area].

Decisions about patient care in the hospitals can therefore be perceived in terms of conflict -

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between various clinical specialities, and between the professional and allied health sectors -
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each with different understandings of the nature of illness and convictions about the most

appropriate form of therapy. However a significant component of this conflict can be

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characterised in terms of a clash between cultural and economic capital. Gatekeepers who

act from a basis of cultural capital, where healthcare is valued in itself and good health as a
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right of citizenship, come into conflict with others for whom health and healthcare is a
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commodity, with an ascertainable economic value. One of our participants, Ashak, a

gatekeeper in a management position, described his role as having to negotiate between

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those with and without 'resource knowledge'. For Ashak, one group in his hospital has clinical

knowledge, making decisions based on 'clinical reasons basically for the best of the patient’;
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while those in the other group, such as his Director of Finance, have only 'resource
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knowledge':

'... she's had to draw on our experience [i.e., of the executive team]… to understand

why you may not put two infectious patients together on a site, or other times we can

put them, cohort them. Because their infections are complementary so to speak, if you

can say that. …Whereas other times you have to have people that are totally isolated

from each other because of that. Now from a legal-come-finance background, that

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means nothing to people like that. Yet she’s had to learn those things … about the

clinical impacts of their decisions … [likewise] we [the team has] to be resource

knowledgeable to understand what impacts it has on our resources. So we can’t just

say oh yeah, well that patient needs a hundred thousand dollar machine to save its life,

because that’s a clinical decision. Now what impact would that have, if we bought that.

So that’s another side of things, that we’ve got to learn the financial constraints to our

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clinical outcomes’ [Ashak, General Manager, large metropolitan public hospital, mixed

SES].

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The two groups in the hospital organisations, with their perhaps incommensurate views of

health and healthcare, and stemming from very diverse habitus, are nevertheless forced into

regular negotiation in the gatekeeping process. The possibility for an intensification of conflict

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within the healthcare field has also grown as new 'rules' emerge for 'the game' of health
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services. Public hospitals in Australia, like many other organisations, are increasingly

outsourcing services, ostensibly as cost saving measures (Collyer et al., 2015b). One such
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service is pathology, now often outsourced to a private laboratory rather than conducted in-

house. The common view is that pathology is simply about information, and most pathology
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processes can be done by machines and computers. When carefully investigated however,
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pathology is demonstrably a matter of skilful interpretation and relies on years of experience

and considerable biological as well as social knowledge (e.g., Forss, 2007).

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One participant, with a long career in a public hospital pathology department and now
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managing a private laboratory, spoke about the difficult cases where pathology results are
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unclear and yet urgent. While in the past a pathologist could ring experts in the field who

work in other hospitals, in universities, and in other states of Australia, and ask for their

assistance; increasingly these experts are having to account for their time and can no longer

openly provide advice:

‘… traditionally [their advice has] been free of charge and it still mostly is, by far the

majority of those referrals we would send off either interesting or problematic or rare

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cases we would send off to an expert… they would be paid by their own employer

whoever that may be… at a university or government lab or even a private lab… it’s

just a cross-professional service that’s provided by experts… There are occasional

institutions now that are charging for an expert opinion. It is starting to happen in

Australia’ [Roland, Pathologist, private pathology laboratory, high SES area].

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As healthcare is increasingly commodified, new sets of rules are developed about appropriate

forms of practice, and conflicts can intensify between gatekeepers in different parts of the

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healthcare system. Some frame the problem in terms of differences in perspectives and in

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values. Their views reflect both differences in their prior experiences (their habitus) and their

current positions within the healthcare field. For example, Lawrence, an executive of a

religious, not-for-profit healthcare provider, said that all hospitals, public or private, keep an

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eye on the bottom line, but there are competing values between the sectors, and from his
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perspective, the values that prevail will determine the outcome of negotiations over funding.

For others, such as Patrick and Alan, both CEOs of Primary Healthcare Networks set up to
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improve coordination, and therefore health outcomes across the system, see the conflict as

one of ideology. They argue that the current Commonwealth government (upon which they
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are dependent for their funding), has an ‘ideological dislike’ of anything to do with the public
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sector:
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‘…they did a review of Medicare Locals - some of them had only been in operation for

12 months and they… saw these as the “spawn of the socialist left”… they were tried
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and they were found guilty and they were condemned to death. Their crimes were
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they had established services in competition with the private sector’ [Patrick, CEO,

Primary Healthcare Network].

Our study, which spanned the period in which both Medicare Locals and Primary Health

Networks were in operation, captured a sense of the ‘public service ethos’ of these

organisations - the majority of which are arranged on a not-for-profit basis. Pierre, the CEO of

a Medicare Local, suggested members of these organisations are more comfortable

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commissioning not-for-profit health providers than for-profits, and he believes this to be the

result of their ‘backgrounds’. From Bourdieu's (1993) perspective, this would be explicable as

a consequence of the habitus, where an individual's life experiences solidify thoughts and

actions into ‘durable dispositions’ that guide their future behaviour (Bourdieu 1993:86). In

sharp contrast to the perspectives and practices of the not-for-profit managers Pierre, Patrick

and Alan, the manager of a for-profit, private hospital, who we call Cleo, clearly has a private

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sector ethic. She states 'everything should be run as a business in order to be able to control

costs', and claims 'the private sector can run their services for 30% less than the public sector

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can, and that’s well proven in documents that you can get your hands on'. Although such

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claims to knowledge are strongly disputed by others in the policy community (e.g., Acerete et

al., 2012; Collyer et al., 2015b), Cleo gives legitimacy to a set of 'truths' that she shares with

many of the senior government bureaucrats. Neville, for instance, a senior executive in a

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State health department, explained why he outsourced aged care services to the private
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sector in his region, arguing it is not going to save the government money, but it is better to

have a specialist, non-government organisation provide this, someone who will 'diversify the
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options people have'. In this, Neville adopts the orthodox view that 'choice' is an inherently

good thing and can only be offered by the private sector (Collyer et al., 2015a).
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Gatekeepers and the Control of Knowledge

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In the later stages of our research project we turned our focus from clinics and hospitals to

the broader policy community, interviewing participants in research institutes, universities

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and government departments. These participants had a generally high level of system
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knowledge, which, as gatekeepers, they used to shape (directly or indirectly) the structure of

the health system, and thus indirectly determining the kind of choices available to patients

and the gatekeepers directly involved in their care. They spoke freely about the way services

are organised and funded, and could point to various places within the system where key

decisions are made. Not surprisingly, members of the policy community place a strong

emphasis on the need for both knowledge and information, seeing these as essential for

good patient care and a viable healthcare system. Many showed a concern about the

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insufficiency of good data available to decision-makers about patient movements between

services and about treatment outcomes. Participants offered several reasons for this. One

saw this as the result of an on-going ‘lack of political will’ to invest in data collection. He

spoke of both state and federal governments as having failed to provide ‘real’ investment in

patient data, both inpatient and outpatient, over the past 40 years:

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‘There just was no leadership nationally on collecting any data, let alone waiting time

data... And I think that there is the issue about waiting times that, to some extent, state

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governments haven’t wanted to open up a can of worms' [Austin, health economist,

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independent research institute].

Another suggested the paucity of health information reflects the organisation of the system

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itself, that is, fragmented and uncoordinated. As a clinician involved in a government project
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to investigate problems with obtaining good patient data and sharing this, Dylan suggested

that information collected in multiple formats, with different software systems, make it difficult
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to transfer between healthcare providers. For several participants, the incompatibility of data

systems is in large part a product of the mixed public/private health system. Padriac spoke
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about the difficulties of understanding:

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‘...what GPs are actually doing… [their] prescribing patterns, the sort of patient care
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issues that are being managed and how the GPs are actually managing them in so far

as referral… information that’s often quite difficult to get simply because general
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practices for the most part are individual businesses’ [Padriac, GP, public hospital
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clinic, low SES area].

A similar point was made by Alyssa about the lack of good outcome data:

‘I mean, we’ve got... lots of MBS data, most of which is not made publicly available for

various reasons. And then there’s lots of privately held data from private service

providers which is almost impossible to obtain, you know, and they lock it away from

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each other. I mean, ask the private health insurers and the private hospitals how well

they share data. They’re the most antagonistic of all because they lock it away for

commercial reasons. Until we can get sort of better connections amongst all of that

data and actually understand how patients move through the system and how services

are provided to them, it’s actually really hard to solve some of these issues’ [Alyssa,

CEO healthcare advocacy organisation].

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Difficulty obtaining data from private practitioners and commercial operators is not a problem

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confined to the general practice or hospital sectors. Although major statistical agencies are

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all government funded in Australia, decisions to build, reduce, or change statistical

collections, are decided by committees or boards of 'stakeholders' (such as the private

hospital sector, the insurance sector and the department of finance), and this results in data

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being gathered on only particular issues, and in particular ways. For example, social class
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has largely disappeared from government statistical bulletins over previous years, with

illness categories increasingly reported by 'risk group' (e.g. smokers). Equally, little
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information can be found about the extent to which public hospitals - and the services within

them - are privately owned and managed and how much additional cost to government this
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represents. When asked about these issues, one participant explained that the major
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agencies don't provide such information:

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'...because we haven’t had stakeholders saying to us that that’s something that’s

important to them... it’s not that we make the decision, if you like, I mean we produce
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these publications in consultation with stakeholders, particularly states and territories,

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but also the private sector and the Commonwealth Department of Health. So [in this

case] there have been no stakeholders who have said to us to do that... we respond to

what we see stakeholders are interested in and would be useful as information to drive

policy development or policy debate' [Dorothy, Statistician, Australian government

research organisation].

Concluding Comments

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Our study has sought to demonstrate the importance of theorising gatekeepers as social

actors, who assist patients with their health needs, directly intervening in the choices they

make, or more indirectly, managing and organising services and programs within the health

system or producing data upon which decisions can be made. These gatekeepers, we have

argued, draw on different forms of knowledge, including clinical knowledge, system

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knowledge, resource knowledge, and knowledge about the 'rules of the game', to assist with

the functioning and maintenance of the healthcare system.

RI
SC
Mapping the healthcare field, we revealed significant forms of capital in operation - cultural

and economic - that organise the gatekeepers into opposing positions. Some gatekeepers,

such as Alan and Lawrence in the non-profit sector with what they called their 'public sector

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ethos' and working to the logic of cultural capital, uphold values about healthcare and good
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health as rights of all citizens. Others, such as Cleo in the for-profit sector with its logic of

economic capital, value health and healthcare as a commodity and a right for those who can
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afford it. Neville, at the core of government, uneasily straddles both sets of values, but is

impelled to support economic capital for the survival of the capitalist state.
D
TE

These opposing value sets operate as capital within the healthcare field, but how they do so

and whether they are able to determine practices and policies depends not just on the
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habitus of the gatekeepers, but on the hierarchical arrangement of the field. Gatekeepers

who have access to cultural forms of capital (from which they make claims to equity, human
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dignity and community resilience), are in a struggle with gatekeepers who embrace
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knowledge claims about the invincibility of the capitalist market and have greater access to

economic capital. Thus there is a contest here over what constitutes capital within the

healthcare field. Indeed the differentially positioned gatekeepers with their contrasting value

sets, are engaged in a game that is not just a struggle for legitimate forms of capital

appropriate to the field, but a contest over knowledge itself, over what is worth knowing and

measuring.

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In a field where dominant forms of knowledge and practices valorise the biomedical model

and the commodification of health and healthcare, data which could challenge the status quo

is tightly controlled, provided only in a very dense or obscure form (for instance, health

insurance policies), or not produced at all. The dominance of the field by gatekeepers who

are in support of private medicine ensures this kind of data is not produced by the

independent, well-respected statistical agencies, making it difficult for other gatekeepers to

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have their alternative knowledge claims recognised as legitimate. (And we point here, for

instance, to data about the differential benefits and costs to patients using private rather than

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public services, the differential costs to government in providing services privately rather

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than publicly, or even data about class-based health inequalities - which reveals the social

basis of health and illness). Without such data, gatekeepers working directly with patients, in

public hospitals, in not-for-profit organisations and those in the bureaucracy, largely operate

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'in the dark' about the availability of possible treatments and the benefits of various options.
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As a consequence, significant reform of the healthcare system is difficult, and the

commercial interests of the private medicine industry are protected.

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Acknowledgements

The support of the School of Social and Political Sciences at the University of Sydney is fully

acknowledged, as is support of the Australian Research Council (DP130103876), and the

research assistance of Marika Franklin and Ian Flaherty.

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The healthcare field is biomedically structured and commodified

Gatekeepers are differentially positioned within the Bourdieusian field

Gatekeepers struggle over the definition of health

Private sector gatekeepers control healthcare knowledge

Inadequate knowledge prohibits effective reform of the healthcare system

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M
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C EP
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