Negotiating access : Practices of inclusion and exclusion in the performance of 'real' emergency medicine.

This ethnography examines how Accident and Emergency (A&E) operates as both threshold and gatekeeper. The study draws upon field work undertaken in the accident and emergency department of a major UK teaching hospital. Focussing on patients' and staffs' everyday practices and interactions, the study shows how, and in what moments, medical, administrative and cultural classifications are drawn upon to legitimate and contest different interests. The exploration of categorisation and classification practices is important, not only for a better understanding of A&E as a site in which access to important life chances are negotiated, but also for understanding more about the relations between medicine and socio-cultural classification, and the consequences for those enrolled in their re-making. A&E is shown to be an important sociological site in which forms of knowledge, moral values and relations of power are produced. The thesis situates itself between a body of sociological research that focuses on medical practices as socially constructed, and that pays attention to how medicine re-produces socio-cultural classification, and a set of literatures that account for medicine as particular forms of knowledge. Building on an emergent tradition of research that extends and moves beyond this division, the thesis adopts a particular view of medical knowledge practice that is performative, existent in and through social relations, not only the social relations that occur between people and between people and materials, but also the relations that occur with other modes of ordering such as those produced through clinical governance guidelines. The thesis shows how staff continually perform 'real' emergency medicine. 'Real' emergency medicine is shown to be produced in a number of different ways. It is often accounted for as purely clinical, and as a knowledge practice that relies upon a specific form of medical perception and clinical practice. However, in their accounts of those persons presenting at A&E who fall beyond the boundaries of the purely clinical, members help to accomplish what the 'real' is not. In other moments 'real' emergency medicine includes the organisation and rationing of resources through medical staffs' managing of clinical expertise. Finally, during processes of patient assessments 'real' emergency medicine can be accomplished through patient's own performance of good citizenship as they negotiate their access to health services. Thus, in developing 'accessing' as its central trope, the study shows how A&E as a critical site, is one in which medicine emerges as deeply implicated in mundane practices of social inclusion and exclusion