45 Boundary work and social closure

Boundary work is one of the most studied concepts in the sociology of the professions over the last 50 years. Keith Macdonald called it ‘One of the most important means by which the professional project is pursued’ ^[1]. It draws on the agricultural metaphor of an open field that has been divided up into separate enclosures. Each enclosure represents a parcel or share of the field’s resources. The field could represent anything from the world’s stores of petroleum to the football teams in a particular division. Here, the field is healthcare, and the crops in the field are the patients, their body systems and parts.

The idea that, at some point in the past, healthcare was organised into disciplinary enclosures seems obvious to us today. But it reminds us that for much of human history, healthcare was an open field. It also raises some important questions about who designed the enclosures? Why were they distributed in this way and not other ways? Why, in the West, were the enclosures distributed to suit the medical profession? And why do we need boundaries at all? The walls around the enclosures are each profession’s scopes of practice, and they define what students learn, how people work, and the need for authorities to police the boundaries.

Social closure is the mechanism used by different groups in society to colonise and claim exclusive access to certain resources within the field. These may be particular kinds of knowledge, patient groups, or kinds of skill or aptitude. And the ways groups secure closed access are many and varied, including:

• The implementation of systems of registration or examinations to restrict access to the group;
• The creation of scarcity by limiting the number of training places, monopolising supply, or controlling access to certain desirable resources;
• Creating a sense of occupational homogeneity and a closed ’club’ culture of solidarity;
• Setting complex or lengthy skill standards for training or discrediting competitors ^[2];
• Claiming high levels of indeterminacy (see later) making entry into the profession complex and external comprehension difficult;
• Promoting kinds of work that are claimed to supersede consumers’ desires (i.e., ‘the doctor knows best’).

All of these are all strategies used by professions to secure their enclosure. The process of training and registration of professionals for neo-Weberians is, therefore, much more than just the way in which someone acquires additional knowledge for practice. It is about how an individual supports a professional project directed at securing progressively higher levels of social advantage.

Magali Larson showed a different way social closure had been deployed. She argued that the kinds of upward social mobility pursued by medicine and the other emerging professional elites after 1850 relied entirely on the division of labour, and the incorporation of ‘pre-industrial ideals of gentility (disinterestedness, manifesting in objectivity, value-neutrality, and detached experimentation, as well as noblesse oblige)’ ^[3]. Larson argued that these were used by professions like medicine, law and the clergy, to obtain prestige. Eliot Freidson echoed this in The theory of professions, arguing that we should be less concerned with professional ‘traits’, and more with the way that certain groups in society have ‘achieved’ professional prestige, and the role that ‘supportive social elites’ (like legislators and funders) play in sponsoring these actions ^[4]. Traits, Larson argued, don’t tell us what a profession is, how it got there, or how it functions in each different social moment. What traits tell us is what a profession ‘pretends to be’ ^[5].

Anne Witz’s classic study Professions and patriarchy ^[6], examined how the division of labour had been constructed around gendered lines. But as well as arguing for structured relations of power (see Chapter 4), Witz showed that both men and women had actively pursued professionalisation projects in the 19th and 20th centuries. The key difference in outcomes, though, was the unequal access to resources available to male and female dominated professions. Male dominated professions like medicine were able to claim characteristics of elite professions (objectivity, detachment, and a strong affinity with scientific principles), while the female dominated professions like nursing and midwifery took over roles which carried much less social capital ^[7][8][9]. From a social action perspective, Witz showed that not only were women professions engaged in all manner of different boundary tensions, but that women were active in all aspects of the process ^[10].

Valerie Fournier talked of the ‘labour of division’ that professions go through to create and maintain their professional boundaries ^[11]. Fournier argued that there was no ‘natural’ basis to the hierarchy of elite professions in society. Rather, it is a dynamic, interactive, and contested process that requires constant attention and performative work. Olivia King and colleagues have called this process ‘an act of creation and not revealing. In other words’, they suggest, ‘the field does not reflect a naturally occurring phenomenon but rather one that is created by the profession itself and expanded over time’ ^[12].

For neo-Weberians like Fournier, professions create the fields in which they practice, and the field is continually shaped by their actions. The field does not pre-exist, waiting to be discovered. Western medicine, for example, defined how people should think about the body (anatomically, pathologically), and has shaped what constituted normal practice (studying ‘cases’, diagnosing and testing), and how services should be structured (reductively around body systems) ^[13]. Sarah Nettleton has argued much the same about the way dentists constructed the mouth as a problem worthy of special professional interest, creating a dental profession as a response to a problem of their own creation ^[14][15].

The value of a profession does not, therefore, lie in ‘the inherent socially valued skills or expertise’ the profession possesses ^[16], but in the ‘production and maintenance of the body of eccentric knowledge’ (ibid, p.132), that allows the profession to shape its field of interest and distinguish itself from others. Similarly, access to a particular client group is not based on the profession’s access to any particular truth about health and illness, per se, since we know that medicine came to prominence long before it could prove its therapeutic efficacy. Rather, access to clients depends on a profession’s ability to control certain socially mandated forms of knowledge and maintain a particular ‘market situation’ (ibid, p.131). Eliot Freidson stated that this was how medicine won the support of political, social, and economic elites ^[17], and achieved its ‘organized autonomy’ (ibid, p.71). But by placing so much emphasis on objectivity and technical knowledge, inter-personal aspects of practice had atrophied ^[18][19]. As a consequence, medicine had become reliant on the control of institutional structures, like the control of referral processes and clinical decisions, and ‘the reduction of the client to an object’ ^[20], as a way to secure market shelter ^[21].

In Andrew Abbott’s book The system of professions ^[22], he argues that professions constantly compete over existing, empty, and emerging areas of expertise, and are always looking to exert their economic, legal, training, research, and political advantage over the competition. Indeed, professions cannot be understood in isolation, but ‘only in the sense to which they constitute and reproduce themselves, relative to others’ ^[23].

Boundary tensions between professions have become ever more visible over recent years, as healthcare services are increasingly opened to competition and trans-disciplinary practices. Brian Hodges has argued, though, that while we should be ‘[m]atching the supply of health workers to need’ if we want ‘sustainable, affordable and fit for purpose’ health services, ‘I see our professional organisations concerned with clinging to their current scopes of practice, replaying tired historical battles for control of little patches of professional turf’ ^[24]. The problem is that ‘[t]he medical profession has effectively controlled the healthcare division of labour, with its unique capacity to determine its own role boundaries as well as those of the health occupations lower on the hierarchy’ ^[25]. But all social action theorists believe that fields like healthcare are in a constant state of flux, so much of their interest has focused on how Western healthcare has remained so stable for so long. One of the contests constantly being played out in healthcare is around encroachment.