I have been reading an influential essay by Arjun Appadurai, ‘Introduction: commodities and the politics of value’ from Appadurai, A. (ed.) (1986) The Social Life of Things: Commodities in Cultural Perspective. Cambridge: CUP, pp. 3–63.
Although focused on ‘commodities’ which implies an economic context that is missing (overly at least) from the NHS context, points in the essay have made me think about how one might frame a critical study of gratitude and the giving of gifts to healthcare professionals.
It is not customary to give gifts in the NHS (although this needs further research). Most anthropological studies of gift-giving are focused on the trajectory of gifts within relatively isolated, small-scale societies. Whilst a hospital environment, or a GP practice, could be viewed as analogous to a non-capitalist society (at least at the patient-facing end), gifts are meant to be ‘terminal’ (or ‘enclaved commodities’) rather than circulating. There may be very interesting things to say about how gifts are usually consumables or have a short shelf life. According to some studies (cited in this excellent article by Spence on patients bearing gifts), chocolates and wine are most often given. These are ‘luxury’ items that are relatively low priced and thus less potentially threatening to the professional/private boundary than more personal gifts.
Gifts given at Christmas are customary, and possibly more acceptable because they form part of rituals surrounding celebration and one need not be suspicious of ulterior motives on behalf of the giver. In an article for the RCGP’s The New Generalist publication in 2005 (quoted here), de Zulueta describes a range of reasons why patients give gifts, including:
- to show genuine gratitude
- to redress the balance in terms of power sharing
- out of affection
- to attract attention
- to manipulate the practitioner to carry out preferential treatment or some other treatment they would not normally give
- to expiate guilt for burdening the practitioner.
Anthropological studies are woefully inadequate when it comes to addressing motives for giving, yet assumptions made about motive is what drives policies about gift giving, including widespread advice not to accept any gifts at all. ‘Gifts’ also see to be treated as a homogeneous category regardless of the giver, so that gifts from patients are treated as if they are the same as gifts from pharmaceutical companies (which are unlikely to be stimulated by genuine gratitude – the most ‘sincere’ motivation for gift giving – and inevitably carry a whiff of moral taint).
My hunch is that the nature of gift giving in the NHS has changed in response to the way healthcare is organised. I predict that the rise of teams responsible for care has meant that fewer patients identify a single individual as being particularly worthy of gratitude. Gifts that can be shared are likely to continue to predominate (chocolates especially). I think (hope!) that a greater awareness of religious sensibilities of healthcare providers make a gift of wine a less popular choice (about 10,000 workers in the NHS are Muslim and eschew alcohol).
The role of patronage is important here too. Gifts from patients are often channelled though charities associated with hospitals or particular fund-raising initiatives. This separates the gift and any possibility of it contributing to individual gain. Initiatives like the ‘giving tree’ at the Brompton Hospital helps to bridge the gap between the impersonal cash contribution and the expression of gratitude to individuals or teams within the hospital.
Appadurai’s essay examines ‘instruments of value’ and reminds us that status participates in the economics of exchange. League tables, and specific ranking of individuals, could be seen as a rather insidious form of what Appadurai calls ‘tournaments of value’, involving status, rank, fame, reputation and ‘central tokens of value in the society in question’ (in the NHS, that could be analogous to ‘patient safety’): ‘Tournaments of value are complex period events that are removed in some culturally well-defined way from the routines of economic life. Participation in them is likely to be both a privilege of those in power and an instrument of status contest between them.’ The worrying aspect is that league tables treat people and skills as commodities, whose worth can be quantified by simplistic measures. In the context of concerns about the privatisation of the NHS, the use of league tables is held up as an example of transparency and accountability, and in the interests of patient choice (however illusory that may be), whereas the rhetoric of the hierarchy which is entrenched in the very notion of ranking reinforces the metanarrative of the NHS as a ‘market’ in which value is distilled into a set of indicators reminiscent of the trading floor.
Perhaps the most salient take-home message from Appadurai’s essay is that politics govern the contexts of value-based exchanges: ‘not all parties share the same interests in any specific regime of value.’ It is those interests that are woefully understudied.