To Choose or Not to Choose: Questions about the Role of Gatekeepers in the Australian Healthcare System

Since the 1990s and the spread of neo-liberalism across many of the world’s healthcare systems, patient ‘choice’ has increasingly become a central topic of debate. One focus in the emerging literature concerns the capacity of patients to make choices about their healthcare service needs, and there is growing evidence of the influence of wealth, education, and geographic location on the production of greater levels of choice for some social groups of patients. Of less concern to date has been a focus on the role of ‘gatekeepers’ - health professionals, hospital administrators, policy researchers and policy-makers – whose actions directly or indirectly have an effect on patient ‘choices’ and thus shape patient trajectories as they make their way through the healthcare ‘maze’.

This paper reports on a study, funded by the Australian Research Council, of gatekeepers in the Australian setting: a highly regulated, semi-market context where patients have the ‘choice’ to engage with private or public services and practitioners. Drawing on qualitative, in-depth interviews with a selection of private and public sector gatekeepers located in both low and high socio-economic areas, and employing Pierre Bourdieu’s concept of the ‘field’; results point to the way the perspectives and actions of the gatekeepers are structured not only by their habitus and forms of capital, but their location within a specific social arena and its social rules of engagement. The study therefore reveals the particular salience of institutional and market location on the views and actions of both public and private sector gatekeepers, avoiding the tendency, well-established within medical sociology, to focus on professional self-interest as the sole explanation for the behaviour of doctors and other health workers.