Paper short abstract:

This paper explores an innovation in the delivery of health care. By holding specialized consultations in a primary care setting, patient and specialist are nudged towards making cheaper decisions. The presented ethnographic research shows how such a strategy turns out in practice.

Paper long abstract:

This paper explores the response of an organization of primary care professionals to the widespread concerns about growing health care costs. With specialized consultations in a primary care setting instead of in a hospital, patient and specialist are 'nudged' toward making fewer expensive decisions that are medically redundant. By analyzing justification registers on the managerial and operational level, the paper aims to show how such a strategy to deal with the growing challenges of health care turns out in practice.

The paper first presents a short overview of the debate around nudging. A nudge is a policy tool used to change behavior of people by changing the decision environment, supposedly interfering in the so-called automatic thinking system instead of the deliberative system. Although not explicitly denoted a nudge by any of the people involved, I argue that understanding the innovation as such will give insight into the registers of justification applied when using such a tool. Secondly, I present the results of an ethnographic research into both managerial and operational levels of the innovation. On the managerial level I focus on how the innovation is presented internally and externally by looking at justification statements but also at the practices of evaluation. On the operational level, I describe how specialist and patient, dealing with the limitations of the environment, are engaged in intricate justification work. By analyzing both levels as practices of justification and critique, I show on which points registers clash and to what extent this is problematic.