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Information and communication technologies are an important driver for network-based forms of governance. These technologies include computer decision support systems (CDSS) and software algorithms deployed to improve, optimise and manage health service delivery as in the case presented here, the NHS Pathways CDSS. This CDSS operates an algorithm, drawing on an extensive repository of clinical information to support NHS urgent and emergency care telephone triage services. Call handlers using the CDSS make decisions about whether the caller needs an immediate ambulance or can wait to see a general practitioner, and they can also provide advice about self-care. This chapter presents data from two large, comparative ethnographic studies of this CDSS which provide data from over 850 hours of observation, surveys of 700 staff, and interviews and focus group data from over 100 staff. Here I explore the interpretive gap between the promise of digital governance and the attempt to bring this computer technology into use as a way of managing demand for care. The chapter argues that, at its heart the CDSS maintains a model of ‘perfect governance’, premised upon the idea that triage is a rational, rule-governed, standardisable process. The reality, as we will see, is that this vision is thwarted, adapted, and resisted in the everyday situated practices and networks of care that involve human and non-human actors. The chapter presents a thematic analysis of a series of assumptive rules about disease presentation and decision-making to demonstrate how digital governance is resisted.

Original publication





Book title

Organizational Behaviour in Healthcare

Publication Date



121 - 140