Neoliberalism: Rhetoric and Reality.

This paper was prepared as background to the 4th edition of ‘Communication and Interpersonal skills in nursing (Grant, A. and Goodman, B. forthcoming). In that book discourses of neoliberalism and their effects on health and health service delivery as well as the interpersonal communications nurses have with people will be explored and critiqued. An example is the discourse on ‘individual responsibility for health’ and ‘lifestyle drift’ responses to public health which draw upon the concept of ‘sovereign individual’ of neoliberal philosophy. This paper explores what neoliberalism might be to argue that it is more a discursive practice than a political action.

 

Neoliberalism is at once everywhere and nowhere. There is ‘appearance’ and ‘reality’, there is reification and fetishisation. Its name is spoken in certain circles and vilified (Springer 2016), it is an ‘imprecise exhortation’ (Thorsen and Lie 2007, Thorsen 2009), in others there is denial that it even exists (Talbot 2016). It might be best to understand neoliberalism as a ‘discourse’ (Foucault 1969) rather than an actuality of political practice, as a “rather radical set of ideas which nevertheless have had a certain influence on society and politics in recent times” (Thorsen 2009 p20).  It is a word used by the progressive and critical left, e.g. Saad-Filho and Johnson (2005), to counter what the right call the ‘free market’ in the context of the breakdown of the post war consensus around the social welfare democratic state.

 

I suggest that the discourse of the ‘Free Market’ was, and is, used to reshape the State, and civil relationships, away from ownership and control of the means of production, away from Keynesian state intervention in the economy and away from providing all social security (including housing, health, education, and transport). Free market rhetoric is used to mask the reshaping of State apparatus towards State intervention for wealthy landowners and corporates (financial and industrial). This is a bid by a capitalist class to (re)capture the State’s support for capital and property accumulation in their favour. This ‘support’ is referred to as a ‘framework’ in which ‘free’ markets are to operate. I also argue that there is nothing ‘neo’ or ‘new’ about the practical reality of this form of liberalism, tied as it is to the capitalist State.

 

The term ‘Free market’ is often preferred to ‘neoliberal’ by its supporters according to Talbot (2016) and Thorsen (2009) who argues that the term neoliberal is now most often used in a pejorative way by the left. We say ‘Neoliberal’ you say ‘Free Market’. ‘Free market’ or ‘neoliberal discourse’ is used as part of the Ideological State apparatus backed up by the Repressive State apparatus of the judicial system, police and ultimately, if needs be, the military.

 

An important idea of ‘Free Market/Neoliberalism’ is the espoused theory of a minimalist State. The theory in action is a State becoming minimal for social security but otherwise continuing the facilitation of capital accumulation and the ownership of wealth especially by the 0.01%. The ‘Nightwatchman’ minimal state of the 19th century is a goal of free market (or liberal) ideology, but this has not been achieved for all of the talk of the Reagan/Thatcher years of the 1980’s. This is possibly because the reduction of State spending down to 10% of GDP from the current 40% of GDP (per year, see figure 1 in the appendix) would be as disruptive for the capitalist class and the political power elites as it would for everyone else. This is also because key sectors of the economy such as agriculture, the military-industrial complex, and the nuclear power and fossil fuel industries, rely on government funds and subsidies without which their business models would have to be radically altered. Capitalism’s ‘creative destruction’ is a lauded dynamic feature, as long as its not your industry or business model that goes bust or, in the jargon; is ‘disrupted’.  It is also because in theory, liberalism is not a monolithic philosophy, ‘classic’ and ‘modern’ Liberalism (Ryan 1993) have different views of the State’s role.

 

The minimalist state (‘Nightwatchman’) ‘classic liberal’ solution to questions of political economy might still be the goal of some current thinking. This may include the Tea Party in the US, kicked into life by Rick Santelli’s comments on President Obama’s mortgage bail out plan (Pallasch 2010),  and perhaps in the UK by the Adam Smith Institute. Yet in current practice many of the Conservative capitalist class, and their political voices in the Tory party, seem as wedded to state intervention as they claim socialists to be.

 

Neoliberalism as a discursive practice, embedded and supported by an ideologically driven, highly funded ‘intellectual’ infrastructure, can also be linked to around 1,000 self conscious neoliberal intellectuals organised in the Mont Pelerin Society (Plewhe et al 2007). Its proponents fight for hegemony in research and development, and engage in political and communication efforts with well funded, well coordinated and highly effective new types of knowledge organisations: partisan think tanks such as the Cato Institute and the Heritage Foundation in the US, the Institute for Economic Affairs (IEA) and the Centre for Policy Studies (CPS) in the UK and the Institute of Public Affairs in Australia (IPA) (Beder 2001).

 

A Discursive Project.

 

This is an ongoing rhetorical project in the UK because as Desai (2007) argues, the values and principles of Thatcherism, which did not call itself neoliberal but did emphasis similar ‘free market, small state’ principles mixed with ‘Victorian values’,  were not wholly accepted by the British public. This is evidenced in surveys of public opinion in the 1980’s and 90’s and arguably even today if support for the socialist inspired NHS is an indicator.

 

Support in elections since 1979 have not won over majorities of the electorate, and it is only thanks to first past the post that Tories and clause 4 ditching ‘Tory lite’ New Labour, were able to win. See figure 1 (appendix) which shows what % of the electorate actually voted for the government of the day.

 

These figures show that at its peak only 33% of voters could be bothered to put an x next to free market rhetoric. This was down to 24% by 2015. Neoliberals/Thatcherites/ Conservatives have not won the hearts and minds of the British Electorate and neither has the goal of a small state in terms of GDP spend been achieved. Their success in the US and the UK, is to be measured not by the popular vote, but by their assaults on Trade Unions, by Privatisations, Tax breaks and Labour market and Financial deregulations.  And by the increasing share of wealth and high pay going to the 1% and 0.01% (Saez and Zucman 2014, Dorling 2014, Moshinsky 2016).

 

I argue here in accordance with Desai (2007) that:

 

“Market dogma may well be entrenched in capitals around the world, but its intellectual vacuity and practical failures have been documented in a vast literature. It would be truer to say that neoliberalism’s intellectual pretensions are designed to provide a fig leaf of intellectual respectability to the most naked pursuit of the interests of capital and property (my emphasis) than that neoliberalism has motivated this pursuit by intellectual force and political influence” (Desai 2007 p220).

 

In other words, powerful and rich individuals have used talk of free markets (and neoliberalism) to justify their ongoing grab of global wealth through using the levers of State power, rather than it being the case that the intellectual case motivates their actions.

 

Graham Scambler (2012) also points in this direction in his exposition of the ‘Greedy Bastards Hypothesis’ which is underpinned by the strategic actions of ‘focused autonomous reflexives’ in the capitalist class executive and the political power elite.

 

 

 

 

Discourse

 

 

In common understanding a ‘discourse’ is an exchange, perhaps of ideas, between two people involving language as the medium of transmission. This can be seen as a neutral exercise between two people of equal power and status using certain phrases, words, jargon and syntax to share understanding or to question the other’s statements. Consider the situation when two Tory MPs are talking to each other about a ‘flexible labour market’  or the need for people to be ‘taking responsibility for one’s health’. The first is an example of the neoliberal/free market discourse that favours weak labour regulations to make it easy to hire and fire staff making them ‘flexible’. The second brings in and joins the ‘Moral Underclass discourse’ (Carlisle 2001) to the free market’s central idea of ‘free sovereign individuals’ in charge of their own destiny in order to shift responsibility fully onto the shoulders of individuals. This discourse can then blame individuals for being obese, for smoking or for any other ‘moral failing’ such as catching an STI or binge drinking.

 

Discourse as a critical concept is associated with Michel Foucault. For Foucault (1969) discourses are institutionalised patterns of speech and knowledge seen and felt in ‘disciplinary’ structures, e.g. in the medical clinic or in the prison (Foucault 1963, 1975). Discourses connect knowledge to power. Knowledge is power. To oversimplify, the concept refers to the idea that a discourse shapes, or constructs what we know, what we can say and also reflects differences in power between people. Becoming a Tory MP introduces one to the institutionalised patterns of speech which might be very familiar to that experienced in public schools (e.g. Eton) and certain Oxbridge clubs (e.g. Bullingdon).

 

 

 

 

Discourses are more than mere words.  A discourse, Foucault (1969) suggested, actually brings into being that of which they speak.

 

“…discourses…are nota mere intersection of things and words….

 

The task of analysing discourses is to show that they are not just:

 

groups of signsbut as practices that systematically form the objects of which they speak.discourses are composed of signs; but what they do is more than use signs to designate things. It is this more that renders them irreducible to language and to speech. It is this morethat we must reveal and describe (1969 p 54)” (my emphasis).

 

By continually repeating the discourse, and getting it accepted by enough people, that “There is no money” or “There is no Alternative” or “Labour caused the public debt” or “Banks are too big to fail” or “Top cornflakes rise to the top” or “high pay rewards hard work and intelligence” or “Inequality is good for competition” or “Skivers v Strivers” or “In this together” or “we must balance the books and bring down the deficit” these things are brought into being. They are part of a larger, taken for granted, understanding of the ‘proper’ role of the state, the individual and the corporation.

 

 

What then is ‘Neoliberalism’ and what is formed by that of which it speaks?

 

 

Traditional Enlightenment ‘classical liberalism’ (Ryan 1993) emphasises:

 

  1. Individual Freedom (liberty) through limiting government and maximising capitalist market forces.
  2. Civil liberties under the rule of law and laissez faire economics.
  3. Free markets, utilitarianism, natural law (inherent rights which are universal, uncovered by reason) and progress.

 

Key thinkers: Adam Smith, John Locke, Thomas Hobbes, David Ricardo. Alexis de Tocqueville

 

Modern liberalism accepts a greater role for the State in the economy, manifested in regulation and the State supplying of goods and services (Ryan 1993). Laissez faire economics cannot in this interpretation meet the goals and purposes of liberalism. Thorsen (2009) argues that liberalism has many facets and has become in effect a contested concept particularly over the role of the State.

 

 

Neoliberalism is associated with ‘Austrian’ economists Ludwig Von Mises (1881-1973), Friedrich Hayek (1899-1992) and the American economist Milton Friedman (1912-2006). Around 1950, the classic liberal state had grown into, for some, a social democratic monster driven by Keynesian economic theory and the growth of Welfare States. In both the US and the UK, governments were beginning to spend more and more of GDP and intervening in many areas of the economy including social security programmes. Von Mises, Hayek and Friedman would have noted that the share of GDP spent by the State on welfare and public services had grown from about 10% in the middle of the 19th Century (figure 2 in the appendix) to around 40% by the 1970’s.  Today the share of GDP spent by the government in the UK is about 41% (figure 3 in the appendix).

 

In the context of the centrally planned Soviet Union and Hitler’s Germany, Hayek (1944) argued that any government control of economic decision making through central planning leads to tyranny and that civilisation requires liberty as a prerequisite for wealth and growth (1960). Hayek and Freidman (in the 1950’s) referred back to classical liberalism rather than ‘neoliberalism’ in their reaction to the amount of state intervention in the economy.  Yet, they accepted some aspects of welfare provision by the State although this provision in their view should be greatly reduced. Their status as fringe economists  in the 50’s was altered when their economic theory and political philosophy was then taken up by Reagan in the US and Thatcher in the UK around the late 1970’s. At this point there had been a sort of post WW2 consensus between Conservatives and Labour regarding the level of state intervention in the economy.

 

 

 

Margaret Thatcher was to change that cosy relationship.

 

At a Conservative Party policy meeting in the late 1970’s, Thatcher made it clear upon what her approach to the economy was based:

 

Another colleague had also prepared a paper arguing that the middle way was the pragmatic path for the Conservative party to take…the new Party Leader [Margaret Thatcher] reached into her briefcase and took out a book.  It was Friedrich von Hayek’s The Constitution of Liberty…..she held the book up for all of us to see.  ‘This’, she said sternly, ‘is what we believe’, and banged Hayek down on the table.” (Ranelagh 1991).

 

Neo simply means ‘new’ and refers us back to the earlier liberal small state. The ‘Nightwatchman’ state in the 19th century provided for property rights, contracts, markets and personal/national security. That was about it. No provision for schools, health, transport or subsidies for industries. Hence the relatively small % of GDP being spent by the government. Talbot (2016) argues that the 1950’s Neoliberalism was new in that it also embraced social as well as economic and political rights. Social protection, workers rights and public health would actually help the capitalist society, however following the Chilean coup of 1972 a theoretical inversion took place in which it now meant a reversion to 19th century free market liberalism.

 

Four Definitions

 

Stuart Hall (2011) argued that:

 

The term ‘neo-liberalism’ is not a satisfactory one. Intellectual critics say the term lumps together too many things to merit a single identity; it is reductive, sacrificing attention to internal complexities and geo-historical specificity. However, I think there are enough common features to warrant giving it a provisional conceptual identity, provided this is understood as a first approximation…..What, then, are the leading ideas of the neo-liberal model? ….neo-liberalism is grounded in the idea of the free, possessive individual. It sees the state as tyrannical and oppressive. The state must never govern society, dictate to free individuals how to dispose of their property, regulate a free-market economy or interfere with the God-given right to make profits and amass personal wealth”.

 

A ‘tyrannical and oppressive’ State was of course Hayek’s view.

 

George Monbiot (2016) outlined its main principles in this way:

 

“Neoliberalism sees competition as the defining characteristic of human relations. It redefines citizens as consumers, whose democratic choices are best exercised by buying and selling, a process that rewards merit and punishes inefficiency. It maintains that the marketdelivers benefits that could never be achieved by planning. Attempts to limit competition are treated as inimical to liberty. Tax and regulation should be minimised, public services should be privatised. The organisation of labour and collective bargaining by trade unions are portrayed as market distortions, that impede the formation of a natural hierarchy of winners and losers. Inequality is recast as virtuous: a reward for utility and a generator of wealth, which trickles down to enrich everyone. Efforts to create a more equal society are both counter-productive and morally corrosive. The market ensures that everyone gets what they deserve”.

 

David Harvey (2005) defines it thus:

 

Neoliberalism is in the first instance a theory of political economic practices that proposes that human well-being can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterized by strong private property rights, free markets, and free trade. The role of the state is to create and preserve an institutional framework appropriate to such practices. The state has to guarantee, for example, the quality and integrity of money. It must also set up those military, defence, police, and legal structures and function required to secure private property rights and to guarantee, by force if need be, the proper functioning of markets. Furthermore, if markets do not exist (in areas such as land, water, education, health care, social security, or environmental pollution) then they must be created, by state action if necessary. But beyond these tasks the state should not venture. State interventions in markets (once created) must be kept to a bare minimum because, according to the theory, the state cannot possibly possess enough information to second-guess market signals (prices) and because powerful interest groups will inevitably distort and bias state interventions (particularly in democracies) for their own benefit.

 

 

Thorsen (2009) after an examination of literature on liberalism including the critical literature argues:

 

“Neoliberalism is…a loosely demarcated set of political beliefs which most prominently and prototypically include the conviction that the only legitimate purpose of the state is to safeguard individual liberty, understood as a sort of mercantile liberty for individuals and corporations. This conviction usually issues, in turn, in a belief that the state ought to be minimal or at least drastically reduced in strength and size, and that any transgression by the state beyond its sole legitimate raison d’etre is unacceptable (cf, especially Mises 1962; Nozick 1974; Hayek 1979).

 

This latter two descriptions  are that of the ‘Nightwatchman State’. Remember at this time in the 19th century less than 10% of GDP was spent by the government on public activities. Is this the goal of current Conservatives? Or is neoliberal/free market discourse an ideological mask for something else?

 

A minimal state safeguarding individual mercantile liberty and that is it?

 

We have to question whether in action Tory ministers believe this and wish to cut public spending from around 40% to 10%. To see what that would mean, we would need to look at the current 2017 budget (approximately £800 billion which is 40% of GDP) and note that to get down to 10% of GDP the budget would have to be £200 billion. See the appendix figure 4 for the 2017 budget. This is not 10% of GDP. Social Protection (pensions in the main) is over 10% on its own.

 

This is not a ‘Nightwatchman’. Is it a socialist utopia? The State is spending a lot of money still. However, what is actually happening is that in each sector, privatisation means that more and more government money (taxpayer’s money) is subsiding private provision. This is an explicit aim of the Adam Smith Institute who explicitly call for private provision but public funding for health. In Rail the government is subsiding private train operating companies and in housing the government is subsidising landlords through housing benefit.  In employment the government is subsidising employers through tax credits.  Figure 5 in the appendix shows where the revenue comes from.

 

The UK government spending accounts for about 40% of GDP, leaving 60% going elsewhere. Spending on health, social care and social protection (pensions) accounts for £426 billion, that is over 50% of the total spend. Add £102 billion for education (total now is £528 Billion).

 

Who pays for that? Well, whoever pays Income Tax, National Insurance, VAT, Council Tax and excise duties. All of this accounts for £628 billion.

 

What we have is redistribution from the 99.9% to the 99%.

 

‘Neoliberalism’ as rhetoric actually works for 0.01% – the plutocrats, the global capitalist executive. Henry (2012) argues that anything between $21 to £31 trillion as of 2010, has been invested tax free in about 80 ‘offshore’ secrecy jurisdictions. That is trillion not billion.

 

What we don’t have is a minimal state focused solely on safeguarding liberties for markets.

 

This idea of a small state free market economy is of course patent nonsense as it has just not happened. The reduction of public spending and deficit reduction are two current policy goals (i.e. Austerity) but this is hardly neoliberalism.  Neoliberal purists have failed to get the Tory party to reduce spending to these ‘classic liberal state’ levels. So what was all that Thatcherite talk for?

 

The reduction of state spending down to 10%, I suggest is either a complete failure of the neoliberal project or it is deliberate policy failure in that this is not the neoliberal goal at all.

 

It could be the case that the free market discursive practice is a cover for capital and property accumulation through curbing what is seen as labour power but more importantly by capturing the levers of the State. Cutting state spending to 10% would be seen by the capitalist executive and the political power elite to be socially and politically dangerous to capital accumulation.

 

Marx once remarked in the Communist Manifesto:

 

the executive of the modern state is but a committee for managing the common affairs of the whole bourgeoisie”.

 

One does not have to be a communist to begin to see how executive power is being used to the advantage of Capital (deregulations, subsidies and offshore tax breaks) while at the same time weakening labour through strict union laws, wage freezes and labour market ‘flexibility’.

 

Prior to 1900, no state spent more than 3% of GDP on ‘social programmes’. Around 1870 the average public spending level of ‘advanced economies’ was 10% (Talbot 2016). The 1914-1918 war saw an increase to 20%, followed by a steady growth to the 40% of today. This leads Talbot to argue that the neoliberal state of the 1970’s with 40% spending is actually little different from liberal market/social democratic states. Therefore it is all talk and no action since that level of spending has not been reigned back to 19th century levels.

 

Does this mean that Thatcherism was not neoliberal in action? Yes, if by that we define a neoliberal state as that in which only 10% of GDP is spent. Was Thatcherism even ‘free market’ in action given the continuing level of state intervention in many sectors of society and economy? Both Thatcher and Reagan promised to ‘roll back the frontiers of the state’ or that ‘government was not the answer, it was the problem’. This was ‘New Right’ talk to distinguish it from post WW2 Conservatives who accepted the post war social democratic consensus based on around 40% GDP spending and intervention.

 

Talbot (2016) argues that neoliberalism exists only as a ‘bogeyman’ created on the left to oppose various conservative attempts to ‘rebalance’ government-market relations. Bruff (2017) however argues that ‘neoliberalism’ is not about a return to free markets and 10% spending levels but is an ideology to mask a coercive, non-democratic and unequal reorganisation of society. There is seeming agreement that this is not about cutting government spending per se down to 10% but about reshaping democratic social and political relationships in favour of Capital. To repeat Desai (2007):

 

neoliberalism’s intellectual pretensions are designed to provide a fig leaf of intellectual respectability to the most naked pursuit of the interests of capital and property”.

 

Bruff (2017) points out that many current governments are not neoliberal in that they actually oppose free markets in practice and instead are engaged in protectionist rhetoric and practice. A 40% GDP spend does not indicate much in the way of ‘cutting back the state’ except for the working classes as a result of austerity politics and social security spending decisions.

 

This results in socialism for the rich (state spending) and neoliberalism for the poor (welfare cuts).

 

If neoliberalism is narrowly defined as a political programme valorising free markets then indeed leaders such as Trump, Modi, Erdogan and Abi are not neoliberal. Instead ‘free market’ rhetoric is just that: rhetoric. Bruff goes on to suggest that actually Hayek et al constantly invoke ‘free markets’ as an abstract principle but then they have a preference for certain types of markets to prevail in actuality. Neoliberalism in this definition is the use of the State in a central role to maintain a certain kind of market:

 

“neoliberalism has nothing to do with markets as commonly conceived, and everything to do with the orchestration of social relations in the name of markets…it is about the coercive, non democratic and unequal reorganisation of society along particular lines…intensification and extensification of the differences, inequalities, hierarchies and divisions that pervade capitalist society as delivered by authoritarian states and global corporations…neoliberalism is a way of seeing the world that is carved from the empty words ‘free’ and ‘markets’ ”. Bruff calls this ‘Authoritarian Neoliberalism’

 


 

Some Free Market advocates get this too.

 

Jamie Whyte is a free market advocate and in the BBC radio programme Analysis ‘Keeping the Free Market faith’ (8th October 2012) thinks Conservatives are now losing that faith in the free market, implying neoliberalism has lost its grip. Of course, as figure 1 to 5 show, it never had one.

 

Three Conservatives said this about the state of politics in 2012:

 

An Unholy alliance between a free market ideology which took over a government and a process of social change in which fair dealing and trust were ditched in favour of get rich quick economic libertarianism”

 

“We have to challenge the assumptions of laissez faire economics…”

 

“…the left wing account (of a conspiracy of the rich against poor people) is much more believable (since the credit crunch) than in 1990, although I don’t believe it”.

 

(Jessie Norman, Matthew Hancock (Tory MPs) and journalist Charles Moore).

 

In the ‘Free Enterprise Group’ in the Tory party, Andrea Leadsom argued deregulation in the banking sector had caused major problems. Ferdinand Mount also queried deregulation and the big bang which ‘had its downside’. Matthew Hancock (Tory Minister for Skills) also of the Free Enterprise Group, argued free markets need strong frameworks. He argued we should not muddle up laissez faire economics with free markets, and that the banking sector is special, it is an exception where free market principles should not hold! The State also should have a view of what are sustainable business models for many industries.

 

Jamie Whyte interviewed Ferdinand Mount, who helped write Thatcher’s manifesto in 1983, argued in the radio programme that ‘bankers are the worse kind of oligarchs, immune to old standards of corporate governance, paying themselves whatever they like. Shareholders are sleeping and are not taking them to account’. Qualms about high pay, argued Mount, is about social justice and economic efficiency (rewards gained despite performance). He argues against total deregulation and against withdrawal of state support for the ‘too big to fail’ banks.

 

Whyte interviewed Lord Griffiths (advisor to Thatcher in 1986) who dents Thatcher’s image as a neoliberal or free market ideologue. He argues that Thatcher believed in a ‘moral market’ and the value of enterprise but was never a total free marketeer. Free markets yes, but within a boundary of social justice, including consumer protection. Thatcher he suggests was not a purist Hayekian. Despite the earlier Hayekian gesture in the 197o’s, Griffiths argued that Thatcher believed that the market economy had a moral basis in a Judeo-Christian ethic; a ‘moral market’ and this was the underpinning of the economy. Thatcher was free market enough to let the UK coal mines close and railed against support for ‘lame duck’ industries. She also began the wave of privatisation of nationalised industries.

 

What then now of Theresa May’s reintroduction of industrial policy, of explicit talk of government involvement in various sectors of the economy? Since 2010, there has been the  setting up of a British Business bank and the rebalancing of the economy as policy goals. Government should now have a view over the structure of the economy (Matthew Hancock MP), and support for successful business is a legitimate role. ‘Active and thoughtful’ government should support successful companies, and not be neutral between sectors. Hancock argued that there needs to be a strong framework around a market supporting successful industries, i.e. those that work well. An industry strategy must allow new challengers, but there must not be a planned economy. This must be done through looking at regulation and providing industry with the skills it needs.

 

Pro-Business rather than Free markets?

 

However, businesses are good at lobbying government (Zingales 2012), they ask for and get support rather than just asking for arm’s length regulation.  Zingales (2012) also argues that the US risks deteriorating into a pro-business rather than pro-market system. Jamie Whyte calls the relationship between business and government  ‘cosy and corrupt’.

 

Trump’s election and his appointees and advisors might indicate or vindicate Zingales’ point. His first big meeting in January 2017 (Feloni 2017) was with 12 CEO’s of the United States’ largest companies and he told them that he would ‘prioritize corporate tax cuts and decrease regulation’ (free market talk) and impose a ‘border tax’ on companies that move production outside the US (state interventionist).

 

Key appointments include:

 

Rex Tillerson (ex CEO of ExxonMobil), Steven Mnuchin (Goldman Sachs, Hedge Funder), Robert Lighthizer (Corporate and Trade Lawyer), Andrew Puzder (CEO of restaurant chains) and Wilbur Ross (Billionaire Investor). Well, who else would you want to run the capitalist executive but capitalist executives?  Smith (2016) suggests that ‘Trump’s billionaire cabinet could be the wealthiest administration ever’:

 

Todd Ricketts ($5.3 bn), Betsy DeVos ($5.1 bn), Wilbur Ross ($2.9 bn), and Steve Mnuchin ($46 m).

 

In the UK, May’s cabinet are pretty rich but look like paupers compared to Trump’s (Saner 2017).

 

As for business connections, in the UK, there are 50 official ministerial ‘business buddies’ for large firms in the Business Council. Glaxo Smith Kline had David Willetts while Vince Cable worked with Oil and Gas. Hancock in the Whyte radio programme argued they ‘listen’ to their companies and the government then does what they would like. This is not only a UK phenomenon. Angresano (2016) argues there is a ‘Corporate Welfare Economy’ in which the US government has increasingly been influenced by corporate lobbyists with regulation skewed in order to suit the interests of the privileged.

 

Other examples include the United States Department of Agriculture’s plan to buy 11 million pounds of cheese worth $20 million (USDA 2016) to support US dairy farmers. The Overseas Development Institute (ODI) and Oil Change International found that as a whole, G20 nations are responsible for $452bn (£297bn) a year in subsidies for fossil fuel production. Bergin (2016) reported that compensating carmakers in Britain for any post-Brexit tariffs on exports to Europe could see the government hand the companies more money than they need to pay the salaries of all their British workers. For decades British farmers have received subsidies under the EU’s Common Agricultural Policy (CAP). Full Fact (2016) report that the average farmer made £28,300 in subsidies in 2015 and £2,100 from agriculture. Wealthy land owners, such as the Daily Mail’s Paul Dacre, the Queen, a Saudi Prince, the Dukes of Westminster and Northumberland, the Earl of Moray also received subsidies from the CAP (Press Association 2016). Hinkley nuclear power station will have a subsidy worth £30 billion (Ward 2016). George Monbiot (2011) wrote:

 

the Guardian revealed that the government’s subsidy system for gas-burning power stations is being designed by an executive from the Dublin-based company ESB International, who has been seconded into the Department of Energy. What does ESB do? Oh, it builds gas-burning power stations. On the same day we learned that a government minister, Nick Boles, has privately assured the gambling company Ladbrokes that it needn’t worry about attempts by local authorities to stop the spread of betting shops. His new law will prevent councils from taking action”.

 

The Economist (2012), a free market paper, also reports on the US Chamber of Commerce and its lobbying and influence in US politics:

 

“Small firms can get a lot out of the Chamber—its annual small-business summit is well-regarded, for instance. But some feel under-represented: most of the firms represented on the board are large. Others worry that they are being used as pawns. In a letter to a Philip Morris executive just after he took over, Mr Donohue said that small firms provide the foot soldiers, and often the political cover, for issues big companies want pursued, because Congress listens more to them than to big business”.

 

Traynor et al (2014) similarly reported on corporate lobbying in the EU, claiming that there are over 30,000 lobbyists operating in Brussels while Drutman (2015) argues US lobbying is ‘America’s Business’ leading to ‘politics becoming more corporate’.

 

Jamie Whyte argues for a genuine free market, unregulated and free from government, even in the banking sector whereas Ferdinand Mount argued that it would be a ‘brave thing to do’, and it is  “rather terrifying”. Whyte argues however that the market is a mechanism for experiment and trial and thus there is no place for state regulation and subsidy. Banks should be allowed to fail. However, not bailing out the banks in 2008 would have been a brave thing to do, argued Mount, but he thinks ‘free market’ ideology will return.  Luigi Zingales (2012) supports Whyte in arguing that too much intervention creates perverse incentives. The State’s involvement in protecting money lent by the banks, means we have socialised the losses and privatised the gains. Free markets should apply to banks, they should not be bailed out, and government protection of their lending, subsidises the bank’s risks.

 

Neoliberalism, if defined as ‘small state’ and free markets, does not exist. If however ‘neoliberalism’ is understood as a discourse including ideas around individual liberty within free markets with minimal state intervention including cutting welfare programmes  aimed at the ordinary people, then it does. Its function is to reshape society by using the rhetoric of free markets while at the same time controlling certain markets though state intervention. Neoliberalism for the poor, socialism for the rich.

 

We have the data on wealth and income distribution, land ownership, offshore tax wealth, derivative values, corporate subsidies and the connections between the capitalist class executive and the political power elites which includes the military-industrial complex.  We know what money is, that it is not a physical commodity or has material existence in any form whatsoever (Harvey 2008, Pettifor 2017) and is therefore not in short supply. We know that it is now nothing more than a set of social relationships, ‘promises’, and thus is in infinite supply, but it is backed by judicial and ultimately military power. One reason we perhaps do not join the dots is too many of us have swallowed neoliberal ideology that argues ‘free markets and individual effort brings success’ while ignorant of its real effect to cover the actions of Capital which operate in rigged markets.

 

 

What should current neoliberalism look like?

 

The Adam Smith Institute (ASI) (https://www.adamsmith.org) is a free market think tank. It calls itself, “independent, non-profit and non-partisan…(to) promote neoliberal and free market ideas through research, publishing, media commentary and educational programmes”. Their priorities:

 

…are driven by a desire to rid the system of rent-seeking and inefficiencies that destroy wealth, and to create public services that are both innovative and in the hands of the people who use them, not the people who run them”.

 

The use of the word ‘neoliberal’ is interesting because it is not easily clear at first from the website that the ASI wants actually to be as neoliberal as Talbot’s ‘Nightwatchman’ state. It is not immediately obvious at first glance that they would wish to reduce public spending from 40% to 10% of GDP. However, the ASI published a blog on the level of public spending (as a % of GDP) that states that we are stuck with current levels “much as we ourselves would prefer the Hong Kong option”. Hong Kong’s spending ranges from 5.7% in 1960 to 10.9% and in 2015 was 9.15%. Therefore, buried in a blog an aim would be levels of spending equal to the ‘Nightwatchman’. The ASI believes in ‘market efficiency’:

 

  1. Low, simple, flat taxes that encourage investment and innovation, and hence economic growth (OK, need to read upon on that).

 

  1. A voucher-based education system that gives parents and schools complete freedom over how and where children are educated. (Hang on, vouchers, who is paying for that?)

 

  1. A privately-provided, publicly-funded healthcare system where patient outcomes, not NHS wages, are the focus. (what, publicly funded?)

 

  1. Freedom of trade with the world, and a liberal immigration system that is designed to work for migrants and natives alike.(open borders and requires ‘flexible’ labour markets?)

 

  1. A liberalised planning system that lets many more houses be built, so everyone can afford to own their own home. (so, environmental protection to go?)

 

  1. A simple welfare system based around a Negative Income Tax or Basic Income that tops up the wages of the poor and guarantees that work always pays. (basic Income…that’s more like it…something Marx would approve of)

 

  1. Free market money and an end to bailouts of private banks, in all their forms (Yes, nothing for a Marxist to disagree with).

 

 

 

 

The need to ‘rid the system of rent seeking’ echoes Thomas Picketty’s (2014) analysis of current capitalism and Marxist critiques of rentier forms of capitalism. The importance of wealth in attracting rent, is once again asserting itself as wealth grows faster than economic output. The ASI is sounding a bit marxist here.

 

Conclusion

 

If it is serious about a minimalist state and protection only for market transactions then free market/neoliberal ideology ought to be seeking to get private corporate and wealthy landowning snouts out of the State trough. In that, Marxists would agree. A free market should be just that. No bank bail outs, no subsidies for private schools in the form of charitable status; Oil, Gas and Nuclear power to stand on their own two feet; Farmers to earn from agriculture not government handouts; Aristocratic grouse moor owners likewise; Employers should pay what the market bears and not rely on working tax credits; Private health care companies should rely on what private individuals are willing to pay; Train operating companies should pay the full price of running the network and keep all of the profits from passengers while receiving no state funding; social care to be provided by charity, families or private individuals buying from care companies; private citizens should insure themselves for ill health and old age; Schools and Universities should compete in a market for students paid for by their parents or themselves with no state funding or through loans at market rates of interest; the road network sold off and motorists to pay to access; no housing benefit, no unemployment benefit, no sickness benefit, no pension unless paid for by private schemes, no business rates, no corporation tax; Free trade across borders with no tariffs, free movement of people, capital and services.  With the state off your back: “no income tax, no VAT, no money back, no guarantee…Good Bless Hooky Street” in a ‘Del Boy’ economy.  Libertarianism for all. Freedom from the State! Let the market decide!

 

A bit much?

 

The problem with neoliberalism and free market ideology is indeed a Hobbesian one: life could be ‘nasty, brutish and short’ as we compete one with another in a dog eat dog ‘ubermensch take the hindmost’ world.  And there’s the rub. Do they really mean it, or have they not only accepted a role for the state but embraced it for their own ends under the guise of ‘market efficiency’?

Appendix

 

  winning % Turn Out Total who did not vote

at all

Total Electorate

Who voted for

Thatcher 1979 44% 76% 24% 33%
1983 42% 72% 28% 30%
1987 42% 75% 25% 31%
Major 1992 42% 77% 23% 32%
Blair 1997 43% 71% 29% 30%
2001 41% 60% 40% 25%
2005 35% 61% 39% 21%
Cameron 2010 36% 65% 35% 23%
2015 37% 66% 34% 24%

 

 
Figure 1. Voter support for free market discourse. Increasingly it is the case that nearly a third (range 23% to 40%) or more of voters were either apathetic, disillusioned, disengaged or too distracted to bother to give their support for any political party.

 

 

Figure 2.     1900-2010 spending  as % of GDP

http://www.ukpublicspending.co.uk/past_spending

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 3. 1996-2017 spending as % of GDP.

 

 

The following two figures illustrates the degree of State involvement in the economy. The spending accounts for about 40% of GDP, leaving 60% going elsewhere. Spending on health, social care and social protection (pensions) accounts for £426 billion, that is over 50% of the total spend. Add £102 billion for education (total now is £528 Billion).

 

Who pays for that? Well, whoever pays Income tax, National Insurance, VAT, Council Tax and excise duties, accounts for £628 billion. What we have is redistribution from the 99.9% to the 99%.

 

‘Neoliberalism’ as rhetoric actually works for 0.01% – the plutocrats, the global capitalist executive, as Henry (2012) argues that anything between $21 to £31 trillion as of 2010 has been invested tax free in about 80 ‘offshore’ secrecy jurisdictions.

 

 

 

 

Figure 4. 2017 UK budget. Spending £802 billion

 

 

 

Figure 5 Revenues. £744 billion.

 

UK Budget:  https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/597467/spring_budget_2017_web.pdf accessed 22 march 2017

 

 

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Picketty, T. (2014) Capital in the Twenty-First century. Harvard. United States

 

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A manifesto for Action Nursing

A manifesto for Action Nursing

(Acknowledgement: Many thanks to Graham Scambler for his work on action sociology which inspired this manifesto).

“NOTICE: this is the author’s version of a work that has been sent for publication in Social Theory and Health.  Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may be made to this work since it was submitted for publication.

 

This manifesto calls for a social movement for political activism by nurses and other health professionals, to address inequalities in health and the social inequalities that highly structure, but do not determine, health outcomes. This action can operate at individual, clinical, organisational, national and international level.

 

Our aim is to respond to threats to health and socialised health service delivery from corporate, financial and political interests.

 

Our vision is for decreasing social and health inequalities in which the social gradient is greatly diminished.

 

Our goal is to create a networked social movement involving political and civic activism to bring critical understanding and action into the public sphere.

 

As millions of people in the UK, and billions across the globe, experience a daily struggle to both give and receive care, nurses must ally themselves with the progressive forces which seek to redress the balance of power of the ‘Greedy Bastards’. To paraphrase Graham Scambler, it is the largely unintended consequences of the actions of the ‘Greedy Bastards’ which results in gross social inequalities and inequalities in health. Action Nursing, alongside an ‘Action Sociology’, wishes to remove the ‘flowers from the chains’ so that we more clearly see what holds us back from understanding care as vital, as central, to our ‘species being’ and is not mere adjunct, to be ignored within the private (female) domain.

As many governments embrace austerity policies within a neoliberal political economy, capital accumulation takes on various anti-democratic forms unaccountable to the people engaged in what Marcuse (1964) called ‘the pacification of the struggle for existence’.  The provision of nursing may be seen as a cost and not a benefit to those who decide where the investments should be made. Capital accumulation practices in health care delivery, especially in the care of older people and those with mental health issues, often results in absent or stretched services, or hiring under educated and poorly trained staff who too often lack supervision and development and who work in high patient to staff ratios. It also seeks private insurance based schemes and prefers services which can return profits. Care givers also work in the private domain, the informal sector, providing vital support to the wider business of capital accumulation but with very little or no recognition or return for such efforts. This ideology is maintained by appeals to the moral character of such work, often locating it firmly within kin networks as a ‘reciprocal gift’ that would be sullied by any suggestions of a cash nexus.

Nurse educators, clinicians and students do not work in a socio-political vacuum. However, one would think that they do if the content of curricula and the learning experiences planned are anything to go by. Indeed any discussion around political economy, patriarchy and capitalism is liable to be met with surprise, apathy, or disdain apart from those engaged in teaching the social sciences in nursing. Nursing cannot shy away from addressing these questions. Nurses as women, who experience the requirements to care in both their domestic and public lives, bear the brunt of the demands of a society which needs that care to be done but is unwilling to fully fund it. We need to argue for the social value of care and against privatised individualised provision which falls unfairly on the shoulders of those who often do not have the resources to provide it.

Intrinsic to the nursing project is a concern for the health of individuals, communities and populations but in any point in history nurses will find themselves confronting ideologies; these are erroneous worldviews or theories that justify, sanction or provide cover for financial, business or political interests. Nursing’s ethics of care should include opposing forces that suppress truths about the societies we inhabit.

Nursing care in an often uncaring society should necessarily be oriented to justice and solidarity. It should be active not passive and should exist as a form of intervention against ‘distorted communication’ that interpellates nursing and nurses into subservient subject positions.  This has never been developed fully in Nursing theory because the discipline has been focused on other laudable aims. The result is a large number of workers in health services have no analytical tools or critical thought in which to contextualise and critique their experiences with vulnerable people. Critical theoretical concepts, such as ‘governmentality’ or ‘praxis’ or ‘frontiers of control’ ‘or ‘critical reflexivity’, would be sadly be alien to most nurses.

Action Nursing therefore contests the (often biomedical) ‘taming’ of nursing especially in the post-1970s neo-liberal era, including the shying away from arguing about contentious or ‘risky’ issues. Witness the uncritical passivity with which nurses in the UK have accepted ‘values based recruitment’, the ‘6Cs’ and ‘revalidation’ as panaceas to the issues of the quality of care; witness as well the lack of action regarding the structural conditions of the NHS following the Health and Social Care Act.

 

An Action Nursing cannot stand on the sidelines as a passive recipient of the decisions made by other powerful actors. It has to dwell on exploitation and oppression that result in inequalities in health for the population and stress, burnout and compassion fatigue for nursing staff and other care givers in their homes. Action Nursing should engage in the Marcusian ‘Great Refusal; it stands against the actions of the wealthy and powerful and actions whose consequences include the social gradient seen in the mass of data on health inequalities and evidenced in people’s lives in such works as ‘The Life Project’ (Pearson 2016).

 

This manifesto also allies itself with the manifesto ‘from Public to Planetary Health’. This is the voice of health professionals who together with empowered communities could confront entrenched interests and forces that endanger our future. This could be a powerful ‘social movement from below’ based on collective action at all levels to create better health outcomes, protect our futures and support sustainable human development.

Marcuse H (1964) One Dimensional Man. Routledge. London.

Pearson H (2016) The Life Project. Penguin. Allen Lane. London.

The missing two C’s – commodity and critique

http://tinyurl.com/the-missingtwoCs   This is the link to the published article in the Journal of Research in Nursing.

This discussion paper argues for understanding nursing care as a commodity within capitalist relations of production, ultimately as a product of labour, whose use value far exceeds its exchange value and price. This under recognised commodification of care work obscures the social relationships involved in the contribution to the social reproduction of labour and to capital accumulation by nursing care work. This matters, because many care workers give of themselves and their unpaid overtime to provide care as if in a ‘gift economy’, but in doing so find themselves in subordinate subject positions as a part the social reproduction of labour in a ‘commodity economy’. Thus they are caught in the contradiction between the ‘appearance’ and reality. A focus on the individual moral character of nurses  (e.g. the UK’s 6Cs), may operate as a screen deflecting understanding of the reality of the lived experiences of thousands of care workers and supports the discourse of ‘care as a gift’. The commodification of care work also undermines social reproduction itself. Many nurses will not have tools of analysis to critique their subject positioning by power elites and have thus been largely ineffectual in creating change to the neoliberalist and managerialist context that characterise many healthcare and other public sector organisations. The implications of this analysis for health care policy and nursing practice is the need for a critical praxis (an ‘action nursing’) by nurses and nursing bodies, along with their allies which may include patient groups, to put care in all its guises and consequences central to the political agenda.

 

Action Nursing? Addressing politics and ideology?

I read this http://www.cost-ofliving.net/a-case-for-action-sociology/ a while ago, and I published this on the one dimensional state of UK nurse education, http://www.nurseeducationtoday.com/article/S0260-6917(11)00135-3/abstract back in 2011. Graham Scambler’s outline of an action sociology (AS) made me think about an ‘action’ nursing. To use/paraphrase Graham:

 So what might action sociology/nursing deliver? It has a number of discernible properties:

It is intrinsic to the sociological/nursing project: in any era sociologists will find themselves contesting ideologies (that is, erroneous worldviews or theories that sanction or provide cover for financial, business or political interests). Sociology’s very rationale is to oppose forces that suppress truths about the societies we inhabit: pace Habermas, it is necessarily oriented to justice and solidarity. It is active not passive: it lives or dies as a form of intervention against – Habermas again – ‘distorted communication’.

Nursing similarly has an ethical dimension to it, to confront the same forces, and to fulfil its role in public health at individual, community and population levels. This has never been developed fully in Nursing theory because the discipline has been focused on other laudable aims. The result is a large number of workers in the NHS have no analytical tools or critical thought in which to contextualise and critique their experiences with vulnerable people.

‘AS’ therefore contests the ‘taming’ of sociology in the post-1970s neo-liberal era, including a shying away from contentious or ‘risky’ issues.

This taming has certainly occurred in Nursing as it is largely bereft of critique.

Sociology’s focus is the study and theorizing of what Comte called society’s ‘statics’ and ‘dynamics’ in general, and of collective action to accomplish change in particular. This encompasses recruitment, context, and the dialectics of framing and implementing strategies. Same goes for Nursing?

Sociology’s brief extends to forays into Giddens’ ‘utopianrealism’, involving the mapping of alternative futures. This may well involve challenging or superceding the discourses or narratives for change on offer at any given time. An example of utopian realism would be a model for an NHS beyond the truly iniquitous Health and Social Care Act. There is a lack of positing alternative futures by nurse scholars that is leaving the field to others.

Scambler argues: “The Health and Social Care Act, designed to re-commodify health care in England, will accentuate health inequality.  It is a paradigmatic example of policy-based evidence. The data do not speak loud enough for elite politicians, let alone their financial and business masters, to bend their ears in fear of a crisis of legitimation. So how to remove from the statute book an Act inimical to the wellbeing of most citizens?  An action sociology cannot shrug its shoulders. It has to dwell on and exploitation and oppression. It is the actions of the wealthy and powerful that condemn those in low-income households to suffer more than their share not only of long-term but of acute illness and to die prematurely, as the likes of Engels and Virschow who charged rulers with ‘murder’ recognized in the 19th century. And health inequalities afford but an illustration here: we could have pinpointed welfare as a whole, education, housing and so on with the self-same consequences. Action sociology offers resistance to ‘formal’ democracy in the name of ‘substantive’ democracy. It underwrites ‘effective’ as opposed to symbolic resistance”.

 

This aspect (e.g. health inequalities, social determinants of health, ecological pubic health) of action sociology surely should resonate with nurses? We have been interested in how the social sciences inform nursing education and practice, well this is one way. What we do not have perhaps is a journal which is read by nurses which will focus on critical theorising and exploration of the context of nursing practice. The Sociology of Health and Illness often does a sterling job but do you think there is a gap here? if so how might we go about filling it? My very small sphere of influence is nurse education and arguing for a more fully rounded curriculum, so I’m feeling my way forward for an ‘action nursing’. Thoughts? Of course I almost blush at such a ‘radical’ action is suggesting a ‘journal’, the anthropologist David Graeber at the LSE (http://www.thewhitereview.org/interviews/interview-with-david-graeber/), or of course C Wright Mills,  might laugh at such a ‘bold’ move.

Simone de Beauvoir: The second sex – the social construction of women and implications for wellbeing.

Simone de Beauvoir: The second sex – the social construction of women and implications for wellbeing.

 

In 1949 Simone de Beauvoir published ‘The Second Sex’, a book that was put on a ‘prohibited list’ by the Vatican. In 2015, the ideas within should also make the non-religious think again about what makes for femininity and why. Women suffering from eating disorders, or spending a great deal of money on cosmetic surgery, might wish to consider why they are doing so and who profits from it. Nurses as women, and a nurse education interested in the personal growth of its students, might profit from this analysis as they experience, almost daily, images of what the ideal body type should be. This experience is implicated in negative evaluations of body shape (e,g, anti-fat bias); evaluations that even health professionals engage in (Teachman and Brownhill 2001), and the prevalence of eating disorders (Garner and Garfinkel 2009).

 

Biology is not destiny. To begin with, the fact of female biology is an ‘is’ but should not be automatically linked to the ‘ought’ of social roles around, for example, child rearing and the plethora of social and domestic roles women have played for centuries. In 1740, the Scottish Enlightenment philosopher David Hume, in his ‘Treatise on Human Nature’, pointed out that human reasoning can so easily jump the gap between what ‘is’ and then declare that it also ‘ought’ to be. This gap between the ‘is’ of fact and the ‘ought’ of value requires examining rather than uncritical acceptance. Just because we eat meat, ought we to eat meet? For women, examining the gap between fact and values means realising that reproductive biology (an ‘is’) is not their destiny linked to a subordinate domestic role (an ‘ought’). In part 1 of the book ‘Destiny’, Beauvoir argues that the facts of biology must be viewed in the light of the ontological, economic, social, and physiological contexts in which they exist.

 

Beauvoir goes further into the nature of female sexuality and their feminine forms to suggest that notions of female beauty are socially constructed, and most often by men. In addition, women learn how to be women often in relation to male ideals. Beauvoir argued: “one is not born a woman, one becomes a woman” (book 1, part 2 ch 1). This feels counterintuitive and goes against natural thinking at the birth of a child in which the sex of the child is established by biological factors but almost immediately gender constructions begin. Sex and gender are intertwined and erroneously conceptualised as being the same thing. In western societies, the bestowal of the pink and the blue begins that process of the social construction of gender which then overlays the biological sex of the baby. Howard Garfinkel (1967) in ‘Studies in Ethnomethodology’, later described the continuous process of the social production of gender roles, whereby ‘Agnes’, born with a penis, passed as a woman.

 

In part two ‘History’ Beauvoir describes the historical subjugation of women by men for example quoting Proudhon who valued a woman at 8/27th the value of a man. The almost total subjugation of women, and their subsequent invisibility in history, results from patriarchy often underpinned by religion. Biology (the ‘is’) is invoked to put and keep them in their subordinate place (the ‘ought’). However, in the modern era, two key factors were involved in the evolution of the female role in society: 1. participation in production and 2. freedom from reproductive slavery. ‘Modern’ women, such as Rosa Luxembourg and Marie Curie, who were able to exploit these factors:

 

brilliantly demonstrate that it is not women’s inferiority that has determined their historical insignificance: it is their historical insignificance that has doomed them to inferiority” (p131).

 

Industrial, and now postindustrial capitalism as a dynamic system, has both freed women and created new forms of subjugation. Factory work, especially during war, gave opportunities for women to, en masse, demonstrate their strength and provide alternatives to lives of domestic labour. Nursing arguably began its professionalisation following these factors, and nurses themselves enjoy almost total freedom from obligatory reproductive labour secured by the contraceptive pill. Yet, new forms of subjugation have been created. Advances in cosmetic technologies and medical practices have now given women new tools to construct themselves as befitting whatever cultural artefact is now considered as beauty. We now have labiaplasty offered, not to correct genital ‘malfunction’ but as an aspect of new norms of beauty possibly in response to exposure to pornography (Davis 2011). Beauvoir pointed to the male gaze, but it now seems that women themselves are complicit in this reconstruction of the feminine.

 

In part three ‘Myths’, Beauvoir discusses such as issues as men’s ‘disappointment’ in women revolving round issues such as menstruation, virginity, copulation and motherhood. Myths about the female role abound in literature written by men, especially the ‘mystery’ of woman to man, perhaps foreshadowing Betty Friedan’s later work, ‘The Feminine Mystique’ (Friedan 1963). Friedan argued that male editorial decisions in women’s magazines, insisted on articles that showed women as either happy housewives or unhappy careerists. This was the “feminine mystique” the idea that women were naturally fulfilled by devoting their lives to being housewives and mothers. In both books there is this suggestion that men misunderstand, or perhaps even fear women, and engage in creating a simulacrum (Baudrillard n.d.) of femininity to best fit their own gendered and sexual needs. It might be that male fear of women, their lack of control of female reproduction, is at the root of ‘femicide’ – the killing of females by males because they are females (Russell and Harmes 2001).

 

Volume two of the work is also divided into 4 parts; ‘Formative years’, ‘Situation’, Justifications’ and ‘Towards Liberation’. Beauvoir describes the learning of appropriate femininity and subsequent domestic roles. Her critique of marriage and acceptance of lesbianism no doubt helped the Vatican in its decision.

 

Beauvoir assembles an historical account using examples from literature, politics and philosophy to argue that to fully understand what it is to be a women requires moving beyond biology as destiny to examining the myths of femininity, myths often created by and for men, and then towards constructing emancipatory practices.

 

Women should come to see that they are under a ‘male gaze’ which constructs who they are and that beauty itself is a social construct. It is through other people’s assumptions and expectations that a woman (sex) becomes ‘feminine’ (gender). Part of that feminization is the requirement of women to strive after beauty, defined by mens’ view of what they would like women to be. A view that denies women the capacity for action and thought, to be passive objects of the male gaze, and to use artifice in order to be ornamental, to disguise the more animal aspects of their bodies, e.g. the removal of body hair in western aesthetics. The pressure on women to become an object, to be conventionally beautiful, to diet, is intense.

 

Of course, the male gaze can be internalized by women, and it is the case that women’s magazines produced and edited by women perpetuate beauty myths (Wolf 1991). Aesthetic technologies, such as dermal fillers and botox, are often advertised by women, performed by women, performed on women. Beauvoir focused on patriarchal values and concepts as drivers for these processes, whereas and especially since the development of liquid modernity (Baumann 2000) characterized by individualism, consumerism and atomization, and by the increasing marketisation of society (Sandel 2012, Marquand 2014), consumer capitalism has also targeted men as consumers of beauty products. We have now the construction of the male body type with the ‘six pack’ as its apotheosis.

 

The creation of dissatisfaction with one’s body, be it male or female, is now a marketing tool to sell product. This process may have become a dominant ethic in contemporary society. Booth (2014) refers to a contemporary concerns with ‘mammon worship’ defined as ‘seeking satisfaction through the superficial’ while Skidelsky and Skidelsky (2012) focus on the dominance of the values of acquisition and ‘insatiability’ while societies have lost the sense of what the good life might be. If this is the case, then Beauvoir’s focus on patriarchal values and the male gaze, allied with more and more of a concern with financialisation and the creating of new markets for profit,  come together as dominant social ethics to create who we are at both emotional and physical levels.

There is resistance of course. Since Beauvoir’s publication, some have suggested that ‘second wave’ feminism (Gamble 2001) and ‘third wave’ feminism (Tong 2009) arose to address the rights of women. Resistance to the male gaze can be seen in Susie Orbach’s work (1978). For Orbach, gender inequality makes women fat; compulsive eating and being fat is one way to avoid being marketed at or being seen as the ideal woman. Orbach suggested it was some womens’ way of rebelling against powerlessness in society. More recently, the ‘Everyday Sexism’ project exists to address instances of sexism experienced by women on a daily basis. Within a health context, Hagell (1989) discussed the conceptualization of nursing work as women’s work while Aston (2011) have used feminist post structuralism (FPS) as a way of understanding obesity. Sundin-Huard (2001) used subject positions theory to illustrate how nurses in a gendered profession can be positioned into subordinate roles within hierarchical medical and managerial structures.

 

The value of returning to Beauvoir’s work is in reminding us that what seems normal and natural for women’s place in society and what seems normal in their ‘natural’ attributes as carers and nurterers, may not be normal or natural. We need to remember the ‘is’ and the ‘ought’. The pressures women experience, and the tools they use to provide an acceptably pleasing face to themselves as well as to men, are cultural artefacts bound up within systems of power. Powerlessness in the face of the social construction of feminities that lead to abject and subordinate subject positions can lead to reaction which might even be self harming. Feminist theory may not find a home in nurse education, perhaps it should?

 

 

 

 

 

 

Aston M, Price S, Kirk S, and Penney T. (2011) More than meets the eye. Feminist poststructuralism as a lens towards understanding Obesity. Journal of Advanced Nursing.

Baudrillard, J. “XI. Holograms.” Simulacra and Simulations. transl. Sheila Faria Glaser. http://www.egs.edu/faculty/jean-baudrillard/articles/simulacra-and-simulations-xi-holograms/ retrieved 20 February 2015

Baumann Z. (2000) Liquid Modernity. Polity. Cambridge.

Beauvoir, Simone de (1949 (translated 2009)). The Second Sex. Trans. Constance Borde and Sheila Malovany-Chevallier. Random House: Alfred A. Knopf.

Booth, P. (2014) Straw Mammon: An essay on Mammon’s Kingdom by David Marquand. Institute of Economic Affairs. July 2014. http://www.iea.org.uk/blog/straw-mammon-an-essay-on-mammon’s-kingdom-by-david-marquand

Davis, R. (2011) Labiaplasty surgery increased as a result of pornography. Women. The Observer 27th February http://www.theguardian.com/lifeandstyle/2011/feb/27/labiaplasty-surgery-labia-vagina-pornography

Garfinkel, H. 1967 Studies in Ethnomethodology. Englewood Cliffs, NJ: Prentice Hall.

Gamble, s. (2001) ed. The Routledge companion to feminism and postfeminism . Routledge London.

Garner, David M.; Garfinkel, Paul E. (2009). Socio-cultural factors in the development of anorexia nervosa. Psychological Medicine 10 (4): 647–56

Hagell, E (1989) Nursing knowledge: Women’s knowledge. A sociological perspective. Journal of Advanced Nursing, 14: 226–33

Hume, D. (1739-1740) Treatise on Human Nature. Section 3.1.1. Moral Distinctions Not deriv’d from Reason. http://davidhume.org/texts/thn.html

Marquand, D. (2014) Mammon’s Kingdom: An Essay on Britain Now. Allen lane. London.

Orbach, S (1978) Fat is a feminist issue. Arrow. London.

Russell, D and Harmes, R. (eds) Femicide in Global Perspective. Ch 2 p 13-14. Teachers College Press, New York.

Sandel, M. (2012) What money can’t buy. The moral limits of markets. Allen lane. London.

Skidelsky, R and Skidelsky E, (2012) How much is enough? Money and the Good Life. Other Press. New York.

Teachman, B.A.; Brownell, K.D. (2001). “Implicit anti-fat bias among health professionals: Is anyone immune?”. International Journal of Obesity 25 (10): 1525–1531

Tong, R. (2009). Feminist Thought: A More Comprehensive Introduction (Third ed.). Boulder: Westview Press. pp. 284–285, 289

Wolf, N. (1990) The Beauty Myth. How Images of beauty are used against women. Vintage. London.

Why do nurses behave as they do?

Subject Positions Theory.   Why do individual nurses behave as they do?

SPT tries to explain how ‘subjects’ will behave in certain situations. It can be used to explore what ‘positions’ we take up and what identities we either assume or refuse within a social context that is characterised by power relationships. It allows the question about how powerful ‘others’ (i.e. Health Secretaries, CEOs, Consultants, Managers) position the relatively powerless ‘subject’ (staff nurse, patient) into certain subject positions (e.g. handmaiden, passive recipient) simply through an unconscious, uncriticised and shared language, discourse and power. Objective formal power involving clear boundaries, sanctions and authority also operate in social relationships. Objective formal power needs to be called out, and its foundation clearly described as operating often on an unspoken ideology. In the current context of health care delivery, that ideology is founded upon the twin pillars of neoliberalism and managerialism. These are macro level positions, whereas SPT allows exploration of informal power at the micro level that might go otherwise unanalysed.

 

The ‘subject’ within this theory refers to the individual human being who engages in creating an identity and does so partly by being the ‘subject’ of language, discourses and power relationships. The subject position, or identity, one takes is created by language, discourse and power and in doing so also creates that identity. This operates within a set of social relationships that are characterised by differences such as ethnicity, sexuality, gender and class. These relationships are also relationships of power. They operate through and within language. Our subject positions are partly defined by others unless we recognise the process of positioning and resist it. However, a good deal of positioning by others can be successful because we take subject positions often unconsciously. We have already accepted the language, discourse and power of others. Within any social interaction, powerful ‘others’ may engage in ‘interpellation’ (Althusser 1989). They ‘call’ us into a subject position by our intersubjective acceptance of the language, discourse and power of the other.

 

When a doctor, or manager, calls upon a nurse to do something, they are often ‘interpellating’ the nurse into a subject position of obedience to a medical or hierarchical regime. This can only work if the nurse recognises and accepts the subject position of junior partner. This process of identification creates an identity. The doctor identifies the nurse and the ‘subject’ within the nurse becomes a nurse. The subjective ‘I’, which in other social situations is not identified as a nurse, now becomes one. This is not to be confused with the formal title that the qualification RN bestows upon someone. Merely having been registered with the Nursing and Midwifery council does not identify a subject as a ‘nurse’, it is merely a formal recognition of one’s status on a register. One becomes and assumes the identity of nurse through social interaction and the ‘interpellation’ of others. A nurse is a nurse only when others say so within a social context. Upon leaving the clinical setting, the subjective ‘I’ is now free to assume other identities such as mother, friend, runner or dancer.

 

When a nurse is called in this manner, it may well be the case that the nurse recognises this calling, and that the subjective ‘I’ is now the subject position of ‘me’ as nurse. This operates through the unconscious acceptance of that subject position. Through such mechanisms as ‘occupational socialisation’ the calling out of ‘me as nurse’ feels natural and in that acceptance further cements this identity. The nurse has been ‘recruited’ into that subject position and over time bonds with that identity and its underlying ideological sets of discourses and power relationships that go with it.

 

Within the occupation of nursing there may be a number of subject positions open to individual nurses. Some of those positions are overt and openly discussed, others operate within the covert, intersubjective, lifeworld of nursing. Thus, nurses assume certain subject positions, such as ‘nurse advocate’, and attempt to assume this identity to further patient care. In doing so, do other ‘powerful subjects’ may position the ‘nurse advocate’ identity into one of ‘whistleblower’ or ‘uppity nurse’, ‘non-medical care worker’ or ‘junior partner’.

 

Potential Subject Positions that might be open to nurses: they operate as binaries – one position is assumed other is an ‘abject’ position.

 

·       Advocate/Non advocate

·       Carer/patient

·       Empathiser/task completer

·       Doer/Organiser

·       Whistleblower/Compliant worker

·       Educator/Student

·       Trainer/Trainee

·       Supervisor/worker

·       Female/male

·       Good nurse/uppity nurse

·       Coper/Whinger

·       Emotional supporter/distant professional

·       Responder/avoider

 

 

‘Subjects’ have the ability to occupy and move between a variety of identities, or ‘subject positions’, within an interaction in the clinical setting but this depends on the power dynamics and context of that exchange. We can therefore try to analyse in any given interaction what those power dynamics are and what the context consists of. So, how do nurses either comply with or resist positioning for example as a ‘doer’ within a power struggle?

 

Lacan (1977) suggests we assume identities, or positions, in response to punishments or threats of punishment. In the clinical context that might include bullying, intimidation, snubbing, patronising language or lack of promotion. The fear of punishment arises out of ‘knowing’ the rules of interaction and being aware of power and the rules of hierarchy.

 

Once an identity has been assumed it is associated with a particular discourse, i.e. a stock of words, phrases, concepts, theories, that support and explain the position taken. The subject position of nurse, according, to society, should display feminine attributes based in an ethic of care. The discourse associated with this is about being a ‘good nurse’ emphasising nurturance, obedience, support, listening and helping. This recently has been given even more support through emphasising the 6 Cs. This sits in opposition to critical advocacy especially in relation to the medical profession and NHS management. The discourse available to critical advocacy emphasises challenge, assertiveness, rights, and standards. The subject position of whistleblower is similarly contradictory, at once being that of advocate and patient champion while the reality is also one of irritant, turncoat and rebel to the hierarchies of power. SPT requires a critical theory of power to move beyond analysis at the micro level to critique of power structures (be they gendered, class, managerial) at the macro.

 

Clinical decision making, such as advocating a certain course of action such as moving an older person within the hospital at night, or changing the operating list to avoid delays, or getting analgesia prescribed, operates within this matrix of subject positions involving negotiating the social order of hierarchy and power. Sundin-Huard (2001) argues the subject position of advocate is countered by the subject position of ‘good nurse’ in that in exercising advocacy the nurse threatens the identity of ‘good nurse’ and becomes the ‘uppity nurse’. A vignette illustrating this positioning is used as an exemplar. In the vignette, a neonatal nurse advocates, unsuccessfully, for analgesia as she is positioned and assumes the position of advocate and uppity nurse. In the training film ‘just a routine operation’, two nurses are similarly positioned as ‘junior without formal decision making power’ within a critical airway emergency in theatre. The resulting death of the patient in that scenario clearly demonstrates that this analysis is no mere sociological abstraction.

 

Conclusion

 

Nursing does not operate in a neutral power context. Nurses work in a gendered occupation underpinned by a range of discourses using certain languages that often position them into subordination. Those in formal power positions also understand these discourses and through language use can ‘call’ nurses into subordinate and contradictory subject positions. Hierarchies of gender, class and occupation provide the context for these positionings to take place. In order to minimise moral distress and the burden of emotional labour, nurses require an emancipatory understanding of these taken for granted power plays to enable practical resistance to develop. In this they can be aided by the discourse of humanism recognising the requirement for patient safety, comfort and cleanliness in the provision of quality care. The nurse who feels emotional and moral distress as a result of the actions and omissions of other power actors in the workplace, requires an analysis of the basis of this power relationship so that rather than turning in on oneself in defeat, a resistance can be mounted by creating alternative languages, discourses and power bases. Resilience in the face of threat in this context is not enough. Nurses need to find a language to speak truth to power and then forge political alliances with other actors, e.g. patient advocacy groups, to create alternative visions and structures to that which is advocated by neoliberals and the dead hand of managerialism.

 

 

 

 

 

 

 

Althusser, L. (1989). ‘Ideology and ideological state apparatuses’ in Lenin and Philosophy and other Essays: pp 170-186. London. New Left Books.

 

Lacan, J. (1977). Écrits: A Selection. Trans. Alan Sheridan. New York: Norton

 

Sundin-Huard D. Subject Positions Theory. Understanding conflict and collaboration in critical care. (2001). Journal of Advanced Nursing 34 (3) pp 376-382

Nursing care scares and Moral Panic

Nursing, Care scares and Moral Panic.

 

The number and tone of reports of poor quality care (e.g. Simmons 2011) especially, since the Mid Staffs NHS trust inquiry but by no means is defined by it, may be described as a moral panic and has been described as a crisis in care (Hari 2011, Phillips 2011a, 2011b) and “reveal a moral sickness in the professional ethic of nursing, and more particularly nurse training…” (Phillips 2011b). These media reports over poor quality care (Marrin 2009, 2011, Shields et al 2011) and the identification of graduate nurses as folk devils who are “too posh to wash”, lead us to ask why this moral panic over graduate nursing has arisen?

 

A ‘moral panic’ is when a population feels the ‘social order’ is threatened, and that this threat is felt intensely, it is a certain reaction to a perceived social problem. A moral panic may be characterized by irrational, inappropriate overreactions to problems. Stanley Cohen (1972) applied the term to press reports and establishment reaction to the phenomenon of ‘Mods and Rockers’, a moral panic arises when:

 

“a condition, episode, person or group of persons emerges to become defined as a threat to societal values and interests” (Cohen 1973 p9). The scathing criticism of graduate nursing in the press looks very similar to this sort of description. So, what societal values and interests are thought to be threatened by graduates?

 

The first aspect is that some feel a loss of ‘the proper place of women/nurses as mother archetypes’ which is part of the longer term process of female entry into the labour market and the break from domestic duties. Feminism has been blamed for this process (however the requirements of consumer capitalism and the need for labour has also had its effects).

 

The second is the ambiguities felt over the care of elderly people which increasingly has been seen to be the State’s proper role since the introduction of the Welfare State. Although the expressed social order demands that care of the elderly be done within families, the economy demands labour mobility resulting in geographically fragmented families unable to care for elderly relatives. The loss of the family wage and the rise of consumer culture also affects our abilities to care for both children and the elderly as both parents work. The actual social order is that elderly people are, en masse, in institutions and that allows us to abrogate our responsibilities. Although no one expresses a wish to be in a nursing home, no-one either wants (or is able) to take responsibility for elder care.

 

The third aspect is that body work which involves intimacy, closeness as well as dirt and disgust, is again seen as female caring work which does not attract any social value or support beyond expressions of stoic heroism on behalf of carers.

 

Graduate nurses challenge these conceptions by being women who are educated, who work and expect like any other professional to be rewarded for their efforts, there is then a cognitive dissonance between on the one hand a vision of nursing as self sacrificial angels and as professionals requiring proper education and reward as professionals. One way to solve this dissonance is to reframe professional nursing, i.e. ‘train’ them in hospitals (putting them in their ‘proper place’).

 

However, the place of women, and women as nurses, the ambivalence towards care and its meaning, the increasing marginalisation of the elderly and their devaluing may be manifestations of society’s turn from solid to ‘liquid modernity’ (Baumann 2000). Social values, aspirations and expectations are played out within the themes of globalization, individualization, marginalisation, poverty and consumerism. These are the actual social threats that this moral panic cannot actually name and identify. ‘Folk devils’ have to be found to explain these new forms of alienation. Poor care has been around as long as there have been carers, and so we need to be careful not to argue that liquidity causes poor care, rather it may the case that liquid social conditions predispose individuals to perform in particular ways and for their actions to be interpreted in particular ways. The folk devils are in, this instance, graduate nurses. However, blaming nurses refocuses attention away from more difficult problems and gives easy solutions (‘return training to hospitals and all will be well’).

 

Liquid modernity, according to Baumann, involves community fragmentation, eroding social bonds, atomized relationships and individualistic expectations all in the context of the globalization of capital and markets which dislocate communities. Workers have to respond to calls for mobility and flexibility or face redundancy. Communities struggle to reconcile competing demands especially with the increasing numbers of elderly people and costs of care. Nurses and midwives find themselves caught between all of these competing demands unable to make the links between their individual experiences and larger social conditions,

 

If only one nurse abuses a patient we should properly look to the character of the individual nurse for reasons.  When cases of reported abuse become legion then the personal troubles of the patients should be seen in the context of the public issues of society. To fully comprehend the position of the abuser we need to address their personal biography and history and the relationship between the two in society. Anyone wishing to analyze why there is poor care needs to avoid simplistic knee jerk moral panic type reactions and grab the idea that nurses can understand their experiences and gauge their fates only by locating themselves within their period, that they can know their  own lives only by becoming aware of all those nurses in the same circumstances. Focusing on the personal accountability of care staff without addressing the structural conditions in which they work simply will not do.

 

So what then is the answer?

 

Care has to be really valued, and in current society the main way value is ascribed is to place a monetary value onto it and bring it centrally into business planning. Therefore the cost of care has to be brought into all accounting. Capitalist production currently does not take into account the care (and environmental) costs that society bears for that production. However caring still has to be done or else production cannot continue in its current form. This is not a new argument, feminists and environmentalists have been arguing this for years. If society wishes to value care then it has to pay for it. That means increasing the number of staff and paying them a competitive wage so that good quality staff are educated, retained, supervised, developed and valued. Or, as Sue Gerhardt (2010a) agues we should refocus on caring as a real social value and perhaps introduce a ‘caring wage’ (2010b) say £12,000-£16,000 per year? Society has to value care with more than lip service and the stoic angels tag, but in the current economic setting social values are not strong enough to ensure we will do this.

 

 

 

 

 

 

 

Baumann Z. (2000) Liquid modernity. Polity. Cambridge.

 

Cohen, S. (1973). Folk Devils and Moral Panics. St Albans: Paladin, p.9

 

Gerhardt S. (2010a) The Selfish Society. How we all forgot to love one another and made money instead. Simon and Shuster. London.

 

Gerhardt S.(2010b) The Selfish Society. RSA events. 22nd April. http://www.thersa.org/events/audio-and-past-events/2010/the-selfish-society

 

Hari, J. (2011) The plan to resolve our care home crisis. The Independent January 26th http://tinyurl.com/5ugyond

 

Hawken P (1994) The Ecology of Commerce. Harper Collins. London

 

Marrin, M. (2009) Oh Nurse, Your degree is a symptom of equality disease. The Sunday Times. November 15th

 

Marrin, M. (2011) Our flawed uncaring NHS is a self inflicted wound. The Sunday Times. May 29th

 

Phillips, M (2011) The moral crisis in nursing, voices from the wards. Daily Mail. October 21. http://melaniephillips.com/the-moral-crisis-in-nursing-voices-from-the-wards

 

Phillips, M. (2011) How feminism made so many nurses to grand to care. Daily Mail. October 17. http://melaniephillips.com/how-feminism-made-so-many-nurses-too-grand-to-care

 

Shields, L., Morrall, P., Goodman, B., Purcell, C. and Watson, R. (2011) Care to be a nurse? Reflections on a radio broadcast and its ramifications for nursing today. Nurse Education Today. doi:10.1016/jnedt.2011.09.001

 

Simmons, M. (2011) Poor Nursing care. NursingTimes.net. 4th July. http://www.nursingtimes.net/poor-nursing-care/398.thread

“The University in Ruins”

Constructing the Paraversity using the web.

 

Introduction

Higher Education institutions across the globe are changing and changing fast. Several writers have expressed dismay, as well as seeing opportunities to move in different directions, in response to what has been called the ‘University in Ruins’ (Readings 1996).

 

Gary Rolfe (2013), picking up on Reading’s work addressed ‘scholarship in the corporate university’ and suggested that academics must ‘dwell in the ruins’ in an authentic and productive way through the development of a community of philosophers who will dissent, subvert and challenge the ‘corporate university’ from within. Tools for subversion are at hand. Social media, blogging, open access journals and the development of new academic websites such as Researchgate and academia.edu, give academics new ways to reach students, and indeed anybody, way beyond the physical confines of their campus. Accepting that there are issues of peer review and hence quality, these tools allow free access and may facilitate dialogue in ways unheard of just few years ago. This paper explores the ruins, argues for critical dissensus, and shares one experience of using such tools and suggests that this might then assist in building Rolfe’s ‘community of philosophers’ or what Slavoj Žižek has called ‘liberated territories’ (Žižek 2008).

 

Following a note on pedagogy and addressing what the purpose of education  might be,  the idea of the Paraversity will be outlined, and importantly a central notion of dissensus highlighted. Why nurse educators and student nurses should engage in dissensus, as well as professional training, is a point to be debated. To do so, I will refer to the work of C Wright Mills’ on ‘intellectual craftsmanship’. Secondly, an example of constructing this Paraversity will be shared, not that this is a paradigm case, but as only one way to do so, a way that of course may prove fruitless as we acknowledge the variety of approaches and uncertainty of any outcomes. Indeed ‘outcomes’ themselves may be part of the language of a certain mindset that is antithetical to the Paraversity.

So, what follows is a thesis, which may draw forth an antithesis resulting in a new synthesis, which in turn can be challenged. Consensus and agreement is not the point; dialogue is. This paper is overtly political; drawing upon Freire’s ‘pedagogy of the oppressed’, Marx and the heirs of Marx, to argue that nursing is locked into a matrix of social systems that are oppressive and marginalising, and that Higher Education itself, in the guise of the ‘University of Excellence’ is increasingly commodified, and losing its way as it tries to meet the needs of the ‘Knowledge Economy’ in the production of ‘Cognitive Capitalism’.  I argue we need to revisit the question ‘what is education for’?

 


 

A note on Pedagogy

 

Paulo Friere’s first premise concerns a humanistic value base, upon which a pedagogy should be constructed. The human being is a ‘subject’, rather than an ‘object’ ready for construction by oppressive forces. Our ‘ontological vocation’ is towards ‘humanization’; to be able to engage in ‘conscientização’   which is learning to perceive social, political and economic contradictions and to take action against the oppressive elements of reality.

Stephen Sterling (2001) later argued that we need a paradigm shift away from transmissive forms of education towards transformative forms of education. Transmitting an education that ensures graduates are better equipped to perform clinical skills is first order learning.  However it is a partial education at best. First order learning takes place within current educational boundaries and philosophies. It is adaptivelearning, e.g. the acquisition of skills and knowledge to assist in adapting to new roles as registered nurses.

 

Education ought to be a process of transforming individuals so that base values, assumptions and paradigms are taken into account and challenged  – this is what Sterling calls second and third order learning.

 

Second order learning involves critically reflective learning. This is about examining the assumptions that underpin first order learning.

Third order learning is transformative learning and allows us to change perspectives and paradigms. It is creative, is a ‘shift in consciousness’, and involves a ‘deep awareness of alternative world views’ (Sterling 2001 p15).

 

Education in this sense is for humanity rather than just the transmission of knowledge, skills and values for the corporate, or employment, sphere. The Paraversity could be such a space in which this pedagogy operates. Thus, the process of education is as important, if not more important, than the end product. However, this is an issue for nurse education – to what degree is the product more important than the process? Do certain professional values, regulation and the needs for an NHS workforce outweigh the experience of a critical pedagogy? If so, are we constructing the student as passive object, who also self governs, rendering them unable to engage with countervailing voices against a one dimensional political hegemony in which the ‘market is king’?

We need to challenge pedagogical assumptions because, contrary to what many would have us believe, history has not ended, business can’t be ‘as usual’ and this is not ‘the best of all possible worlds’:

“The truth is that many things on which our future health and prosperity depend are in dire jeopardy….this is not the work of ignorant people. Rather it is largely the results of work by people with BAs, BScs, LLBs, MBAs and PhDs.” (Orr 2004 p.7)

The global financial crisis of 2007-8 was not caused by blue collar workers, nurses or teachers, but arose out of the activities of very clever people recruited from so called elite universities, many of whom studied economics mired in orthodoxy, rendering it unable to foresee the systemic risk building up within finance capital.

Jihadist social movements have gained ground in part to the ideologically based bumblings of Yale, Harvard and Oxbridge Educated elites, who with characteristic hubris and with appalling lack of insight, declared ‘mission accomplished’, and are now fretting about ‘radicalisation’ while doing little to address the socio-political causes of jihadist ideological narratives that drive young men and women into armed conflict.

Older people, their families, and those with mental health problems, in contemporary capitalist societies are experiencing crises in health and social care provision as successive governments have failed to put the interests of people before profits and capital accumulation.

With a few exceptions, for example Michael Burawoy’s (2004) notion of ‘public sociology’ or Paul Hawken’s notion of the ‘Blessed Unrest’, we have largely failed to produce enough countervailing voices, or a new vision of care that is fit for the 21st century. There is little in the way of critical guiding philosophies in operation for nursing beyond individualised biomedically dominated notions of ‘care and compassion’ in the context of instrumentally orientated curricula obsessed with competence – ‘doing rather than thinking’. This is not to deny the existence of critical voices in the literature, just to acknowledge the often ahistorical, apolitical and anti theoretical nature of what passes for scholarship in and for clinical practice.

This might seem irrelevant, idealistic, utopian and antithetical to professional nursing practice. Nonetheless, it is a notion that can be discussed within the paraversity as an element of dissensus.


 

What is the ‘paraversity’? (Rolfe 2013).

Gary Rolfe  suggest that the ‘paraversity’ runs alongside the visible University, going unnoticed or unseen. The paraversity is a ‘mental space’ of dissensus, seeking no unity of thought or acceptance of any grand narrative. As such, the Paraversity may well throw up an antithesis to this thesis. It is invisible, subversive and a virtual institution. It is not owned by corporate interests, it is not influenced directly by research bodies, funding streams or research programmes or corporate management strategies. The national student survey is irrelevant to its continuance. There will be no physically identified building or faculty – it exists in the form of a community of philosopher scholars exploring and deconstructing and reconstructing ideas.

In the paraversity there is no need to arrive at consensus or agreement or a system of unified thought. It does not exist to fulfil the corporate university’s aims and objectives, it is the ‘pursuit of difference’ to keep open debate and discussion and not to shut it down. It also operates to call the corporate university to intellectual account.

In this aim, it fosters countervailing voices to critique one dimensional thought and implicitly evokes the critical theory of Herbert Marcuse, Theodore Adorno and Louis Althusser, but is of course not merely the intellectual heir to such thought as if the matters regarding ontology, epistemology and philosophy were settled. This uncertainty of certainty could be potentially unsettling for nursing thought and practice which seeks certainty and truth in professional practice.

 

What are Universities for?

“In a world characterised by complexity and uncertainty, our long term survival lies…..in our willingness to bend the rules in unforeseen circumstances and even operate beyond our level of knowledge as we make our world view” (Paul Vare p2).

Vare acknowledges that the problems besetting the world require thinking differently, acting differently and challenging many long held assumptions. Academic disciplines which cannot evolve their thinking will produce graduates who will engage in ‘business as usual’ chasing fewer and fewer ‘plum’ jobs as they join the precariat (Standing 2011) as ‘graduates with no future’ (Mason 2012) .

 

The ‘University of Excellence’.

It might be argued that within the ‘Enlightenment’, the historic missions of Universities focused on ‘truth’ and ‘emancipation’. Docherty (2014) writes

“In 1946, the political theorist Hannah Arendt received a copy of The Idea of the University, which was written by her mentor, Karl Jaspers. Jaspers had revised the book, originally published in 1923, for the post-war context, when German universities needed to recover from explicit institutional and ideological conformism to Nazism. He advances a reconfiguration of academic freedom that, today, is everywhere threatened again, thanks to a failure of political will – and of leadership – that allows intellectual freedoms to be sacrificed to financial priorities. Writing to Jaspers on receipt of the book, Arendt firmly expressed the view that, given the cost of the higher education system, it must be state-funded. But it was vital that the professoriate should not thereby become tacitly politicised “civil servants”. Academic freedom meant that universities should be governed by intellectual demands, without improper political interference”.

Now, this narrative has been replaced with that of the neoliberal capitalist narrative of efficiency and profitability, i.e. the narrative of the market. Readings (1996) argued that the ‘pursuit of excellence’ within this narrative is a legitimising idea. However, ‘excellence’ refers more to administrative processes in which ‘excellence’ is a unit of measurement, devoid of qualitative content, which we now measure through such metrics as attrition, the number of firsts, impact factors, the number of research grants awarded and student perception questionnaires. An excellent nursing degree is one with low attrition, satisfied students, high employability and high numbers of firsts. Who would disagree with that?  Rolfe (2013) suggests this view of excellence is one of quantity rather than quality and brings us into the realms of ‘efficiency, profitability and administration’ (p9). He goes on to argue

“The vision and mission of the University has shifted from the production and dissemination of thought and ideas to the generation and sale of facts and data” (Rolfe 2013 p 81).

This suggests that the role of Universities now is often that of contributing to the local and national economy and to train graduates for the job market, and I would suggest that in many nursing departments that is the sole ‘raison d’etre’.

This instrumental orientation to nursing education (Goodman 2012) is evidenced by the dominance of competency based education, fit for practice, fit for purpose curricula, based on the NMC’s educational standards. The student nurse or graduate registrant who questions and critiques the ontological, political, ideological and epistemological assumptions upon which care is designed, delivered and evaluated would not be that welcome in clinical practice and perhaps only marginally tolerated in many nursing modules based on the transmission of facts and theories for clinical practice, grounded as many are in the assumptions of positivist and empiricist science. Nursing theory, let alone feminist or critical theory, may have disappeared from nurse education.  We may now be less able within nursing curricula to question the basis of social knowledge and care practices from critical perspectives that seeks to illuminate the subject positioning of women and the marginalisation of older people as unproductive burdens on society.

What is being lost is the notion of ‘intellectual craftmanship’ in favour of the search for empirical certainty, data and hard facts to guide practice. Indeed, evidence based practice education can be reduced to issues of methodology rather than issues of epistemology, philosophy and ontology. Perhaps many nurse scholars themselves have lost the ability to engage in this activity, and thus to be role models, buckling under the pressure to deliver clinical skills and other diverse teaching while also delivering empirically based research which provides facts and answers to practical questions. Many of course will have been schooled in the biomedical sciences and thus would not have had the critical epistemological enquiries and paradigms of social science. What we end up with is the pressure to produce ‘denotative’ writing – the telling and informing process through powerpoints and scientific reports as the dominant discourse of knowledge production and dissemination.  This is the ‘University of Excellence’.

 

What are academics for in the ‘University of Excellence’?

 

Brock (2014) asked “what is the function of the social movement academic’? However I would rephrase this and ask “what is one of the functions of the nurse academic? I would respond, as Brock does, with the suggestion that it is partly “to debunk the knowledge on which the powerful rest”.  One of those notions being peddled currently is that the NHS and society will not be able to afford care for older people,  that free at the point of delivery will no longer be possible, and that expensive external monitoring and inspections are worth the money spent on them. All the while corporates lobby behind the scenes for bits of the profitable NHS pie; see this list by Andrew Robertson on his site ‘social investigations’.

To engage in debunking requires ‘intellectual craftsmanship’ and is important for critical enquiry in the paraversity. What might that look like?

 

On Intellectual Craftsmanship  (C Wright Mills 1959).

 

In the appendix to ‘The Sociological Imagination’ Wright Mills outlined his view on ‘doing’ social science in which he suggested that ‘Scholarship’ is more important than empirical research for the social scientist. He considered that Empiricism was the ‘mere sorting out of facts and disagreements about facts’. Wright Mills’ critique of abstract empiricism contained in ‘The Sociological Imagination’ is that argument made manifest. Rules of method and arguments on methodological procedures and validity are just so much navel gazing which Wright Mills wished to avoid if he could possibly do so:

 

“Now I do not like to do empirical work if I can possibly avoid it” (p205) and “there is no more worth in empirical enquiry as such than in reading as such” (p 226).

 

The task of social science is thus to critically engage in the real world, joining personal experience and intellectual life through critical reflective reason as the

 

“advance guard in any field of learning” (p205).

He argued:

“It is the political task of the social scientist — as of any liberal educator — continually to translate personal troubles into public issues, and public issues into the terms of their human meaning for a variety of individuals. It is his task to display in his work — and, as an educator, in his life as well — this kind of sociological imagination. And it is his purpose to cultivate such habits of mind among the men and women who are publicly exposed to him. To secure these ends is to secure reason and individuality, and to make these the predominant values of a democratic society” (p187).

The personal trouble of obesity is a public issue not a personal moral failing of weak willed individuals. We must look to the role of fossil fuels instead of food, in providing energy; we must look at the marketing and distribution activities of the food industry; we must look to portrayals of the body in the media;  we must look to the structures od sedentary employment…..

Nurse educators might read this and think, actually, no it is not my political task at all!  Nurse students do not need to think about their personal lives and the lives of others as they relate to wider social and political issues…they need to be able to deliver care – to provide pain relief, comfort and explanations to vulnerable people, to interpret cardiac rhythms and administer medications, to assess wounds and decide upon management plans….that is the stuff of nursing and the rest of this is mere frippery. This is a view I have heard expressed by students as they cry “when are we going to learn proper nursing?”

In this they might be supported by the Corporate University which, in response to the demands of its customers, industry, commerce and the economy, has shifted the emphasis of the role of the academic from raising questions to providing answers, from problematizing to problem solving. Many nursing students want answers, not to raise questions. Thus empiricism and the tenets of positivistic science have been dragooned to support this mission. This is in opposition to many notions regarding personal and social transformation.

 

Michael Burawoy argued:

“The original passion for social justice, economic equality, human rights, sustainable environment, political freedom or simply a better world, that drew so many of us to sociology, is channeled into the pursuit of academic credentials. Progress becomes a battery of disciplinary techniques—standardized courses, validated reading lists, bureaucratic ranking intensive examinations, literature reviews, tailored dissertations, refereed publications, the all-mighty CV, the job search, the tenure file, and then policing one’s colleagues and successors to make sure we all march in step. Still, despite the normalizing pressures of careers, the originating moral impetus is rarely vanquished, the sociological spirit cannot be extinguished so easily”.

Can we replace sociology with nursing in this paragraph? Can we say our original passions have been channeled into pointless mindnumbing bureaucratically led education programmes that do nothing to challenge or change the context of care in which currently we are facing major issues in mental health and the care of older people with long term conditions?

Antonio Gramsci’s (1971) archetypal theory of the intellectual may also be illuminative and raises questions about what we are here for. Gramsci described two types of intellectual: the ‘traditional’ and the ‘organic’. The traditional is the academic who secures the status quo and the organic as the activist whose function it was to ‘construct a transformative historical bloc’, an alternative basis of consent for social order (Cresswell and Spandler 2012 p4). Although written many decades ago, this archetype may well be seen within the corporate university which supports and encourages the traditional and ignores the activist.

Nursing, and nurse academics, have a question to address. Are we engaged in the development of a practice based discipline interested only in the ‘sorting out of facts and the disagreements of facts?’ Are we traditional and/or organic academics? Is there room for both, either as separate individuals or as two roles within the same person? Justification for the ‘discovery of facts’ may be founded on its usefulness for policy and clinical practice and of course should be foundational knowledge for clinical nursing practice, after all we do not want the wrong drug to be administered because we have not sorted out the ‘facts’.

However, empirical research does not take place within a political vacuum and it would be a mistake to see the relationship of research to policy and practice as a simple linear relationship. The purist model of ‘research-policy relationships’ which takes for granted that research informs policy action by generating knowledge, or the problem solving model whereby research is driven by the need for a policy answer, do not adequately describe the process and is a far too narrow a focus for scholarship. It just does not address some of the fundamental questions underpinning human health and well-being which are as much to do with human agency and social structures within certain political economies, as to do with biomedical processes.

Research and policy then is a political activity. Wright Mills in arguing for craftsmanship in intellectual life implicitly acknowledges in the Sociological Imagination the need to go beyond simple empirical knowledge in forming policy action when he enjoins social scientists in a political and intellectual task to clarify the contemporary causes of “uneasiness and indifference to personal troubles and public issues” (p13). The social scientist is not to merely describe the contemporary elements of social life, but to engage in it.

The use of the word ‘craft’, undefined by Mills, appears here to differentiate the activity from that of (mere?) mastery of elaborate discussions of research method and ‘theory-in-general’, which would quickly make one “impatient and weary” (p195). A craft suggests development of skill by diligent constant practice, honing one’s technique by reference to finished products and products in the process of being to evaluate their flaws and strengths and then adjust accordingly. This is reflexive practice in that the work as it continues is being constantly worked and reworked as required. It suggests leaps of imagination and intuitive thinking and practice in the creation of a project. It calls for a departure from strict adherence to a rigid structure of routines, methods and frameworks. It also suggests a measure of artistry in thinking.

The scholarly craftsman is his work as his craft develops alongside who he is. Scholarly craftsmanship then is a state of being not only doing:

When Wright Mills argued that:

“admirable thinkers…do not split their work from their lives” (p195), he also argued

“Scholarship is a choice of how to live as well as a choice of career” (p196).

And:

“Scholarship is writing”.

To undertake this craft he asked students and social scientists to keep a journal to enable the development of the intellectual life, of the craftsmanship of social science. This should consist of ideas, personal notes, excerpts from books, bibliographical items and outlines of projects. He suggests that journals should record ‘fringe thoughts’, snatches of conversation and even dreams. This will also include the taking of copious notes from books and this needs developing into a habit.

Since Wright Mills outlined notes on journal keeping there has been the explosion onto the scene of information technologies, elearning and web 2.0. These are now new tools that were unavailable to Wright Mills. However the essential nature of scholarly activity should not be lost in any infatuation with new technologies, rather these gateway technologies could facilitate critical enquiry, journal keeping and the connection of a community of philosopher scholars engaged in dissensus and critique through a process of what Paolo Freire called dialogics.

To assist in this process, scholars need to write, and to write essays or blogs and not just research reports; to engage in discussion and not just to tell; write to invite commentary, to clarify one’s thoughts, to learn about oneself as well as to explore ideas and investigate one’s area of interest. Nursing is a socio-political activity and not just an applied set of techniques; and as such requires critique, understanding, discussion, reflexivity and transformation. The corporate university may not be interested in these ‘outcomes’, fixated as it may be on contracted commissioning targets, workforce development, league tables, SPQ results, attrition rates and ill defined notions of the ‘student experience’. The early career nursing academic will be faced by a host of external constraints on their intellectual development and their ‘success’ or performance development reviews may rest on targets and values not of their own making. What may be ignored by ‘impact metrics’ is any of their writing, which is createdover and above the research ‘write up’ focused on answering an empirical question according to a matrix of methodological imperatives. Graham Scambler (2014), as a now retired academic,  makes the point that he benefitted from the freedom to engage in intellectual activity unchained from the demand s of the Corporate University chasing its position in league tables:

“I was rarely during my career forced onto the back-foot, obliged to define achievement in terms of research revenue generated or publications in high-impact journals.”

And…

“I have encountered several ‘young’ sociologists whose expertise by far exceeds mine and who have played significant roles in facilitating as well as contributing to virtual networking and innovation but whose pioneering expertise in social media remain institutionally unrecognized and unrewarded” (my emphasis).

 

Karl Marx, C Wright Mills, Antonio Gramsci, Paulo Freire, Pierre Bourdieu, Michael Burawoy,  recognized that intellectuals can play a crucial role in ideological warfare against the dominant classes. The Paraversity may assist in this by creating

 

“havens of thinking into which thinkers can migrate and from which thoughts can proliferate and social change can reify” (Žižek 2008).

 


 

What might the Paraversity begin to look like?

 

The examples below are not definitive, it is up to the community of scholars to construct the Paraversity and if it is based on dissensus, it may look very different and take on a dynamic nature. If the idea is to create dialogue, to share ideas, to critique, to go beyond the physical confines of the Corporate University, the web 2.0 technologies might assist in this process.

 

1. Social Science and Nursing

2. Graham Scambler

4. Benny Goodman’s blog

5. Researchgate

6. Academia.edu

7. Facebook

8. Twitter

 

The links above will provide examples of critical thought and the sharing of ideas accessible by anyone anywhere and at anytime. They provide platforms for commentary and feedback, both synchronously and asynchronously. Their credibility may be built upon already established reputations and research outputs and/or by the clarity and force of the arguments. They will stand or fall by the readership wanting to engage and share and the commitment and enthusiasm by the creator.

 

Conclusion

 

Human health and wellbeing depend on many things. Critical education and challenging taken for granted assumptions are part of the foundations for human progress, if we still believe in progress. Universities may not provide the fertile soil for critical enquiry and discourse, but we do not have to wait for this to occur. We can right now live in the ruins of the University and engage in scholarship that is subversive, critical and potentially engaging and do so in the full knowledge that traditional rewards and recognition may not be forthcoming. That makes it risky. That also makes it fun.

References

Brock T (2014) What is the function of the Social Movement Academic? The Sociological Imagination. http://sociologicalimagination.org/archives/15545

 

Burawoy, M. (2004) Public Sociologies: Contradictions, Dilemmas and Possibilities. Social Forces, 82(4), 1603-1618.

 

Cresswell M. and Spandler H. (2012) The Engaged Academic: Academic Intellectuals and the Psychiatric Survivor Movement, Social Movement Studies DOI:10.1080/14742837.2012.696821.

 

Docherty T (2014) Austerity canard stymies funding debate. THES. July 7th  http://www.timeshighereducation.co.uk/story.aspx?storyCode=2014367

 

Goodman B (2013) What are nurse academics for? Intellectual craftsmanship in an age of instrumentalism. Nurse Education Today 33: 87-89

 

Gramsci, A. (1971) Selections from the Prison Notebooks. Lawrence and Wishart. London

 

Mason, P. 2012 The graduates of 2012 will survive only in the cracks of our economy. The ‘Graduate without a future’ series. http://www.guardian.co.uk/commentisfree/2012/jul/01/graduates-2012-survive-in-cracks-economy

 

Orr D. (2004) Earth in Mind. On Education, Environment, and the Human Prospect. Island Press, Washington.

 

Rolfe G (2013) The University in Dissent. Routledge. London

 

Readings B (1996) The University in Ruins. Harvard University Press. Cambridge. MA.

 

Scambler, G. (2014) A 100th Blog: A reflexive interlude.http://www.grahamscambler.com/a-100th-blog-a-reflexive-interlude/#respond

 

Standing, G. (2011) The Precariat: the new dangerous class. Bloomsbury. London

 

Sterling S (2001). Sustainable Education – Revisioning Learning and Change, Schumacher Briefings 6. Green Books, Dartington.

 

Vare P (2014) Sustainability Literacy: role or goal? (online) http://arts.brighton.ac.uk/__data/assets/pdf_file/0010/6202/Sustainability-Literacy-Blewitt-and-Vare.pdf in Stibbe A (2014) Handbook of Sustainability Literacy http://arts.brighton.ac.uk/stibbe-handbook-of-sustainability

 

Wright Mills C (1959) The Sociological Imagination. 40th Edition. Oxford University Press  Oxford.

 

Zizek S (2008) Violence. Profile. London.

 

The personal is political; care in an age of spectacle.

Are we really surprised that the BBC’s  Panorama has again uncovered  poor quality care and abuse in a home for older people?

We know the roots of this, and I have previously argued that this is a political game. This is also personal because, and this point has been made many times  before, I will be old one day and may well require care. Therefore I do not want to be treated like sh*t as a resident on the Panorama  film stated. It happens because the care sector is undervalued, invisible, ‘women’s work’ and it is thought by some  that it can be done by those with little training, poor supervision, risible pay, poor patient ratios, no professional development and inadequate management.

Individuals will of course be blamed and sacked citing ‘accountability’ as if it is the holy grail of quality care and patient safety.

What to do? The first is to recognise that this personal trouble is a political issue and nurses are front line staff in the trenches. In the UK for far too long nurses have been reluctant to use union power to address these fundamental issues. Yet, just when we need it, union membership across all employment sectors have dropped as workforces became more docile in the face of deregulated labour markets. Faced with the ‘flexibility’ requirements demanded by employers, resulting in the growth of zero hours contracts, part time working, minimum wages as targets rather than base lines, workers have become more pliable generally. Nursing, being a gendered occupation with its emphasis on self sacrifice and care, has historically shied away from exercising any worker power while simultaneously picking up the crumbs from the medics table (doing their ‘skilled’ tasks for nowhere near the pay) and now bowing to the control of their work as dictated by management.

In California, in the US, nurses are joining Unions and have a staffing ratio law of 5:1 for med/surg, 2:1 for ICU, and Psych 6:1 meaning five patients with 1 nurse. CA AB394 came about by the CA Nurses Association to implement their RN Staffing Ratio Law. William Whetstone (Professor of Nursing California State University)  states “Staff nurses were sick and tired of being abused, putting up with crappy workloads, incompetent nurse administrators and managers, and on and on. I can remember when I did staff nursing dealing with a patient load of 10 to 12 patients with no thought to their acuity. As a result, CA became the first state through the effort of the CA Nurses Association to establish RN-to-patient ratios. The law was successfully implemented January 1, 2004”.

Is this an increasing phenomenon? Are we finally seeing a backlash against the dominant political hegemony that does not want to pay for care? We can study this until forever, but that fact remains – care costs. It costs a lot, requires skill and adequate ratios.

In California it seems nurses have had enough, got organised and agitated for change. They have looked beyond the representations of nurses as caring angels and seen themselves as the exploited.  They have plucked the imaginary flowers from their chains and acted.

Consumer capitalism would not want this happen because care is seen, in this context, as a cost to be born not by society but by individuals and families. Consumer capitalism instead wants to fill our heads with distractions and representations using the ‘spectacle’.

News and other media constantly feed us representations of the world that actually do not exist; they are constructed for news and or as entertainment. Panorama falls into that trap because it represents poor care in a particular way and is unable to drill down to the root causes. The TV itself is a medium of the representation of actuality and can lull us in to classifying the poor care we see as almost entertainment; the lines between truth and  fantasy become blurred.

 

“In societies where modern conditions of production prevail, life is presented as an immense accumulation of spectacles. Everything that was directly lived has receded into a representation” (Debord 1967).

Consumer capitalism has ripped the citizen role from the heart of nursing and replaced it with consumerism in which we are presented daily with ‘the spectacle’ – representations of reality that are without form or substance but which service to make sacred the profane. The spectacle specifically aimed at women include the array of women’s magazines which preach that you can never too thin or that your breasts require surgical enhancement; thus are we distracted about what is truly real by a false representation, within care employment contexts that are precarious, undervalued and invisible. Feminists know this, critical theorists know this, those with a sociological imagination know this, many women actually feel the cognitive dissonace that this engenders. In California,  nurses have acted as citizens, able to see pass the distractions for long enough to see exploitation as it really is. In the UK those nurses who can see the reality, need to the support to take charge of care in this country.

Ordinary citizens need to organise their frustrations and anger over health and social care and cohere into a viable opposition. Unfortunately UKIP are currently presenting another false representation with the spectacle of Nigel Farage presented as an ‘ordinary bloke’ that nearly 30% of the electorate are falling for.

We saw a spectacle of poor care again last night, lets not allow it to become entertainment for its shock value, lets instead urge action by all of us to provide the care older people deserve.

 

Care quality in the NHS

.”‘When…only one man is unemployed, that is his personal trouble, and for its relief we look to the character of the man, his skills and his immediate opportunities. When…15 million…are unemployed, that is an issue, and we may not hope to find the solution within the range of opportunities open to any one individual. The very structure of opportunities has collapsed. Both the correct statement of the problem and the range of possible solutions require us to consider the economic and political institutions of society and not merely the personal situation and character of a scatter of individuals’. (p9). (C Wright Mills – The Sociological Imagination).

….today we hear about the safeguarding tragedy that was Daniel Pelka. Again, communication issues between agencies and the failure to act have been highlighted. His parents are in jail. If only one social worker failed then we should look to the character of that social worker. When we have a historical record of failures which all highlight communication issues and failures to act, we will not find solutions only in the failings of individuals, the socio-cultural systems itself fails. The correct statement of the problem and the the range of possible solutions require us to consider the economic, social, cultural and political institutions of society.

….we have heard about the care failings that was Mid Staffs. Again, neglect and abuse of frail elderly patients were highlighted. If only one healthcare professional or manager failed, then we should look to the character of that professional. When we have a historical record of failures which all highlight neglect and abuse, we will not find solutions only in the failings of individuals, the socio-cultural system itself fails. The correct statement of the problem and the the range of possible solutions require us to consider the economic, social, cultural and political institutions of society and not just the striking off professionals from registers.

Sir Brian Jarman stated in a recent Lancet article:

“To improve the quality of care in UK hospitals, I would reintroduce the Independent Review Panels and Community Health Councils and develop monthly complaints alerts similar to the mortality alerts. Regulation would be more independent if the CQC reported in public to Parliament, and there would be better communication if it were integrated with Monitor. Additionally, it is important to ensure  there are minimum staff-to-patient levels of doctors and nurses, with 65% trained nurses and  regulation of health-care assistants (my emphasis). I would aim for

total physicians per head of population at the EU average. Ideally I would also like to see training  introduced for the boards of trusts and for them to
have equal representation of patients, clinicians,  finance, and managers. There has been a decade  of concerns about the quality of care in our
hospitals: patients have been ignored, the  regulatory systems have failed, and there has been a culture of denial”.Instead we get the mess that is the Health and Social Act which is supposedly a ‘reform‘, and the NMC engaging in ‘re-validation’.

When will we learn that inspection and revalidation are external post hoc care quality issues, there is of course a place for these processes but there is a need to ensure the quality of care is structurally built into care delivery systems – and that means ensuring that you have enough staff, enough of the right sort of staff, educate and support them and engage in continuing professional development, appraisal and performance management if necessary.