At the BSA’s Medical Sociology Group conference in York this year the ‘Cost of Living’ group (@Cost_ofLiving) organized a symposium to address the coalition government’s attack on the National Health Service (NHS) in England. It was a privilege, if a disconcerting one, to listen to Allyson Pollock’s update. Her narrative confirmed just how far the re-commodification of health care has gone and how vital it is that we maintain a never-say-die rearguard action against the combination of the Health and Social Care Act and its progeny, ‘regulation 75’. It was my task (a) to offer support for her stance, and (b) to provide a sociological commentary.
Under cover of a rhetoric designed to appease the electorate the Health and Social Care Bill promised a number of innovations, e.g. the abolition of GP-led primary care trusts in favour of GP-led commissioning consortia; that these consortia would control 80% of the NHS budget; that services would be purchased from any willing provider; that all NHS hospitals would become foundation trusts; that the commissioning process would be overseen by Monitor; that patient choice would be improved; and that efficiency savings would be made. Critics immediately asked: why would commissioning consortia work better than ‘commissioning’ primary care trusts?; what would be the role of private companies in relation to commissioning criteria?; how would be the position of Monitor regarding EU law?; how would patients have ‘more choice’?; where would putative ‘efficiency saving’ come from?; and would any savings be made at the expense of quality?
The Bill was not, as many supposed a cock-up, but rather a strategic step towards US-style for-profit health care. Lansley’s original Bill was constructed over a long time period of time in opposition and in consultation with leading international providers in the private sector. It was policy-based evidence’s perfect storm. It defied a pre-election Tory undertaking not to indulge in a top-down reform of the NHS; ran counter to every instinct a Lib Dem MP might and was expected to have; therefore had no democratic mandate; and was opposed, the polls indicated, by health professionals and public alike.
But what is the sociological story here? I start from John Major’s 1992 innovation: the Private Finance Initiative (PFI). Blair and Brown trumped Major on PFIs. A plus for government accounts (the private sector put up the money), PFIs were nevertheless the very antithesis of ‘value for money’ and were destined to be a drain on trusts’ incomes for decades to come. By the close of New Labour’s period in office the PFI chickens had come home to roost, just as Allyson Pollock and her team had predicted from the outset. And this on top of a call for massive savings in NHS expenditure in the wake of the financial crisis of 2008-9, and with the Health and Social Care Bill waiting in the wings. Many of us who publicly contested Lansley’s original Bill despaired at the failure of health professionals to strangle it at birth. The inaction, especially of the medical profession, has been variously attributed to supine or self-interested leadership, political naivety or opportunism.
In my York contribution I offered a frame for a sociological analysis of this extraordinary attack on the public sector in general and the NHS in particular on the part of the post-2010 coalition regime. Key to this frame is the transition to financial capitalism, preceding Thatcher’s election in 1979 by a few years but very much to her liking. This is best characterised in terms of its novel class/command dynamic. Landes has averred that those with money invariably purchase those with power. In financial capitalism, a hard core of rentiers, CEOs and Directors of large companies and, most conspicuously, financiers get more for their investment in the power elite of the state than in the organized or welfare capitalism of the postwar era – this in part explains the appeal of public sector investment on the part of the private sector. Together, these proprietors of capital on the one hand and power on the other, can be said to comprise a governing oligarchy.
Members of this oligarchy are wholly oriented to outcomes; in Habermas’ terms, they are unremittingly and self-confidently strategic or instrumental (as one financier confessed: ‘we don’t do morals’). I have elsewhere drawn on Maggie Archer’s analyses of reflexivity to label them ‘focused autonomous reflexives’. Central to this characterisation is the assertion that they manifest total commitment to their chosen ends. Furthermore they also demonstrate a Nietzschian instinct – ‘him (more rarely her) or me’ – to go for the jugular. They are driven by a neoliberal fundamentalist ideology that brooks no competition or compromise. This is coupled to a sense of cognitive insurance where no room is left for self-question or doubt. All of this is accomplished within a narrow field of tunnel vision, where pursuit of their goals is all that matters. Lastly, they ‘enjoy’ lifeworld detatchment in that others, typically women, assume responsibility for supplying all those day-to-day needs they see as peripheral to the business of ‘working’ capital and power.
It follows that resistance on the part of those of the 99%+ not hanging profitably onto the coat tails of the governing oligarchy is tricky; and so it has proved. Capital and power are not yielded without struggle. And notwithstanding the global financial crisis of 2008/9, and even the naked instrumentalism of the governing oligarchy, no legitimation crisis is yet in sight. So there is urgent need for a sociology of resistance. In this regard, Castells’ recent account of ‘networked social movements’ may offer a way forward. Given the ubiquity of neo-liberal ideology in financial capitalism and the ‘Thatcherite’ decimation of trades unions and allied postwar organs of rebellion, new modes of resistance are indicated and being pioneered. They share certain properties. Drawing from the work of Castells, they are ‘networks of networks’; with de-centred structures, with multiple nodes. They utilise horizontal rather than vertical leadership structures, in the process challenging conceptions of leadership. They are actively democratic, travelling from outrage to hope via processes of deliberation. In terms of action, they favour civil disobedience over violence, they are reflexive, but rarely programmatic, and they live in the moment while remaining open to alternate possible futures. Lastly, they aspire to be ‘viral’, global and accessible across conventional boundaries. The limited, experimental nature of this way of improvising resistance in financial capitalism is part and parcel of any sociological explanation of the passage of the Health and Social Care Bill.
But sociology’s input into understanding and explanation is, not enough. Taking my cue from Burawoy’s discernment of ‘four sociologies’, and his welcome advocacy of a ‘pubic sociology’, I went on to advocate additional new forms of sociology, namely action sociology, and foresight sociology. In a previous ‘Cost of Living’ blog the Scamblers argued that the sociological project neither logically nor morally allows for acquiescence or a reigned shrugging of shoulders when best evidence is ignored or flouted. It is a project beyond satisfying the university managers and the REF or it is nothing. Sociology must ally itself with the new modes of resistance in financial capitalism.
The concept of foresight sociology underlines sociologists’ obligation to research and develop alternative models for the optimal future organization of our institutions and affairs. If the commodified health care system now being introduced under the NHS ‘brand’ is seriously flawed – and it unequivocally is – then what should replace it? Action sociology, needs to be allied to modes of resistance but in ways that permit foresight sociology to develop viable alternatives. The more negatively oriented critique needs to be replaced with more positively oriented alternatives, based on more imaginative, evidence-based outputs.
I am not making a case here for the sociological community to turn its attention en masse to action and foresight sociology. Nor am I in any sense downgrading professional, policy, critical or public sociology; on the contrary. But I am suggesting that – logically and morally – action and foresight sociology are very much part of the sociological project, and that they have to date been neglected theoretically and substantively.
The coalition’s assault on the NHS is a scandal that Allyson Pollock and others have sought to expose and remedy. That we have been relatively ineffective, whilst inviting pessimism of the intellect, must not diminish optimism of the will (a core massage from Allyson at York). The need for further engagement is pressing. At the time of writing, as former New Labour guru and boss of the biggest US health company, Simon Stevens, takes over at the helm of NHS England, the narrative is one of an on-the-surface omnishambles hiding a beneath-the-surface structural shift advantaging the governing oligarchy and the privileged even as it disadvantages the rest of us. Already, £11bn has found its way to private providers.