This blog is based on an article in the Journal of Social Policy. Click here to read the open access article.
A historical perspective is important for understanding many things and this is particularly true when it comes to grasping healthcare scandals and healthcare policy. When we look back in time with the right tools, we can identify social processes that have been, and are still, exerting an influence on healthcare practices, institutions and policies. In our paper, we present a framework for analysing how long-term socio-political changes shape the social construction of scandals and their impacts.
We illustrate our framework though the 2013 Mid-Staffordshire scandal over poor care in the English NHS, which has cast a long shadow on health policy in the UK. Seeking to make sense of this calamity, and the appalling suffering it brought about, other scholars have explored the extent to which institutional failures stem from recent directions in healthcare governance and related financial pressures. One may also inquire whether the scandal exposed a lack of compassion in parts of the English NHS – or interrogate whether compassion is the right frame to think about this scandal. Questions such as these are undoubtedly insightful. However, they face an important limitation: their focus on the very recent past. In our paper, we put forth a different way of asking questions that, we argue, opens up fresh analytical vistas: one that focuses on long-term social processes that bear importantly on the social construction of scandals.
Our approach combines a sensitivity to shifts in face-to-face interactions and wider circles of emotional concern over long periods of time. In this sense we follow process sociologists such as Nobert Elias, Cas Wouters and Abram de Swaan. Our framework also considers long-term developments in the possibilities for public debate amid the warping effects of power, institutional logics and financial constraints – insights we take from Jürgen Habermas’s work. This allows us to identify social processes that, though relevant for understanding the social construction and impact of scandals, remain out of sight if we focus only on the immediate past.
We highlight three areas where the influence of long-term societal changes and processes bear especially strongly on healthcare policy-making:
a) Changing formats of social relations and emotions within and around care provision.
Growing proximity between social groups and reducing hierarchy and formality in social relations have gradually contributed to changes in norms of what constitutes good care. The nature and scope of this change can be appreciated if we look back to the NHS’s inception in 1948. First-hand accounts of doctors working in geriatric care in the NHS suggest that what would be considered as highly deficient neglect by today’s standards was common practice in the 1950s. In contrast, in the 2010s the public has come to expect compassion from healthcare professionals. At the same time, however, growing inequality in England since 1980 has been associated with ‘outsider’ groups becoming more distanced and disregarded in various welfare state settings.
b) Heightened organisational and political sensitivity to failings.
Less asymmetric healthcare hierarchies render care professionals and welfare state organisations more accountable and, in many cases, more responsive to patients and the public than was the case in the 1960s. Historical accounts of the early NHS denote a rather different way in which concerns of poor care were handled. Complaints about long-term care for older people were sometimes contested, then dismissed by investigating committees. In contrast, claims made by patients, carers, professionals and others are more likely to be heard today — not least thanks to reducing power asymmetries and by the normalisation of inquiries, which has played an important role in amplifying and refashioning care scandals. And yet, various institutional logics addressing these claims can lapse into managing reputational risk, therefore stifling organisational learning and effective change.
c) Changes in media reporting on healthcare failings, as well as in policy-makers’ responsiveness to and manipulation of media.
The heightened accountability pressures facing welfare state organisations have rendered governments and policy-makers increasingly sensitive to media reporting and the related reputational risk. Shifts in how media coverage operates has increased collective willingness to allocate blame and take action. In turn, governments have become increasingly skilled and organised in managing and deflecting media criticism: for example, in working with cases of failure to politicise concerns and mobilise support for certain forms of change.
Whereas a short-term lens can lead to invocations of “decadent narratives” whereby worsening manifestations of bureaucracy undermine care, a long-term historical perspective reminds us that this is not the first time claims regarding poor care have been heard. The image of an NHS in decline acquires a different significance when we reflect how steep an incline the NHS has climbed since its inception. A gradual diminishing in professional power in relation to patients leads to interactions and patterns of care which are more susceptible to breaking down in a context where patients’ concerns are more likely to reach the public domain. Taken together, these trends may be making healthcare scandals more possible and more common than before, even if care norms and standards have actually improved. If so, then this represents a potential threat to effective and evidence-based policy-making (as noted by Martin Lodge and Chris Hood among others).
Reconsidering social problems by looking at them from a different angle can be a source of inspiration for finding policy solutions. Locating current problems in a longer-term historical context is one useful strategy in this regard. Adopting a long-term perspective does not lead us to relativize the suffering involved in these scandals, or to a Whiggish version of history. Nor are long-term perspectives a substitute for short-term analysis. Rather, they can enrich a social policy scholar’s toolkit, for example by informing how we evaluate social problems. Further research is needed to interrogate in more depth the different features of our framework, and we hope to see more historically-oriented social policy studies inspired by process sociology. We hope our work may contribute towards a more balanced relationship between more present-centred policy analyses and longer-term approaches.
An ‘Eliasian trilogy’
The article we summarise above is the third publication of a longer-term collaboration reconsidering health care in light of perspectives drawing on the work of Norbert Elias.
Flores, R. and Brown, P. (2018) The changing place of care and compassion within the English NHS: an Eliasean perspective. Social Theory and Health 16(2):156-171.
Brown, P. and Flores, R. (2018) The informalisation of professional–patient interactions and the consequences for regulation in the United Kingdom, in J.M. Chamberlain; M. Dent and M. Saks (eds.) Professional Health Regulation in the Public Interest, Bristol: Policy Press; pp. 39-60.
About the authors
Patrick Brown is Associate Professor in the Department of Sociology at the University of Amsterdam and director of the Political Sociology research group.
Rubén Flores is a Visiting Scholar at University College Dublin (School of Sociology) and at Maynooth University (Department of Sociology), as well as a Fellow of the Norbert Elias Foundation.
Andy Alaszewski is Emeritus Professor of Health Studies at the University of Kent at Canterbury and Founding Editor of Health, Risk and Society.
We are indebted to the enthusiastic Eliasians of Amsterdam and Dublin who have educated and inspired us in equal measure; not least Bart van Heerikhuizen, Rineke van Daalen, Stephen Mennell, Steven Loyal and Barbara Gornicka. We also take this chance to congratulate Jürgen Habermas on his recent 90th birthday!