It is clear that one cannot conceive of a system of health care that does not involve
the delivery of care. The practical tasks such systems deliver are diverse and range
from the mundane, day-to-day and routine to the unusual, ‘high tech’ and singular.
Consider, for example, the following examples: getting people out of bed, washing
them, providing food, ensuring medicines are taken at the correct time and dose, providing
physiotherapy or rehabilitation services, monitoring life signs, conducting tests
(urine, blood, radiographic etc.), providing vaccinations or intravenous infusions,
undertaking internal examinations, conducting operations and transplanting organs.
All can be considered examples of patient ‘care’ and we might, therefore, wonder how
to define care such that it is applicable to this range of activities. We might think
of ‘care’ as a secondary and normative quality of first order tasks or substantive
practices. Whether done badly or well, getting someone up in the morning or providing
a program of rehabilitation is to provide care. However when it is done well it is
done with care. It is this sense of care that is of primary interest, and something that is
present in Tronto’s suggestion that “[c]are is both a practice and a dispositionâ€
3]. In her view we should only refer to care when both are present. Thus, the nurse
who washes patients in an uncaring manner does not provide care in the fullest possible
sense, even though such activities can be considered as care simpliciter.
Tronto and Fisher define care as:
[A] species of activity that includes everything that we do to maintain, continue,
and repair our ‘world’ so that we can live in it as well as possible 3],4]e.
So defined, care is a disposition to ‘living well’ that can be expressed in almost
all activities. As such care almost always occurs as part of other activities. Whilst
some activities instantiate care alone as in, for example, a parent who comforts their
child when they have grazed their knee or a spouse who reassures their partner before
their first day in a new job. Even so, these caring acts can be considered as actions
being done with care. This being the case there is clearly an ethical and normative
dimension to care. We might connect this to the sociological fact that a profession
instantiates an ethics or, better, an ethic5],6]. A professional is someone who has made a moral commitment to their clients, someone
who places the interests of their clients above their own. When considered alongside
the concept of a professional ethics, Tronto’s notion of care makes explicit the double
normativity of the caring professions. As a recent (2014) World Nursing Day slogan
put it: “Nursing is my skill; Caring is my professionâ€. There is a normative dimension
to the intersubjective practice of care-giving as well as in the more ‘skills focused’
formal ethics of the caring professions, and these dimensions may not be aligned in
all cases. Health care professionals do not simply ‘profess’ their training or expertise;
they profess to care. This should not be read in the sense that they say they care but in the sense that they pursue their profession as a means of caring.
The slogan speaks to the moral motivation, both initial and ongoing, of those who
join the caring professions. As Tronto puts it “caring is not so much about the activities
of care, but about the emotional investment that has been made in order to care†3]f.
Given such a perspective we might consider the question of how these ideals – those
of individual professionals, of professions as social institutions, and of the philosophical
characterization of care – connect with the realities of practice and the practical
delivery of care. First, we might note that they often do not. Recent failures in
NHS care been extensively documented but are not necessarily a new phenomenon 7]. In the 1960’s Menzies Lyth’s seminal article ‘Social systems as a defense against
anxiety: An empirical study of the nursing service of a general hospital’ articulated
the difficulties inherent in care as an everyday occupation, and the consequences
for its social organization 8]g. In her work Lyth details some of the emotional challenges that arise within the
practice of nursing – intimate contact with strangers, the uncertainty of recovery,
the distress associated with chronic illness – and how a task-based, rather than patient
centered division of labor provide for a degree of organizational defense or structural
distance.
More recently Mol has analyzed what she calls the ‘logic of care’ 1]h. As an aspect of the logic of practice, care always co-exists with other – sometimes
competing or incommensurable – logics 9]. Part of Mol’s purpose is to contrast the ‘logic of care’ with the ‘logic of choice’
and to examine their uneasy relationship 1]. However, she also suggests the logic of care co-exists with “neglect and errorsâ€,
things that are, unfortunately, ineliminable parts of everyday life 1]i. Mol’s analysis suggests that ‘care’ cannot be used to define what is ‘good’, ‘better’
or ‘worse’, at least, not outwith the logic of care, i.e. the actual practice(s) of
health care 1]. ‘The good’ is defined within such practices and what care is, is the situated pursuit of ‘the good’ according to the contextually relevant logic(s).
Care is part of the situated pursuit of the good, it is part of this species of activity.
Attempts to define the good (or what constitutes care in a particular instance) cannot
“precede practice, but form a part of it†1]. Thus, “[t]he good is something to do, in practice, as care goes on†10] and the practices of care “entail a specific modality of handling questions to do with the good†10].
This view might be taken as being in conflict with the fact that Tronto does define
care. However, her suggestion is that we consider care to be “a species of activity
that includes everything that we do to maintain, continue, and repair our ‘world’
so that we can live in it as well as possible†3]. In this view good care or, we might say, quality care is marked by “persistent tinkering in a world full of complex ambivalence and
shifting tensions†10]. Her definition of care suggests that what care is needs to be determined in practice and according to context. However, in recent times
the notion of ‘quality’ and not simply ‘good’ care has become politically significant
and embedded in the governance of modern health care. In contrast to the idea of an
object’s ‘property’ (or, to use the philosophical term, its predicates) – but like care – the notion of an object’s quality is (like the notion of ‘care’) inherently normative. Contemporary use of the word
‘quality’ in the context of care assumes that we can sensibly talk about quality in
the abstract. This is misguided. If a discussion of quality is to be useful it must
refer to particular historically and socio-culturally situated practices. A definition
of quality, independent of such context, is next to useless. Arguably, then, a concern
for the ‘Quality of Care’ can be taken to be a concern for a level of excellence in
health and social care. Concern for the standard(s) of practice has been translated
into concern for not just the assessment, audit and evaluation of those standards,
but a particular form or approach to ‘quality assurance’. In practice any attempt
to conduct ‘quality assurance’ assessments will be embedded in specific managerial
and bureaucratic processesj. Such processes are the primary mode through which health care is evaluated and governed,
rendering them subject to public and political scrutiny. As a consequence these processes have reflexive implications for the social
organization of practice, a point we discuss further below. They also require some
kind of ‘operational’ definition: whilst the notion of care resists definition, Quality of Care cannot.
What we might take Quality of Care to mean is open to contestation and debate. It
resists simple a priori definition and is always in need of contextual operationalization. Insofar as particular
contexts are comparable, or have common (social or structural) features, such as those
contexts within which various health care practices are to be found, Quality of Care
has been afforded a certain degree of characterization. Goldenberg considers attempts
to provide such characterization a ‘catalogue approach’, the main virtue of which
is that it “helpfully provides at least some guidance for policy and allocation purposesâ€
11]. However, she argues that the various traits and characteristics that are catalogued
for the purposes of defining Quality of Care are not accompanied by a detailed justification.
Instead they are understood to be aligned with the prevailing “norms and values currently
guiding (ideal) health care practice†11].
Goldenberg’s broader argument is that this ‘catalogue’ approach means that Quality
of Care is ‘persuasively’, and therefore politically, defined. Such definitions are predicated on the surrounding discourses through which
they derive constitutive meaning, the discourses of public management, bureaucracy,
and governance being particularly influential. In providing a ‘headline’ definition
of Quality of Care these discourses must also provide for a level of flexibility in
order that the existing variety of services can be evaluated. As such, any definition
of Quality of Care is useful not because of the detail it provides but because that
detail reflects the emotive, evaluative or rhetorical content of the term. If a definition
is to be useful it will leave the rhetorical or political aspects of the term intact 11]. However, whilst any attempt to define ‘Quality of Care’ will contain ambiguous elements
and whilst it will always remain possible to object to particular, ‘catalogued’, details,
it is nevertheless the case that general claims about the importance of ‘quality care’
will remain difficult to resist. Consequently the management and governance of health
care will continue to need and rely on ‘Quality of Care’ discourses. The idea of Quality of Care has a political function, one that can be used to engender the formation of social movement(s) and
promote change. However the idea also aligns with the socio-political context of contemporary
governance, the management of public services and with the specific ‘organizational
format’ of its associated bureaucracyk.
In the context of health care, ideas about Quality of Care can be placed in the service
of a variety of ends, not all of them compatible with each other. For example, we
might think Quality of Care governance acts to improve care itself or acts as a device
that mitigates political accountability by institutionalizing a bureaucratized form
of managerial accountability. In so doing ministers are afforded a degree of protection
since although they remain answerable they are no longer directly accountable 12]. If we think political accountability is important then, as Nelson remarks, “obscurities
concerning the notion of ‘quality of care’ are not matters about which we can afford
to be insouciant†13]. We might then conclude that the obscurities we should be concerned with are not
simply internal but also relate to the broader political role of the notion and its
institutionalization. A definition offered by Goldenberg is useful precisely because
it highlights the potential for internal and external conflicts, the variation in
situated understanding, and the perspectival contestations inherent in the meaning
of Quality of Care. She says that:
Quality of care refers to the attributes of a health care service that are taken by
the relevant stakeholders to be important enough to be measured and promoted within
an organization 11].
With deliberate irony, Goldenberg goes on to suggest that this is “the kind of definition
that should not be entertained in the health quality assurance literature†because:
it offers “no logical room for dissentâ€; it avoids “all potential points of disagreement
by taking no position on whether the term refers to process or outcome, property or
evaluationâ€; it does not imply any “potentially controversial position on the content
or context of quality careâ€; and the vacuity of this “descriptive meaning [means that
a wide variety of meanings or interpretations] can be carefully attached to the term
by savvy policy makers†11]. Whilst we agree with Goldenberg that the flexibility of this definition is deeply
problematic in practical or political terms it is nevertheless particularly useful
for the purposes of critical analysis of Quality of Care discourses and the practices
that are meant to ensure it. The analytic utility of this definition lies in its potential
to highlight the fact that the ability to what is important enough to be measured
and promoted within particular contexts is politically determined; it is a function of power. In more Bourdieuan terms it is a function of ones position
in the field – and therefore the dispositions and capitals that correlate with this
position – all of which provides those in such positions with the ability to impose
their perspective via encoding it in the evaluative procedures of ‘quality assurance’.
A corollary of this is that Goldenberg’s definition also highlights who or what is
subordinated to these measures and therefore, the perspectives that are neglected.
From a socio-analytic perspective the flexibility and contextual utility suggested
by Goldenberg’s definition is not a flaw: it reflects the reality of Quality of Care
discourse.
Rather than taking this to undermine Quality of Care and the bureaucratic processes
that seek to assure it, we might accept it as an unavoidable consequence of the modern
management and governance of health care. Thus rather than question ‘Quality of Care’
per se we might offer more specific critiques that focus on its use, and the effects of
its use, within particular contexts. Goldenberg’s discussion makes clear that we should
not conflate the delivery of care with processes or procedures to ensure its quality
and that both can be distinguished from the theorization of care offered by feminist
ethics, something that should not be mistaken for a singular or fully unified project
14]. Furthermore, whilst the social organization of health care can, and sometimes does,
militate against the caring dispositions of professionals 8], it would be facile to suggest that any and all bureaucratic procedures or managerial
processes should be abandoned because of this; a lack of proper managerial oversight
will also lead to failures in care. Even when a professionally endorsed procedure
becomes the target of criticism, such as in the case of recent controversy about the
Liverpool Care Pathway (LPC), there is no argument that a commonality of approach
is, in itself, undesirable 15].
What is required is a more sophisticated understanding of the relationship between
the front-line practices of care and the way(s) in which they are managed. We must
consider the material and social impact of particular rules, guidelines or management
structures that act to condition and recondition professional practices. This consideration
should go beyond explicitly stated aims and objectives to encompass the broader consequences
or practical effects of the policy. Like any form of surveillance the collection of
data in the context of ‘New Public Management’ (cf. 16]) is subject to Merton’s ‘law of unintended consequences’ 17]. It is particularly important to consider the collection of ‘Quality of Care’ data
and the relationship between this activity and the actual delivery of care. The assumption
underpinning such data collection is that it can proceed in such a way as to leave
the practice it intends to evaluate untouched. However, consider reported attempts
to ‘massage’ or otherwise manipulate records concerning treatment times at NHS Accident
and Emergency Departments 18],19]. Recording the time it takes for patients to receive attention does not leave practice
untouched when front-line staff have been made aware, that: 1) particular waiting
times are acceptable and others are not; and 2) waiting times will be determined in
a particular way. From an ‘audit culture’ perspective the collection of data about
a particular practice has tangible and immediate effects 20]; it is fallacious and potentially harmful to dichotomize frontline practice and the
managerial structures that command, control and facilitate it. Rather, we should reflect
critically on the nature of the picture being constructed by such data and, in so
doing, attempt to develop an account of the relationship between practice and the
management of practice, or between care and Quality of Care, that will facilitate
a more fruitful – mutually engaging and enlightening – dialogue, one that engages
in the holistic promotion of the caring endeavor.
To conclude this section, whilst the moral or normative sense of care resists easy
definition, and this resistance has consequences for our assessment of health care,
the need to define ‘Quality of Care’ is unavoidable; it is required if we are to properly
govern and organize our health care services. Given this state of affairs we should
remain alive to the potential for misalignment and conflict between, on the one hand,
professional practices and delivery of care and, on the other, the management of those
activities at both the meso and macro levels.
The unintended consequences of bureaucracy
In his classic article, ‘The Tyranny of Light’, Tsoukas 21] argues that the pursuit of information can undermine, rather than enhance, our knowledge
of a particular practice. The supposed objectivity of administrative and bureaucratic
records, the instruments of governance, has brought about the dissolution of perspective
and allowed an increase in ‘data’ to be mistaken for an increase in insight and understanding.
Tsoukas identifies two problematic assumptions: first, that information increases
the transparency with which we understand some object; second, that such information
can be used to control or (re)engineer that object. Against these assumptions he argues
that the logic of governance dictates: “that which is measurable, standardizable,
auditable is measured…[such measurements come]… to stand for, to represent, the phenomenon at
hand†21]. The implication is that what is not measurable, standardizable, auditable is not
measured and so cannot be taken as standing for, as representing, the phenomenon at
hand. This is not simply a facet of the ‘objective’ and ‘subjective’ aspects of the
target domain; it is certainly possible (although may not necessarily be desirable)
to subject the latter to forms of standardized assessment (cf. 22],23]). Rather it is about the nature of bureaucratic representations and the degree to
which they can be considered as ‘standing for’ the object, or phenomenon represented.
Tsoukas offers a particularly apposite example:
[T]he quality of teaching (an inherently ambiguous notion) tends to be formally ascertained
by the quality of the procedures that are thought to lead to good teaching. Procedural
ideals of performance represent (and thus reconstruct) our understanding of quality.
Notice, however that, as mentioned earlier, ‘quality in teaching’ is nowhere to be
seen in the information gathered – it rather needs to be inferred from it 21].
Accounts of ‘Quality of Care’ and the administrative procedures – which is to say
bureaucracies – constituted to assess it are similarly and inherently ambiguous. Quality
of Care is formally ascertained by the quality of the procedures that are thought
to lead to or reflect the delivery of good care as it is inferred from the information
gathered by and about these proceduresl. The information is generated by managerial, administrative and bureaucratic procedures.
These procedures shed light on (but do not simply reflect) specific aspects of practice:
those that can be codified and therefore recorded. Other aspects are not only left
in the shadows but are actively pushed into the shadows as a result of the light being
castm. This can be most clearly seen if we consider the reflexive consequences of audit
as a mode of management, evaluation and assurance or control 20]. Once something – or somethings – become an indicator of performance then those whose performance is being assessed
often come to focus on the indicator(s) altering the way in which they accomplish
the practice as a whole. For example, it has been suggested that education has become
overly focused on ‘teaching to the test’. In health care we have attempts to manipulate,
or otherwise circumnavigate, the collection of information used to assess the Quality
of Care. More subtly, procedures put in place to support the collection of data relevant
to the Quality and Outcomes Framework in general practice, such as structured electronic
templates for chronic disease management, have been shown to profoundly influence
and shape the conduct and meaning of chronic disease reviews 24]. The fact the practices of governance have reflexive consequences for the practices
being governed demonstrates the second of Tsoukas’ points. If social practices are
affected by attempts to audit them then the picture generated is not only a poor representation
of practice (at the very least the data is often out of date) but the assumed primary
virtue of this information, its decontextualized nature, is undermined. If the reflexivity
of the social world means that it reacts to our attempts to represent it then our
ability to govern on the basis of ‘objective’ information is questionable. Bureaucratic
records, the levers of governance, do not produce, or ‘archive’, collections of disinterested
facts, or archives of neutral measurements. On the contrary, they are the inscriptions
of a studied, and practiced, disinterest.
This suggestion opens the door to a number of well-rehearsed critiques of bureaucratic
managerialism. In the hands of some this has led to calls to bring the rule of ‘the
bureaux’o to an end and predictions of a ‘post-bureaucratic’ era 25]. However, like du Gay 25], we do not consider ‘bureaucracy’ to be a singular phenomena but a “diversely formatted
organizational device†(2005:1, 3). It, and paperwork more generally 26], can be considered an ineliminable technique in the conduct and organization of contemporary social life, particularly the social
life of institutions. It is a technology and one that structures the social world(s)
we inhabit. The idea of a bureaucracy cannot be considered good or bad in itself, and therefore we should, in each case, consider the inherently normative character
of its socially structuring function and the potential moral implications – both intended
and unintended – of that structure. As such the idea of a ‘bureaucracy’ cannot be
subject to any simply moral evaluation, tempting as it is. Instead we might consider
particular instantiations to be morally problematic, particularly those that can be
described as overly bureaucratic. A bureaucratic bureaucracy embodies “an instrumental rationality through which technical questions
become split from ethical and aesthetic ones†27].
As Kafka suggests “[w]e tend to condemn bureaucracy and bureaucrats when better explanations
elude us†26]. At the very least we ought to look for better or, perhaps, fuller explanations before
denunciating such an easy target. We should consider the way Quality of Care bureaucracies
are constituted and, subsequently, practiced or ‘put into practice’. Which is to say
that we should consider the way Quality of Care procedures are implemented, how the data produced is evaluated, and how these evaluations are subsequently utilized. Furthermore, we should be prepared to do so in an ongoing manner. One might start
with the idea that health care practices and the care they deliver are subject to a set of managerial process that are overly reliant on
a form of bureaucratic rationality. Such rationality deploys a set of techniques for
the ‘disinterested’ (see below for further discussion of this term) objectification
of practice. Insofar as the social organization of health care is a prerequisite for
the delivery and promotion of good care and the identification of substandard care
such objectification has a good deal to offer. However, bureaucratically rational
frameworks can also structure practice in such a way that the provision of excellent
care is discouraged. The objectification of practice is reductive as the focus is
not on ‘care’ – the intersubjective interplay between those who care and those who
are cared for – per se but on measure of Care Quality. Certainly the reduction is, to a degree, a necessary
and unavoidable consequence of bureaucratic objectification. Nevertheless the objectification
of care has, at minimum, the potential to structurally disincentivize the delivery
of health care with care. Using the Bourdieu’s notion of symbolic violence the next section explores this
possibly further.
Bureaucracy and the potential for symbolic violence
Given it is a socio-historically variable phenomena or, as du Gay has it “a many-sided,
evolving, diversified organizational device†25], no singular conception of bureaucracy can be entirely adequate. If we are to extend
our analysis of the disjunction between care and Quality of Care, some greater specification
is needed. Furthermore given that this organizational device is variable, ineliminable
and cannot be subject to a blanket moral disapproval then we can only seek to subject
it to socio-analysis and critiquep. Using the critical potential offered by Bourdieu’s notion of symbolic violence this
section offers a characterization of the particular bureaucracy involved in the organization,
management and governance of UK health care 28].
As Clarke 29] points out the political landscape of the UK is such that the associated bureaucracies
of its government have been fundamentally (re)configured by the ideology of ‘New Public
Management.’ A consequence has been the development of evaluative processes and bodies,
including the Care Quality Commission, which attempts to ensure or assure (through
a process of evaluation) high quality care. These evaluative institutions are a significant
development in modern government’s audit culture and central to the UK’s current ‘arms-length’
approach to the delivery and management of public services 29]. This approach to accountability in the public service sector suggests that bodies
– such as the CQC – are something more than evaluators of the Quality of Care; they are regulators. Given this role we should acknowledge that the process of evaluation – and not simply
its results – are effective in shaping practice. As institutions are required to actively
produce the data required by regulators, managers and practitioners become aware of
the data’s symbolic meaning. Furthermore, the CQC is granted the authority to audit and evaluate the
delivery of care and, in so doing, to ‘operationalize’ and apply the (politically)
working definition of ‘Quality of Care’.
The exercise of authority involves the exercise of what Bourdieu calls symbolic power
and, therefore, an inherent asymmetry. However, we should not assume that the existence
of such asymmetry is necessarily problematic; the existence of symbolic power and
its variable distribution is a fact of social life. Indeed, in this context, it is
important to recognize that “the structural and symbolic power wielded by doctors
is legitimate, socially conferred and indispensible for help and healing to occurâ€
30] and we might think similarly for the management and governance of health care. Furthermore,
once we have recognized the operations of symbolic power then we might concern ourselves
with the way it is being exercised and reflect on whether or not its use can be characterized
as involving ‘violence’ or domination. Given its connection to language and knowledge
31] we cannot escape it and we should, pace Foucault’s conception of power more generally,
see it as a productive phenomena. Nevertheless, as a form of power, there is the potential
for repression as well as production and we should therefore attend to the possibility
of what Bourdieu calls ‘symbolic violence’q.
The notion of symbolic violence might seem unduly provocative. However we are not
suggesting that Quality of Care bureaucracies are, in fact, symbolically violent.
Rather we are suggesting that, whether physical or symbolic, the exercise of power
always has the potential for violence – it is always possible for our activities to involve the domination of others. Our view diverges from the
Bourdieuan orthodoxy, which would appear to suggest that symbolic violence, and not
just symbolic power, can be both legitimate and illegitimate. For example, Bourdieu
appears to consider pedagogy as always involving symbolic violence 32]. However given that pedagogy is unavoidable, particularly insofar as tacit pedagogy
is implicated in human social development (socialization), then it would seem violence
is unavoidable. Such a position means that we must discern ‘good’ and ‘bad’ forms
of violence. Instead we think that we should distinguish between good and bad forms
of symbolic power and consider the latter to be symbolic violence. Thus we prefer
to consider education as involving the exercise of symbolic power. As such it is not
necessarily violent but may dominate rather than emancipate. Similarly Quality of
Care bureaucracies necessarily involve the exercise of symbolic power. The challenge
is to ensure we consider the way this power can be legitimately exercised, in the
interest of whatever ‘good’ is at hand (in this case the good of care), and to remain
alive to the possibility that it might become ‘violent’, illegitimate, and act against
the good at hand (which, in this case, would involve the structural domination of
health care professionals and the practice of care).
Expanding on Goldenberg’s view of the importance of ‘relevant stakeholders’ 11] we can see Quality of Care discourses are not only constructed by distinguishing
between who is, and is not, considered a relevant stakeholder and, subsequently, by differentiating between those who are least relevant and those who are most relevant. The consequences of such distinctions will fundamentally alter the Quality of Care
discourse and those with the symbolic capital to make, and enforce, such distinctions
will dominate the Quality of Care discourse. In this way a particular point of view
will be encoded within the symbolic processes and used to evaluate the actual practices
of health and social care. Furthermore, in order to enquire into the Quality of Care
in specific instances it is inevitable that a bureaucracy procedure will be used and
will, therefore, impose a pre-existing and pre-constructed perspective on the practices
being evaluated. Through the collection of ‘objective’ (or ‘objectified’) data in
accordance with a particular symbolic structure an administrative, or symbolic, representation
of the practice will be produced.
Thus, what we know about the Quality of Care, both ‘in theory’ and ‘in practice’ can
be seen as part of a struggle over ‘methodology’. A Quality of Care methodology is
not simply neutral and objective but productive and world-making;r it brings something new into existence, namely a declaration regarding the quality of the care being delivered. Given that this evaluation (both its results and its
implementation) is designed to have a regulatory function then it should be considered
a significant locus of symbolic power. Audits are contemporary technologies of evaluation
and should be considered part and parcel of the field(s) they render accountable.
This is precisely because as forms of bureaucracy, as organizational devices, institutionalized
audits act in such as way as to engender ‘audit-ability’. Whether or not it is considered
‘successful’ the attempt to exert control runs counter to the narrative of an audit
or evaluation as objective, as leaving that which is audited or evaluated untouched.
The institutionalization of an audit culture entails a (re)configuration of the field
such that it can be audited and is therefore “easier to regulate in the name of qualityâ€
33],34]. The difficulty posed is similar to that raised by Law in his analysis of social
science research methods:
“The argument is no longer that methods discover and depict realities. Instead, it is that they participate in the enactment of those realities. It is also that method is not just a more or less complicated
set of procedures or rules, but rather a bundled hinterland†35]s.
The CQC is part of a ‘bundled hinterland’ and its distance is, in part, created by
the methodologies of audit, something that requires what Herzfeld calls ‘bureaucratic
indifference’ 34],36] and Bourdieu would call (bureaucratic) disinterest37]t. However, in creating a space within which symbolic power can be exercised bureaucracy
becomes distanced from practice. This creates the potential for bureaucracies to not only “slip from
the model of reality to the reality of model†38] but for structurally embedded procedural imperatives to become privileged over the
ends of practice 39]. It is at this point that the potential for symbolic power to become problematic
emerges. The distance that the practice of disinterest creates generates the conditions
within which bureaucratic exercises can become symbolically violent and therefore
come to place structural constraints on the caring practices they are supposed to
promote.
This view accords with Strathern’s suggestion that “current practices of audit and
surveillance are far from ‘indifferent’; on the contrary they present the face of
obsessive concern (care/interference)†34]. The terminology of ‘obsessive concern’ and ‘interference’ is suggestive of intrusion,
violence and domination and, furthermore, the ability of audit to exert its influence
is predicated on its methodology, its ‘objectivity’, something that is not produced
through indifference simpliciter but through a studied and practiced indifference, or Bourdieu’s notion of disinterest. The posture of disinterest expresses a particular kind of interest, one that values
objectivity, which is to say a form of symbolic neutrality and is, therefore, a function of an underlying symbolic capital and power. It is
through the adoption of a disinterested stance that audits (auditors and those who promote the audit as a style of evaluation, management and
quality control/ assurance) purport to care. This is assumed to be necessary because such
disinterest produces an ‘objective’ or, more accurately, ‘objectified’ picture of
health care. This is held to be the first step in a process of ‘continuous improvement’
or ‘total quality management’. Bodies like the CQC are invested with the political
authority to name, categorize, pronounce judgment and determine social reality – the
‘facts’ of the matter – precisely because they appear to express a disinterested form
of interest, they appear to be objective 32]u. However, symbolic domination is not merely a function of these pronouncements but
of the way those judged anticipate and respond to these pronouncements and the way
in which they are produced. Bourdieu and Boltanski suggest that:
“Symbolic domination really begins when the misrecognition (meconnaissance) implied by recognition (reconnaissance) leads those who are dominated to apply the dominant criteria of evaluation to their
own practicesâ€.
(40], cited in 41] authors translation).
In the case of Quality of Care audits or evaluations one should not simply blame those
who are dominated for their own domination. However, they are ‘complicit’ in the way
that the supposed measures of Quality have become reiterated – recognized and misrecognized – as targetsv. This slippage is, in part, a function of the law of unintended consequences, but
one that has come to be embedded in the logic of New Public Management; what was once
a systemic problem, and an organization vice, has been turned into a managerial strategy,
and an organizational virtuew. Quality of Care evaluations have come to have priority in the actual delivery of
care and therefore methodological indicators – measures – of care quality come to
be seen as targets – substantive facts about care quality. The actual practice(s)
of health care have become subordinated to ‘Quality of Care’ and, rather than being
responsive to patients, professionals are increasingly required to respond to the
imperatives of the evaluative bureaucracy invested with the symbolic power to pass
judgment. The violent exercise of symbolic power is essential to the development and
maintenance of this dynamic; it is a consequence of allowing a form of bureaucracy
to become a management style, the function of which is predicated on having the symbolic
capital required to monopolize, which is to say dominate, the process. This all but guarantees that the exercise of symbolic power will entail
symbolic violence and that frontline practices are subject to the symbolic domination
by the organizational mode meant to facilitate it.