The rise of the citizen-consumer: implications for public service professionalism.
John Clarke and Janet Newman
Faculty of Social Sciences
The Open University
(Paper for Changing Teacher Roles, Identities and Professionalism seminar, King’s
College London, 19 October 2005)
This paper draws on a research project on the relationship between images of citizens
as consumers and the reform of public services in the UK.1 This consumerist
orientation has raised a variety of political and academic controversies: about ‘choice’
and the organisation of public services; about the changing character of the public;
about the relationships between public services and those who use them; and about
public service professions and their relationships to managers and users.
Most of these elements are explored in other publications arising from the project,
and here we will be concentrating on issues about public service professionalism. But
we want to address one critical issue about the politics of public service reform before
turning to the more specific focus on consumerism and public service professionalism.
New Labour has made the ‘consumer’ a central figure in its approach to public service
reform. The consumer, in New Labour terms, marks a distinctive shift in British
society: a move from a ‘rationing culture’ to a ‘consumer culture’ (Office of Public
Service Reform, 2002). This is a shift that requires the modernisation of public services
to shed their ‘rationing culture’ birthmarks and fit them for a consumer culture
population’s experiences and expectations. This model and process of reform is clearly
fraught with tensions. Indeed, New Labour clearly experience the process as a difficult
struggle, practically and rhetorically (Blair’s ‘scars on my back’ resulted from efforts
to reform recalcitrant public services).
Much of the debate around consumerism and public services has treated the consumer
as a political or ideological invention: a front for neo-liberalism or new forms of
governmentality (Clarke, forthcoming). In contrast, we have argued that New Labour’s
consumerism draws on and combines several different political-cultural currents, even
Creating Citizen-Consumers: Changing Identifications and Relationships was funded
as part of the ESRC/AHRC Cultures of Consumption research programme between
March 2003 and May 2005 (Grant Number RES-143-25-0008). The project also included
Nick Smith, Elizabeth Vidler and Louise Westmarland and was based in the Department
of Social Policy at the Open University. We studied three public services: health,
policing and social care in two different locations (Oldtown and Newtown) and
involved service managers, front line staff and users of the services. More details
about the study can be found at www.open.ac.uk/socialsciences/citizenconsumers.
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as it tries to organise them in a neo-liberal way (Clarke, 2004; 2005). New Labour
articulates multiple anti-statist and anti-professional tendencies, including:
1. varieties of user and social movements around welfare policies and practices;
2. varieties of ‘demotic’ populism that have made the ‘voice of ordinary people’
more valued (from the greater role of ‘public opinion’ to ‘lay experts’ to the
Daily Mail);
3. varieties of ‘consuming’ practices and identities (from ‘conspicuous’ to
‘ethical’ consumption).
These have been selectively appropriated by New Labour, and organised around a neoliberal conception of public services as a field of conflict between Producer and
Consumer interests. This model, derived from Public Choice theory, underpins a
concern with how to discipline, control or restrain Producer interests in the absence of
‘market forces’. But New Labour is never simply neo-liberal. While their solutions for
public service reform might centre on choice, mixed economies, marketisation (or
quasi-marketisation), they are rarely singular. They often include demands for
processes of participation and consultation; and for processes of collaboration as well
as competition.
In what follows, we want to insist that ‘the public’ represents a problematic subject
for public services and their reform (Newman, 2005a). It resists attempts at disaggregation and individualization. It is shape-shifting, unstable and unpredictable. It
embodies conflicting or ambivalent desires and doubts. Keeping this problematic
public in mind, as we shall try to do in what follows, disrupts some of the conventional
arguments about public service reform.
In this paper we focus on the implications of this ‘consumerist’ moment for public
service professionalism, trying to draw out both some of the specific dynamics of the
three services in our study and some of the common tendencies. In doing so, we think
it is important to keep in mind the multiple pressures that bear on public services in
the present, rather than wanting to pull out and privilege one particular dynamic or
set of forces. Such approaches may produce clearer narratives of change, but at the
expense of underestimating the complexity and unevenness of contemporary change.
Our study suggests that the many pressures around public service professionalism
come to bear on – and are condensed in – what we have called the ‘knowledge-power
knot’. In this we follow Foucault in seeing the intimate, and mutually productive,
relationship between forms of knowledge and modes of power. Professionalism’s claim
to distinctive forms of expertise seems to us to be an exemplary instance of the
knowledge-power relationship `(and indeed many Foucauldian studies operate
precisely on this terrain of professionally organised knowledge and the modes of power
organised in and through it). Our terminology here – linking knowledge and power in
the image of a knot – is intended to convey a more tangled view of multiple threads,
rather than a simple, stable and singular relationship between knowledge and power.
In particular, we intend to draw attention to the ways in which multiple knowledges
(or forms of knowledge) contend the dominant professional institutionalization in most
areas of public service. We might put this crudely: people no longer believe – or are
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willing to accede to – the proposition that ‘professionals know best’.2 In the process
both the situational and wider social authority enjoyed by professionals (even public
service professionals) has become more fragile or contingent.
In exploring these issues and their implications for public service professionalism we
have used the framing device of a diamond:
Fig 1: Framing the knowledge/power knot.
Governmental
Occupational
Organizational
Public
The vertical axis (governmental- public) locates two of the primary sources of
pressures or forces acting on professionals. Governments articulate views of reform;
identify lines of social development; lay claim to particular conceptions of the public
and how it is changing; and – of course – develop and administer policies for public
services. The double meaning of ‘representation’ is central to thinking about this axis.
On the one hand, governments are constructed through the processes of
representative democracy (they have to engage in the business of electoral
calculation, positioning etc). On the other, they are engaged in the symbolic work of
representing themselves as the public’s representatives. This involves constituting the
public and themselves as particular types of social actor. In the case of public service,
both Conservative and `Labour Governments have announced themselves as the
‘People’s Champions’ against the Producer Interest.
At the other end of this axis, the public is also a complex entity. It is an ‘imaginary
unity’ with which (some) people identify: in our study, many people who used public
services identified themselves as ‘members of the public’ (rather than citizens or
consumers, for example,). But the public is also a highly differentiated entity –
traversed by systems of inequality and differentiation that have been profoundly
consequential for the politics, policies and practices of public services.
The narrative of the ‘decline of deference’ highlights important shifts in
institutional relationships, but is too readily aligned with one of those binary From/To
versions of history that only take place in ‘sociological time’. We see no reason to
think that deference was real, rather than performed, and that its decline, therefore,
can be thought of as a loosening of the pressures to be compliant.
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The horizontal axis relates more directly to the sites of professional formation in
public services. Public service professionalism is formed at the conjunction of
occupational and organizational dynamics (Johnson, 1973, on mediating professions).
Each profession has distinctive occupational characteristics (resulting from training
and both formal and informal modes of occupational socialization) and takes place in
particular organizational locations. The forms taken vary substantially – medicine is
clearly different from policing and social work – but all public service professions are
characterised by this mix of occupational and organisational dimensions, pointing to
Mintzberg’s conception of ‘bureau-professional organizations’ (Clarke and Newman,
1997). These occupational-organizational formations have been subject to different
sorts of pressures for change during the last twenty years – specific policy changes, the
redefinition of the occupational dimensions (the contested changes in recruitment,
training and career development, for example) and the ‘redesign’ of the
organizational setting (in the rise of managerialism, especially, see Clarke and
Newman, 1997). Managerialism involved an attempt to construct a new ‘settlement’
along this organizational-occupational axis.
The moderniser’s tale:
One way of using the diamond is to trace the official story: a changing public (one that
has become used to the experiences of a consumer society) is represented by a
government that seeks to modernise public services to fit this ‘modern British people’
(Clarke and Newman, 1998; 2004). In the process it reworks the relationships between
government and service providing organizations – through policy, regulation and
programmes of institutional redesign (from mixed economies, markets, targets and
inspection – the battery of performance management). Such organizations emerge as
high performing, responsive, customer/consumer- focussed agencies. Both
organizations and government have acted on occupational formations to make them
more representative and more responsive to this ‘modern’ public.
Fig 2: The modernisation narrative.
Governmental
modernising
Occupational
Organizational
Representative/responsive
High performing
Public
Demanding
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In this official story line, the key issue remains how to bring organizations and their
staff into alignment with the new public. As we suggested above, we do not see this as
a simple political fiction. Multiple changes and challenges have unsettled the supposed
fit between the public and public services. However, we do doubt that these
disruptions can be made sense of and reconciled in terms of consumerism.
Instead, we want to consider what other stories might be told about the elements of
this diamond, the relationships between them and their impact on the knowledgepower knots at the core of public service professionalism. In what ways are they
becoming unravelled or more tangled? We will consider three different aspects of this
field: first, the dominant imperatives at each of the points; second, the relationships
along each of the sides of the diamond; and third the vertical and horizontal axial
relationships.
Desperately seeking solutions?
If we consider the logics that shape each of the four points, we might sketch three
relatively clear concerns for the governmental, organizational and occupational
imperatives. In doing so we can see some of the characteristic strains and potential
disjunctures that make the governance of public service a field of political difficulty.
When we turn to the fourth point we might see how those difficulties are deepened by
a complex and unpredictable public. But first, governmental imperatives: we can treat
these as a mixture of political and governmental calculation. In the case of New
Labour, a commitment to ‘modernising’; public services has typically meant a search
for a new ‘organisational settlement’ based on fragmented and dispersed systems of
providing services organised horizontally through competition or ‘quasi-competition’
(league tables, etc) and organised vertically through principal-agent models of target
setting and expanded scrutiny systems (Clarke 2004b). This governmental imperative
(the challenge of aligning public services with a neo-liberal globalism) is never simple –
in part because the ‘levers’ used to manage public service have often proved to be
only ‘loosely coupled’ to changed outcomes. Such imperatives are also cross-cut by
problems of political calculation – a tension that we discuss more fully below.
Organizational imperatives are increasingly framed by their positioning in these
horizontal and vertical relationships, such that they become ‘success’ focused
(Schram, 2002). In managerial terms, they strive to become ‘high performance’
organisations, since increasingly both material and symbolic resources are tied to
performance. This does not mean that they are simply ‘implementers’ of government
policy – the spaces involved in ‘arm’s length’ regulation allow the possibility of local
translation and adaptation (Newman, 2005b). But policy goals are inflected, the
management of performance (or at least the management of the representations of
performance) is a key element in the organizational culture of public service provision
(Clarke, 2004b). But note that success is to be established ion the face of competing
and possibly contradictory ‘targets’ (Newman, 2001).
This directs attention inwards to the management of resources – especially the human
resources of the organization. But it also means attention to the environment:
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competitors, collaborators, the symbolic environment of the organization (e.g., the
news that NHS trusts are now monitoring media reportage) And, of course, they face
the problem of managing their consumers/customers/users. Here one key objective is
to stabilise their unsettled relationships with the public. These range from what to do
with unpredictable and excess demand; dealing with different forms of acquiescence
and assertiveness; to managing modes of access and interaction.
And finally, in our study senior managers were preoccupied with the challenge of how
to match demand and resources (Vidler and Clarke, 2005). Managing expectations (and
thus reducing some sorts of demand) was combined with processes of prioritising some
demands over others. In policing, such processes focused on what sorts of policing (the
popular demand for ‘bobbies on the beat’ having to compete with more focused
interventions against burglary, drug use, etc. that were the objects of government
targets and sources of public agitation). In health care, priority setting happens in
national, regional; and local forms – as well as in the front line management of patient
expectations and needs. In social care, organisations were engaged in managing
expectations; in the difficult combination of constant prioritisation against budgets;
and in means-testing for user contributions (social care is distinctive in our study for
having elements of a cash nexus, where both health care and policing are ‘free at the
point of use’).
For occupations, we would emphasise two dominant imperatives – or at least the
imperatives that command attention once the continued existence of the occupation
has been secured (and public service professions have varied in their vulnerability to
diminution and expansion). Autonomy has remained one critical focus of concern,
whether this is the space of ‘clinical judgement’ for doctors or the discretion built
into the ‘office of the constable’. Most studies of managerialisation in public services
have pointed to the attempts to control, constrain and diminish the sites and forms of
professional autonomy. Evaluations of the success of managerialism’s impact on public
service professionalism vary (e.g.,Exworthy and Halford, 1999; Kirkpatrick, Ackroyd
and Walker, 2004).
But we also want to stress the importance of legitimacy for public service occupations.
The challenges to public services have called into question to the ‘public service
ethos’ but it remains a focal point both for public service workers and for the users of
public services. Rather than the specific task or labour process, it is the ethos that is
claimed to mark the ‘difference’ of public services. Despite the decline in deference
and the rise of mis-trust, public service professionals tend to command a relatively
high degree of public trust and confidence in surveys (especially by contrast with other
occupations that sometimes claim the ‘public interest’ defence – politicians and
journalists, for example). But legitimacy now appears more fragile and more
contextually contingent, rather than being available ‘en bloc’ to a public service
organization or occupation. As a result, the exercise of authority has become more
problematic – the consent of those subjected to professional authority is more
explicitly at issue in the encounters between the public and public services. In the
process, ‘negotiating’ skills and strategies have come to the fore in both organisations
and occupational formations (Newman and Nutley, 2003).
The question of legitimacy is most obviously an issue for the relationships between
public service occupations and the public, but it also has what we might call ‘internal’
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aspects. These involve the plausibility and desirability of the stories that the
occupation can tell to itself – and even how individuals can account for their own
working lives to themselves and others. This touches on some of the ‘ethical’ issues
raised in Alan Cribb’s paper to this seminar. How we make sense of, and give accounts
for, what we do may involve ethical concerns – and public service occupations have
both laid claim to the ‘ethos’ and struggled to make sense of its decline or
degradation in recent decades.
These different concerns and objectives are summarised in Figure 3.
Fig 3: Competing Concerns.
Governmental
New organizational settlement
Occupational
Organizational
Autonomy/legitimacy
‘success’
Public
Satisfaction?
Of course, the most problematic element in this figure is the Public. ‘Satisfaction’ may
mean many different things in shaping people’s relationship to public services. It may
include ‘customer satisfaction’ – which has been and remains a focus of governmental
and organizational attention as a measure of performance (The Office for Public
Service Reform is currently working on a universal measure of customer satisfaction
for public services). But satisfaction may mean a complex of other things – the
satisfactory resolution of a problematic condition; the satisfaction of being taken
seriously; the appreciation of well-conducted processes; the sensibility of being a
‘member of the public’ – part of a collective identity that is being served (rather than
an individualised consumer). People who use services in our study combine a concern
for their own needs and desires with a complex understanding that public services
have other calls on their attention and resources and a view that – at times – other
people’s needs and problems may be more pressing than their own. This is a key
element of what we have called ‘relational reasoning’ about public services (Clarke,
2005b). The complexity of people’s relationship to public services suggests that the
idea of satisfaction at least deserves the question mark that accompanies it in figure
3.
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Dynamic Duos: unsettled relationships.
We now turn to the unsettled relationships formed on each of the sides of the
diamond. The governmental-organizational dynamic might be said to centre around
the question of ‘who represents the public?’ In processes of public service reform, the
government has consistently claimed to act as the ‘People’s Champions’, pursuing
better quality public services through a variety of means. But organizations are not
merely the passive vehicle for government action. They may inflect or interpret policy
directions to fit with organizational, managerial or local predispositions. In the
process, they are likely to draw on other representations of the public – or at least
those sections of the public who use the service. Being ‘closer to the customer’ is an
alternative source of legitimacy – particularly where such closeness is institutionalised
in the form of participation or consultation processes. ‘Local knowledge’ – more
accurately, knowledge about the locality – is significant for the formation of
organizational plans or strategies, but is also rhetorically vital for constructing
‘wriggle room’ in relation to central government and its apparatuses of control.
Both central and local representations of the public lay claim to being the product of
transparent (and truthful) processes of knowledge production, from the ballot box to
surveys to participation exercises (e.g., Have Your Say for the NHS). Nevertheless, the
public remains a troublesome collective entity in a number of ways (Newman, 2005a).
Its membership is uncertain (how does anyone get to be a ‘member of the public’?). It
may be constituted out of many different publics, counter-publics and sub-publics –
and may be highly mobile as a result (Warner, 2002). It is fractioned in many different
ways in attempts to identify the key variables or distinctions that account for
differences of interest, expectation or opinion (ranging from socio-demographic
factors through to marketing derived life style categorizations). It is continually
sampled, surveyed and evoked in public/political discourse.
For the relationship between organizations and the public, this uncertainty is
expressed as a dynamic of unpredictability around the question ‘who knows what the
public wants?’ Organizations have an interest in two aspects of this issue. First, they
have an interest in maximising their knowledge of what the public want, both to
organize services, and to use the knowledge as leverage with central government.
Secondly, they have an interest – in terms of managing resources and performance – in
trying to stabilise their encounters with the public. Our interviews with managers are
rich in concepts of ‘reasonable’, ‘responsible’ and ‘informed’ users of their services –
where are an emphasis is placed on making the public manageable. Similarly, an early
New Labour enthusiasm for defining ‘choice’ as a choice of ways of accessing public
services (Cabinet Office, 1999) has given way to efforts to ‘incentivise’ the public to
use the route most convenient to the organization (often through electronic means).
The problem here is that ‘the public’ combines predictability and unpredictability in
unpredictable ways. This mixture tends to outrun the modelling capacity of service
organizations. It is the new ‘common sense’ that public service users have shifted from
the deferential to the assertive; from the ignorant to the knowledgeable; from the
passive to the active voice – in short, from citizens to consumers. But such shifts are
profoundly uneven – they may be socially distributed (by class, by age or generation,
by ethnicity); but they may also be distributed experientially (shaped by involvement
in previous struggles or movements, for example). They may be distributed between
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different sorts of people; but people are themselves neither stable nor unitary in their
encounters with services. The same person may combine being a knowledgeable
expert of their own condition; a rights bearing and assertive citizen; an anxious
dependent and a seeker after professional help and advice across a series of
encounters with the health service. These are ‘unstable encounters’ (Clarke, 2004c) in
which the possibilities of getting it wrong have multiplied as both the public and
service organizations try to manage each other in more uncertain times.
The other line of relationship at stake here is between the public and public service
professionals. We can identify this as organised by the question of ‘who owns needs?’
Perhaps it would be more accurate to says ‘who owns the definition of needs?’ It is
here that the contested character of knowledge/power (or combinations of authority
and expertise) is most visible. Certainly in health and social care, the assumed
dominance/deference relationship has been disturbed by alternative claims to be
knowledgeable – the capacity to be ‘an expert of one’s own condition’. The extent to
which such claims are made – and the extent to which they are accepted or recognised
– remains highly variable. And it remains the case that, for many people, professional
expertise is highly valued. Though whether the desirability of expertise also means a
tolerance of professional authority (or paternalism) is more doubtful. This field of
relationships operates in a range from ‘collision to collusion’ (to borrow a delightful
phrase from Janine Wedel, 2001).
It will be clear that a whole range of governmental initiatives have played a part in
reconfiguring the professional-public relationships – disrupting the claims of
professional expertise and authority. ‘Choice’ – in both health and social care – is a
critical element in this, dislocating the professional control of assessment, evaluation
and specification (diagnosis and treatment) as an integrated structure of decisionmaking. While we might note that the mythology of professions always overstated the
integrated (and untainted) character of such decision-making, the rhetoric and
institutionalization of ‘choice’ is (and is intended to be) disruptive. ‘Choice’ as a
governmental agenda includes a belief that people can define their own needs (see,
for example, the Green Paper Independence, Choice, Wellbeing on adult social care in
England, DOH, 2005; Clarke, Smith and Vidler, forthcoming). In a number of ways, the
line of relationship between public service professionals and government can be
characterised as a tension around ‘who owns users?’ Both government and
professionals lay claim to be the ‘patient’s friend’ – with government serving the user
interest by challenging the knots of professional power; and professionals stressing
their place close the user that allows them to both serve and defend the user interest
(against a distant and intrusive government).
We have summarised the four lines of relationship in Fig 4. Each of them, we suggest,
remains the site of continuing (if low level) contestation and uncertainty.
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FIG 4: Contested relationships
Governmental
Who owns users?
Who represents the public?
Occupational
Organizational
Who owns needs?
Who knows the public’s wants?
Public
Lines of force:
In this section, we turn our attention to the axial lines of force that cut across the
diamond since these are critical to the contemporary dynamics of public services. The
first – the horizontal line linking the organizational and occupational dimensions of
public service professionalism – is well understood. It has been the focus of many
studies of public service managerialism since Pollitt’s path-breaking work (1993). It is
the site of struggles over the forms and limits of autonomy in the context of
increasingly managerialised organisations. The dominant organizational logic has been
to seek the subjection of professional autonomy to organizational goals, values and
missions (see also Julia Evett’s paper to this seminar). This does not necessarily mean
that organizations seek to erode the whole field of autonomous judgement – indeed,
most recognise the necessity of some degree of autonomy for the effective delivery of
the service. But the aim is to specify the limits of such autonomy in organisational
terms, rather than occupational ones. Autonomy in this view is that which is
functionally necessary to the organization’s goals, rather than being referenced to
some extra-organizational source (professional standards, ethos, regulation, etc). Such
external sources look like ‘narrow’ professional interests and produce ‘inflexibilities’
into the rationally ordered world of the organization. We will say little more about this
– except to characterise it as the struggle to ‘corporatise’ occupational cultures:
making them part of the organization, rather than tied to external orientations.
The vertical line of force has also had increasing visibility, much of which derives from
the increasing frequency of public opinion surveys about views of public service reform
and performance. We do not propose to engage in a detailed analysis of the methods
and issues of such surveying – but it is important to note that it is both a significant
governmental technology (in Foucault’s sense) and has proved to be a rather
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problematic technology in practice.3 What is at stake more generally is a problematic
relationship between the public and governmental representations of the public and
its interests. Since the late 1990s, New Labour has benefited from a strong public
desire for public services (and for their improvement after their perceived degradation
under Conservative rule). But the public’s relationship to the processes of
modernization and reform has been more ambivalent.
Our own study suggests a reluctance to identify as consumers or customers of public
services, with people preferring both ‘service specific’ identities (service user;
patient) and images of membership in collective entities (the public; local
communities). Table 1 below indicates how people selected within a range of
identifications on offer in a multiple choice list:
TABLE 1 Self Identifications (up to two choices per respondent)
Consumer
Customer
Patient
Service User
Citizen
Member of the Public
Member of the Local Community
3.9%
12.5%
29.7%
35.5%
13.2%
26.2%
40.9%
Elsewhere we have explored some of the implications of these identifications and the
ways in which they are embedded in relational understandings of public services
(Clarke, 2005b; Clarke and Newman, 2005). In this context, we want to note the
‘distance’ between political discourse about the character of the public and popular
understandings. The same ambivalence can be discerned in relation to the New
Labour’s favoured reform mechanism – choice. Choice is the focus of deep
ambivalence – where people believe it may improve services, but typically prefer
other mechanisms of reform or provision (if the choice is offered). Other papers from
the project have taken this issue up (Clarke and Smith, forthcoming; Clarke, Smith and
Vidler, forthcoming).
The public desire for public services (and their improvement) is not a single or simple
phenomenon. It mixes different sorts of motivations (individual and collective);
different orientations to need and services; different anxieties about personal and
social insecurities; and different conceptions of how people want services to be
delivered. But there are some dominant threads – a commitment to good quality,
readily accessible services; to being treated well by service providers (including the
negotiation of need and treatment/response); and conceptions of equity and
We might suggest that this is a general, if rather unregarded, feature of
governmental technologies, which may fail to achieve their intended objective, or may
create new governmental problems or difficulties. In this case, public opinion has
steadfastly refused to recognise New Labour claims of improvement in public services,
despite (a) performance ‘evidence’ and (b) rising levels of individual satisfaction with
many services. See, for example, Flynn ????
3
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publicness. Such threads are interwoven with a mix of anxieties (about the present
state of services and the adequacy of future resourcing); scepticism (about both the
direction and ‘delivery’ of governmental reforms); and doubt (about politicians,
politics and promises). This is a highly volatile (while strangely persistent) mixture –
and it poses both governmental and political problems for New Labour. Reform
programmes that do not ‘deliver’ (or are perceived not to deliver) are a governmental
problem (as new ‘levers’ are sought to enforce reform). They are also a political
problem – as New Labour seeks to sustain political dominance and popular support.
These issues of governmental strategy and political calculation are difficult ones –
both for New Labour and for anyone interested in policy analysis. There is a recurrent
risk of emphasising one at the expense of the other (such that New Labour either has a
‘grand design’ to make neo-liberalism come true or to privatise everything; or is at the
mercy of ever shifting public opinion…).
Knowledge-power knots: resistance, recalcitrance and tangles.
In this paper we have dealt with public service professionalism in relatively general
terms. But it is clear that the formations and trajectories of specific public service
professions differ greatly: in our study, the medical and related professions are
characterised by sets of tensions – and particular forms of knowledge/power knot –
that set them apart from the issues faced by police staff and social workers. All of
them have in common governmental and organizational efforts to constrain their scope
for autonomy (in part by organizational rules, or by job redefinition for these groups
and related occupations). All of them have to deal with shifting knowledges – about
needs, conditions and rights that interrupt the smooth combination of professional
expertise and professional authority. Equally, the organizations we have studied face
some of the same challenges – how to manage their interactions with the public; and
how to deal with government demands for performance, for greater
consumer/customer responsiveness and other initiatives (new partnerships; new
geographical boundaries) at the same time.
However, at the level of specific services, the particular tensions and tangles of the
knowledge/power knot become more visible. In our study we asked people how
comfortable they were about challenging providers of service (making complaints;
being demanding if they felt they were not being dealt with properly). We also asked
staff in the three services how comfortable they were being challenged by people
using the service. The results (represented as an index of readiness to challenge/be
challenged that is scaled between +100 and -100) are in Table 2:4
In a questionnaire, staff and users were asked to agree/disagree (on a 5 point scale)
with a series of statements about aspects of consumerism: challenge, choice,
inequality and responsibility. If all respondents responded very positively to all four
statements around challenge, the result would be +100.
4
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Table Two: Challenge
100
80
60
40
20
0
-20
-40
Health
Staff
Health Police Staff Police
User
User
Social Social
Care Staff Care User
-60
-80
-100
While the largest mis-match appears between police users and police staff, social care
users seem less willing to challenge staff than in other services (despite the apparent
readiness of social care staff to be challenged). Health users are slightly more willing
to challenge than health staff are to be challenged.
More broadly, we can sketch some of the particular forms taken by the current state
of the knowledge/power knot in the three services. In health care, the knowledge
problem is particularly visible around the figure of the ‘expert patient’. Ideally this
person is equipped with medical expertise and granted ‘regulated autonomy’ in the
management of her own condition. But other sources of expertise may interrupt this
transmission belt model (which sees knowledge being downloaded from doctor to
patient). The Internet and self-help groups, for example, circulate ‘unlicensed’
knowledge that enables other forms of ‘expert’. At the same time, the ‘choice’
agenda threatens to disrupt both organizational and occupational forms of control over
treatment processes (and the processes of priority setting and resource allocation that
are embedded in them). Nevertheless, such relatively restricted enactments of choice
may satisfy neither public/patient nor professional desires for effective treatment
relationships. These issues are explored more extensively in Kuhlmann and Newman
(forthcoming) and Newman and Vidler (2005).
In policing, the tensions and tangles appear to be rather different. Although police
services register a general pressure to be more ‘customer friendly’, the dominant
pressures are perceived to be about building new or better relationships with local
communities. Enmeshed in this are both internal and external dynamics – engaging
police staff in the process of new relationships (which implies challenging some deeply
established features of occupational or ‘canteen’ culture); and finding or constructing
the communities with whom the service can be involved. Both managers and front line
staff in the police see two linked problems about the relationship between knowledge
and power. First, policing is seen to depend upon the application of a specific
knowledge (the Law) in situations that may be contentious, conflictual or dangerous.
In such contexts, authority – embodied in the person of the Constable – needs to be
unchallenged. Secondly, the process of policing is seen to combine occupational and
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organizational knowledges in a way that renders it opaque to outsiders. How to police;
what to police; and what priorities are to be set are seen to be largely ‘internal’
knowledges, though the question of priorities involve intersections with governmental
demands. As a result, the problem for community ‘dialogue’ is how to construct a
community that understands enough of the ‘internal wisdom’ to take part in an
informed conversation. Some of these issues are explored more extensively in
Westmarland and Smith, 2004.
Finally, in social care we can see a number of contradictory tendencies that bear on
the knowledge/power knot. One of these concerns the less than solid or secure status
of social work as an occupation. For some time, social work has been subject to
processes of splitting (especially between work with children/families and vulnerable
adults); ‘dilution’ through the redefinition of many of its tasks as ‘care work’ rather
than ‘social work’; and towards organizational control (accelerating with the
organizational dispersal of social work). Our two social care departments revealed
very different occupational formations. Oldtown was centred on professional social
workers involved in processes of needs assessment, care plan construction and working
with particular users or groups of users. Domiciliary care services were almost entirely
contracted out. In contrast, Newtown was seen as displacing the professional social
worker in terms of building new systems and practices of care management (indeed,
for some, social workers were seen as an inhibition to improving or modernising adult
social care). But only about half of domiciliary care services were contracted out: the
remainder delivered by ‘in-house’ teams, seen to be better equipped to deal with
‘special’ needs.
Meanwhile professional training has grown (both in numbers and duration, with the
introduction of a 3 year degree and an expansion of post-qualifying courses). Given the
likely splitting off of children and family services to new organisations, and an
increasing emphasis on adult social care being delivered in partnership with Primary
Care Trusts (now more uncertain because of plans to reduce the number of PCTs), the
organizational-occupational formation of social work looks increasingly fragmented.
Knowledge and power are, not surprisingly, untangling – albeit in complicated ways.
Social work has always been at risk of being the ‘junior partner’ in multi-professional
partnerships (especially where medicalised professions are involved). It has been
challenged ‘from above and from below’ in many ways over the last twenty years
(Clarke, 1993), and is still engaged by groups and individuals arguing for a rights-based
rather than needs-based approach to social care. At the same time, both
organizational issues of managing resources and priorities and occupational issues of
having professional judgments of ‘need’ and ‘risk’ form focal points for resisting
rights-based approaches (so too does the more recent policy and professional discourse
of ‘vulnerable people’).
Yet, in some ways, social work’s occupational culture precedes and prefigures some of
the government’s reform agenda: values of independence, autonomy and
empowerment have both a long history in social work theory and practice, and have
been reshaped and reinvigorated as part of the profession’s adaptation to some of the
challenges since the 1980s (particularly from black and ethnic minority groups and
disabled people). So, there is sometimes a sense that New Labour’s consumerism goes
with the ‘grain’ of social care. Nevertheless, the model of choice advanced for adult
social care in the recent Green Paper (DOH 2005; see also Clarke, Smith and Vidler,
forthcoming) appears to place a model of individualised consumer choice into the
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middle of these complex occupation-organizational-user relationships, based on (while
changing) the model of ‘independent living’ developed in the disabled people’s
movement. It is not clear that the Green Paper can resolve the long-running debate
about who owns the definition of need in social care.
We have tried to sketch some of the distinctive forms and trajectories of the
knowledge/power knots at the heart of the three organisational-occupational
formations of public service provision in our study. Each of them is subject to forces
that both untangle and re-tangle them and each of them looks like the continuing
focus of concern. We think that one focal issue that they have in common is the
problem of how to imagine and create the ‘informed’ subject of the service. Concepts
of the expert patient, the informed community, and the responsible choice-maker
circulate constantly through governmental, occupational and organizational
discourses. Such terms point to a certain nervousness about the
consumer/community/citizen in the current period. As Gabriel and Lang argued, the
consumer, once evoked and brought into being, risks being an unpredictable and
‘unmanageable’ figure (1995). The expert patient, the informed community and the
responsible consumer look like ways of trying to stabilise the knowledge/power
relationship: the expert patient’s expertise is to be derived from the ‘real’ experts;
the informed community will be informed by what the police already know; and the
responsible consumer will make choices that are reasonable, predictable and
normalised. Whether the public is ready to be so responsible is another matter. As
relationships to public services are changed, so too do the identifications that attach
people to them. We are reminded of the post-privatization Yorkshire Water’s appeal
to ‘the public’ to save water in drought periods – an appeal rhetorically rejected in
the claim that ‘we are all consumers now’ (privatization having dissolved public
ownership, the public interest and public identifications).
The future for public services, those who staff them and those who use them looks
profoundly uncertain. The tendency towards services organised around mixed
economies of competing Small to Medium Enterprises (whether schools, surgeries,
hospitals or communities of Safety), driven by models of individualised market-like
choice, staffed by flexibilised employees (and/or volunteers) promises to eviscerate
older conceptions of the public. It may be that there is no ‘going back’ – and indeed it
is hard to generate much nostalgia for the mean and discriminatory paternalism of
much public service provision of the 1970s. But where might we find expansive
conceptions of the public and how it is to be served to set against the narrowly
‘marketist’ vision of New Labour?
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