Governamentality; State; Health; Public policies
Nikolas Rose is a professor of sociology, founder and head of the Department of Social Science, Health and Medicine of the King’s College of London since 2012.
At the 90 he taught at Goldsmiths College and, from 2002 to 2012, at the London School of Economics. He has published widely on the social and political history of the Human Sciences, Medicine and ‘Psy Disciplines’. On those studies he has been interested, in particular, to make a genealogy of subjectivity and to reflect about the ‘govern of the conducts’ and about the changing rationalities and techniques of political power. His current research concerns the contemporary changes of life sciences - biomedicine, genomics, neuroscience, psychiatry. He is internationally recognized for the contributions of his works to the introduction of the foucaultian’s thought at the Anglo-Saxon countries and to the development and expansion of it. Some of his writings and books are, today, available at Brazil11 Rose N. Inventando nossos selfs. Petrópolis: Vozes; 2011.,22 Rose N. A política da própria vida - biomedicina, poder e subjetividade no século XXI. São Paulo: Paulus; 2013. where Rose have been strengthen his institutional an academic partnership.
We present here the first of a series of three Interviews with Nikolas Rose which, together, sought to explore some aspects of his wide academic production(b(b) This interview was done on May 2014, by Sergio Resende Carvalho during his studies as a Visitor Scholar - under the auspices of CAPES/Ciências Sem Fronteira – at the Department of Social Sciences Health and Medicine of the King’s College of London. The transcript was reviewed by Nikolas Rose before being translated by the interviewer.). We prioritized at the interviews aspects that could contribute to discussions of the Collective Health field that included , among others , questions about the State, Public Policy and Health (interview 1), the role of psy’s knowledge and practices in the government of conduct (interview 2). Recent researches of Rose around life sciences,biomedicine and neuro sciences (interview 3) were, also, focus our attention.
MICHEL FOUCAULT AT UNITED KINGDOM
Can you give us, in a summarise way, some idea of the context of your academic work after the 70’s and make some comment about the meaning and importance for you, and other British scholars, of the contact with the works of Michel Foucault?
My first contact with Foucault’s work, like so many in England, was with a translation of an abbreviated version of the history of madness called, “Madness and Civilization”33 Foucault M. Madness and civilization. 2nd ed. London: Routledge; 2001.which I read when I was at university. I was already rather critical of psychology and psychiatry, and I used Foucault’s work as part of a critical interrogation of psychiatry and more generally of the psy disciplines and the power of the psy disciplines.
This has to be understood in relation to the situation of those of us who were Marxists in the UK at that period, in the late 1970’s and early 1980’s. Many of us had become very critical of the economism of much Marxism, which placed so much emphasis on the transformation of the forces and relations of production and seemed to either ignore, or at least sidestep, the problems of transformations at the level of culture and ideology.
A number of us, many of whom were teachers or working in related professions, thought that it was crucial to analyse the way in which ideologies contributed to social and political reproduction, and in particular the way they contributed to the shaping and reshaping of human identity and subjectivity.
The Marxist resources that we had available to us at that time were really quite limited: Gramsci’s work “The Prison Notebooks”44 Gramsci A. Prison notebooks. New York: Columbia University Press; 2011. had been translated, not long before and many of us were influenced by his ideas of hegemony. More significantly a number of us became interested in French structuralism, in structural linguistics - in particular the work of Saussure -, in structural psychoanalysis - the work of Jacques Lacan-, and in the structural Marxism which was which we associated, in particular, with the work of Louis Althusser.
The most significant paper that we read was Althusser’s paper “Ideology in ideological State apparatuses”, because that argued that it was through ideological means that social formations were able to reproduce themselves generation after generation and those ideological means worked, crucially, through the construction of a certain kind of subjectivity. The language of ideology, the language of the constitution of human consciousness, the discussion of this in terms of a kind of structural psychoanalysis: that became the frame within which a number of us began to try and theorise those issues.
At that time – we are talking of the mid 1970s – I was working with a small number of friends of mine, largely critical psychologists, and we set up a small journal called “Ideology and Consciousness”. We termed this a Marxist journal of ideology, linguistics and feminism: it was in these terms that we were trying to make our own conceptual framework to analyze and critique, and perhaps even intervene in the forms of ideological reproduction.
IDEOLOGY, SUBJECTIVITY AND POWER
How you, and your colleagues did developed the arguments about ideology, subjectivity and power? How did you deal with the difference about subjectivity on psychoanalysis and at the foucaultian approach?
Fairly soon in those analyses we became pretty unhappy with the principle terms, especially with the idea of ideology, because ideology always operated on the basis of truth and falsity, ideologies were false ideas with a social function and in relation with the idea of consciousness.
Because we became much more interested in the formation of subjectivity in which consciousness was an effect but was not “the master in its own house”. We were reading Jaques Lacan at the time, and he had a phrase that made this point well, something like “at the very moment when I assent to my own identity I am wagged by another”. That is to say that the belief that consciousness was in control of the self, that kind of ‘ego psychology’ was misleading – to believe in the primacy of our own consciousness may be necessary for our everyday lives, but it was, to quote Althusser, an “Imaginary relation to one’s real conditions of existence”.
It was in the context of these debates over the nature of subjectivity that a number of us came into a different kind of contact with the work of Michel Foucault – and he, of course, in “The Order of Things”55 Foucault M. The order of things. London: Routledge; 2001., addressed this same issue in a very different way, writing an archaeology of the conditions under which the figure of ‘Man’ emerges as an ‘empirical-transcendental doublet’.
So there were a number of ways in which, together with my colleagues, I tried to develop these kinds of arguments; about ideology, subjectivity and power. For some, the best path was the path through psychoanalysis: and a number of my friends thought that psychoanalysis provided the intellectual framework to understand how human beings were shaped and indeed were transformed by the power relations that they were part of. They were mainly critical psychologists, and they wrote a book called “Changing the Subject”, which argued for the need for a new ‘theory of the subject’ to understand the way in which power insisted in the subjectivity of the individual.
I was one of those who took a different route. We argued that psychoanalysis itself had to be seen as a particular way in which human beings had come to understand themselves, act upon themselves, with its own systems of authority and modes of subjectification: psychoanalysis had to be subjected to the same kinds of critical analysis as one would apply to other modes of understanding human beings that had got bound up with power relations.
We did not think that the answer was to create our own ‘theory of the subject’ – which would just be one more among many – but to ask how, why and in what ways, ‘theories of the subject’ had been bound up with regimes of authority and subjectification. That line of argument, to put it briefly, was the one that I pursued in my first three books: “The Psychological Complex” 66 Rose N. The psychological complex: psychology, politics, and society in England, 1869-1939. London: Routledge & Kegan Paul PLC; 1985., “Inventing Ourselves”11 Rose N. Inventando nossos selfs. Petrópolis: Vozes; 2011.,77 Rose N. Inventing our selves: psychology, power, and personhood. Cambridge: Cambridge University Press; 1998., and “Governing the Soul”88 Rose N. Governing the soul: shaping of the private self. 2nd ed. London: Free Association Books; 1999.. As an aside, I am sometimes amused when some people are critical of my later work for not addressing the question of the subject, as I did spend about ten years, three books and many papers working on that question – and, of course, it is also the topic, or one of the topics, of my recent book on the neurosciences99 Rose N, Abi-Rache, Jelle M. Neuro: the new brain sciences and the management of the mind. New Jersey: Princeton University Press; 2013..
At the end of the 80’s and at the 90’s many of your group took the notion of governmentality to think the relation between the state, the society and the individuals. Can you make some comments about it and the importance of that perspective to your researches?
You have to think your way back to the 1980s, and what was happening politically in the UK, in the US, and indeed in many European countries. To out it simply, it was a large scale, wide ranging and rather fundamental criticism of the welfare state, of the rationale of welfare, of the machinery of State organized as systems of security and planning, and of the consequences of three decades of more or less uncontrolled growth of the welfare apparatus.
How was this ‘event’, if one can call it that, to be understood? Many on the left operated with a kind of nostalgia for the Welfare, forgetting, or so it seemed to me, that they had been among the most vociferous critics of the results of the Welfare State, its class of well-paid and patronizing functionaries, and its failures to increase equity and justice. It was in this context that those of us who had translated and read Foucault’s lecture on governmentality (it was published in English in our Journal) came to think that there was a different way of posing some of the questions that had previously been posed in terms of the State and Ideology.
This different way was to start by thinking about the whole variety of strategies and tactics and technologies for the conduct of conduct, that is to say, to try to characterize the configurations that existed at any one time for the shaping of individual conduct and collective conduct. Posed in that way, in terms of the multiplicity of practices for shaping individual and collective conduct, a number of things became clear to us.
When I say “us” here, I am talking in really rather practical terms, not metaphorical terms. We formed a group, a group called “The History of the Present” and we would meet every four weeks – actually at the London School of Economics as that was a convenient venue – and we discussed papers that people had been reading or papers that people were writing and try and think through from this developing perspective, what might be the concepts and analytical strategies that we might use. The first thing that became clear was that in terms of the conduct of conduct, the state was neither the necessary beginning point nor the end point of all these strategies. States could only govern on the basis of a multiplicity of practices for the conduct of conduct, which they themselves neither originated nor controlled.
These practices for the conduct of conduct involved a multitude of other kinds of authorities, whether they were psychologists, psychiatrists, teachers, accountants, economists, probation officers: the little governors of everyday life who exercised power over individuals within a whole range of different practices and who gained their authority largely on the basis of a claim to knowledge. These were authorities with a claim to knowledge, who were acting upon individuals, in order to shape their conduct, often in quite rationalized ways in order to produce certain objectives.
So we set out to try to analyse these multitude of practices for the conduct of conduct; the forms of authority that existed within them; the types of knowledge on which they depended; the strategies and techniques which they use; and the conceptions of the human subject which kind of underpinned them, because every practice for the conduct of conduct, in our view, contained some explicit or implicit understanding of what human subjects were, and what they were like.
After yours governmentality studies do you think yourself as a foucaultian scholar?
Although this became called governmentality studies, because of the idea of government as the conduct of conduct, because of the work some of us did on mentalities of government, on rationalities and technologies of government, at this time it was connected in the loosest way with the writings of Michel Foucault. We were inspired by a certain ethos of investigation, but most of us were not Foucault scholars, most of us hadn’t attended or read the lectures, which were not in the public domain at that time – you had to go to the archive in Paris to listen to them - and few of us did that. As you know, I worked in particularly with Peter Miller who is now a Professor at the London School of Economics, with Tom Osborne who is now a Professor of Sociology at Bristol, and with Andrew Barry, who is now a professor in the Geography Department, University College London. We’d read a lot of Foucault, we’d read the lecture on governmentality and for us this suggested a powerful way of going forward. But we realized – or believed – that we would have to make up a lot of the concepts and approaches and analytical techniques ourselves - and that’s what we did.
POLITICAL RATIONALITY AND TECHNOLOGY
What means, in your and Peter Miller’s proposal, the concept of political rationalities? Do you think that Liberalism, Welfare State, and Neo-liberalism - named by you as Advanced Liberal Democracy or Advanced Liberal Society - represent the most important political rationalities on the western world? What do you thing as contributions, and limits, of this classification to a political action and to a research program?
This is an important question and I think some clarification is important here. Our work, the work that Miller1010 Hayek FA. The road to serfdom. 2nd ed. London: Routledge; 2001. and I did, was a ‘History of the Present’. We were concerned with trying to understand British and, to some extent, European societies, their modes of government, forms of power, modes of subjectification, in the 1980’s and 1990’s. From that point of view, we tried to trace a genealogy of the emergence of these particular ways of thinking about and trying to govern human subjects.
We argued that at any one time you can see a family resemblance amongst a whole series of ways of thinking about and acting upon subjects, and we tried to show this through quite detailed historical work. For rough purposes of communication we said, “OK, let’s call these Liberalism, Welfarism and Advanced Liberalism”. These were never meant to be more than nominal descriptors, they were certainly not meant to be like such ‘epochal’ terms as modernization or reflexive individualism or the risk society. They were just rough and ready ways of speaking about a family of programs and techniques and modes of interventions at any one time.
We tried to show that you could see similar things in other European countries that initially looked rather different. For instance, if you were looking at the Nordic countries, their road to liberalism, their road to a Welfare State was very different. They came out of very strong theological states and this shaped the way in which they had moved to form their Welfare States. But nonetheless, what was happening as we were writing was that they were, in their own ways, questioning those Welfare States from a perspective of freedom and autonomy, of choice and the mitigation of state powers and so on. So I would want to stress the importance of doing the empirical work, rather than moving these terms like welfarism from place to place, because I think that that can be highly simplistic and misleading.
We see this with neo-liberalism. I have tried to avoid using the term neo-liberalism, except in characterizing those political philosophies and governmental doctrines that explicitly refer to themselves as neo-liberal. Why I used this term, Advanced Liberalism, was to say that a family of ways of governing was taking shape, in which neo-liberalism was just one element. We saw this in Reaganomics, we saw it in the ‘Third Way’ of Bill Clinton, we saw it in the Third Way of Tony Blair. Unless you want to say that Reagan, Blair, Clinton are the same as Hayek, and is the same as the Ordoliberalism in Germany in the 1940’s, unless you want to say they are all the same, you need to be more specific. If you say that they are all neo-liberal, you lose the capacity to analyze their differences. This is why I find myself very irritated with the easy use of the term neo-liberal in contemporary critical discourse to characterize things that are often very, very different from one another, because I think that it often obscures as much as it reveals. Especially because it sidesteps the need for analysis. So you see arguments that say, almost in so many words: “what’s happening in neo-liberalism”, “why is it happening is because of neo-liberalism”, “what’s wrong with it is neo-liberalism”; that doesn’t seem to me to be a terribly helpful way of going.
To go back to your question, I don’t think these three blocks are the most important political rationalities of the Western World. I think those who are doing this work need to analyze those rationalities in relation to the particular problems that they find themselves in and the specificity is more important than the general description. There are many different forms of welfarism, there are many different forms of liberalism. I just want to stress again that the ethos here, really going right back to an earlier answer to your question, the ethos was conceptually informed empirical analysis and the concepts that we used to do the analysis were much more important than the broad scale descriptions.
Besides the concepts of governamentality and political rationality, technology is one of your most important research’s concept. Can you explain what you mean by that and discuss on your answer about how those terms and concepts relate to each other?
There are many different explanations of why Michel Foucault invented this little term governmentality.
Miller and I took this as a provocation, and we worked on it like this: we said: OK lets take the word governmentality and break it up. First, there are certain mentalities, mentalities of rule. What is a mentality? A mentality is a way of thinking, a way of analyzing, certain rhetoric, a way of speaking, a way of dividing up what is legitimate and what is not legitimate, for those who wish to rule, for those who wish to exercise authority. And there are many, many different rationalities, in this way, political rationalities.
What make a political rationality governmental? A political rationality is governmental to the extent that it can make itself practical, to the extent that it can turn itself or ally itself with a particular way of intervening into individual and collective lives in order to manage them, to transform them. So on the one hand you have the rationalities, on the other hand you have these ways of intervening, practical ways of intervening, and we termed those practical ways of intervening ‘technologies’, technologies of governing.
We used the term technology to describe an assemblage of different elements, oriented towards achieving a certain practical objective. Oriented, in this case to achieving a practical objective of governing conduct towards certain ends. I actually don’t like the word assemblage, I prefer the word dispositif, or something like that , but let’s call it assemblage for now. By an assemblage one means a kind of configuration of persons, of activities, of technical resources, of buildings, of machinery, of ways of judging and acting that make it possible to intervene in order to shape conduct.
Can you give us some example of the use of those concepts?
Let’s take Social Work. Social Work is a kind of technology. It involves people with a certain kind of authority and training. They work in very practical ways, they render reality into thought through their case notes, through their grids of perception and so on. They have various techniques of intervention in relation to their subjects, they have certain powers that are given to them by law. They inhabit certain institutional forms, offices, buildings, they have files, they accumulate material in certain ways, they go into people’s homes, they judge people in certain ways, they can deliver certain resources or they can take children away or they can do this, that and the other. So this is a kind of complicated dispositif, involving persons, forms of knowledge, types of action, modes of inscription etc. That’s what we meant by a technology, and it’s governed by a certain practical objective, a certain technique directed towards a particular kind of end.
Not all political thought has managed to make itself governmental. Did Utopianism ever manage to make itself practical, did it ever manage to connect itself up with a technology of rule? Did Communism ever manage to make itself practical, make itself technical? Did Socialism actually invent any technologies of governing of its own? Well, if you look at some of the classical writings on Socialism, you say, no, Socialism didn’t invent the plan. Socialism didn’t invent the centralized state. Socialism didn’t invent a whole series of the ways in which human conduct was governed, in fact it took over many things that had been invented elsewhere and it deployed them for its own ends. So you need to look beyond the thought, beyond political dogma and doctrine to look at the ways in which some forms of thought seek to make themselves technical, to connect themselves to a technology of intervention, and you find that this is not just a matter of implementation of a political doctrine, but a complicated matter of assembling technologies that can seem to translate that doctrine into a set of practices, strategies and techniques.
So, to talk about governmentality, is to talk about the way in which a certain style of thought about what should be done, links itself up with a certain technical mode of realization. Another part of the argument that Miller and I made, is that the characteristic of these governmental styles of thought is that they are constantly reflecting on whether or not they have achieved the ends that they want to have achieved. And by and large, the answer they come to is “no”. So that’s why somewhere we take this phrase, “the will to govern is eternally optimistic, but governmentality is a congenitally failing operation”. You always want to reduce crime, and you do this that and the other to try to reduce crime and you don’t reduce crime and then you say, why haven’t we reduced crime? Is there something wrong with the way in which we are doing it, so let’s try to think of another way of doing it. So the failure of one kind of mode of intervention is always the opportunity for another mode of intervention.
ADVANCED LIBERAL SOCIETIES
Can you comment about the way that ‘Advanced Liberal Societies’ understand the function of the state, the exercise of authority and the relation between autonomy and freedom, taking as reference the problematics of the health field?. Can you discuss it using, as an example, the situation of the health sector in the United Kingdom today?
This is a complicated question, because what is happening in the changes in the health sector in the United Kingdom arises from developments on a number of different pathways, which become connected up but have different genealogies. Actually, this is a lesson that we learnt from Michel Foucault. If you read “The Birth of the Clinic”, you quickly see that the emergence of clinical medicine in the early 19th century arises from an array of quite disparate changes. Changes in the practice of medical education, changes in modes of security, changes in the physical organization of the hospital, changes in record-keeping etc. Together, these changes which arise along different pathways, produce something like an event, an event in that case which is the birth of clinical medicine. So the same, is true of the transformations that occurred around the issue of health in England nowadays.
Let me just try and speak about two or three of these dimensions. The first of these dimensions concerns the possibility of state planning. In Britain, we have a National Health Service. When the National Health Service was set up there was a belief that as the health of the nation improved, the need for the health service would reduce, so costs would reduce. The reality proved to be quite the reverse. The demand for health care grew year by year, decade by decade. The costs of health care were growing and growing and growing. The apparatus of health care was extremely complicated with general practitioners, hospitals, clinics, all over the country, each of them a little complicated universe. And in the centre of this sat the Secretary of State for Health, who was supposed to be planning the health service. If you read the memoirs of the Secretaries of State for Health, you find that again and again they were sitting in Whitehall with their heads in their hands saying “not only do I not have any control over what’s going on in these hospitals, but I don’t even know what is going on, I don’t have the knowledge, let alone the capacity to control it. What makes it worse is that these bloody doctors are incredibly powerful, they have the knowledge and they are controlling the things and I have no way to exercise power over them. Every time I try to cut something, or even to change something, the doctors come along and say, oh, you can’t do this, people are going to die”. So those who are supposed to govern the health service were constantly saying,” we can’t govern the health service”.
The quasi-marketising of the health service
There were many attempts to solve this, all of which failed! So the beauty, the macabre beauty, of the new public management was that it found a way to do this. It aimed to resolve this question by turning the health service into a quasi-market. They said something like: “Right, the Secretary of State cannot know, and cannot control what happens in the operating theatre, what happens at every doctor’s surgery, what happens in every clinic. There is no way that he or she can know, let alone control that. But what we can do is to control the inputs and the outputs: we can control the budgets, and we can control the targets. We can say to the hospitals, we are setting you free, you are autonomous, you determine what happens in your little universe. But at the same time we say “this is your budget and this is what you have to achieve, in terms of operations, mortality rates, waiting times or whatever. And if you don’t achieve these targets, we can cut your budgets. So, at a stroke a new way became possible of trying to govern what was happening in all these far-flung areas, without someone at the centre having to know everything and control everything. To some extent, this was what Hayek talked about in “The Road to Serfdom”11: How impossible it was to control such a dispersed domain by central planning.
Expert-provider and the client-customer: relations
Neo-liberalism is in its 1940’s form, was about the market as the most efficient way of doing things, because in the market, the choices are made by the persons who are closest to the ground, and in the plan the choices are made by someone claiming total knowledge, but who is furthest away from what is happening between you and your doctor in the clinic. A second dimension of the changes in the UK, was the other side of this marketization: markets involve acts of consumption, and that means consumers. One of the interesting things about Margaret Thatcher and Thatcherism was that it was very hostile to professional power. It was hostile to those professions who said, “Well, we know more than you and that is why we have more power than you. You in the State can’t tell us what to do, because we possess the esoteric knowledge and the authority that goes with it. And you the client can’t tell us what to do, because we are the experts and you are not.”
Lawyers, doctors, those were the two principal enclaves of professional power that nobody could break up. They had been much criticized by people from the liberal side, because doctors and lawyers had so much professional discretion and were making decisions which were, in fact, moral decisions not those based on expert knowledge. They were also much criticized by the left and by the right. But from the left, the right and the centre, nobody really knew what to do about them, how to transform these relations of power between experts and clients. So the second key dimension was the transformation of that relationship between the expert and the client into a relationship between a provider and a customer. The client became a customer as in the market, and the lawyer or the doctor or any other authority became a provider of a service, and if the customer didn’t like what the provider did, the customer would go and shop somewhere else. And so, at a stroke, at least this was the intention, the untrammeled power of the professional became opened up. Not because the politicians said, “You can’t do this, you can do that, you can’t do that” but because if the patient didn’t like it, the patient would go somewhere else. The customer is king” – as in your supermarket, so in the health service, the rhetoric was that the customer is king.
This was a really interesting way of challenging professional authority. It involved a transformation in the form of expertise, in the subjectivity of the expert, because the expert now could not just say: “This is what’s good for you, that’s what’s good for you, take that medication, you’re going to have that operation”. They now had to convince the customer that this was the right thing to do. But it also involved a transformation in the subjectivity of the patient: as a customer patients also had to recognize that they were subjects who could choose, no longer a patient patient: don’t be a patient patient, be a choosing discerning customer.
State, the quasi-market and the freedom of choice at the National Health System
And what was the role of the state? The role of the state was to provide the infrastructure for this, the conditions that would enable these quasi-markets to work. This is still going on at the moment: debates over whether hospitals should publish their death rates for people having particular kinds of operations or whether schools should publish their success rates in getting kids through certain kinds of exams and so on and so forth. While there is dispute over the details, the basic strategy required the provider forced to make public this kind of information that the customer would then use in order to make their choice.
This is not really captured by the suggestion that it was a reduction of the power of the state. I think that would be the wrong way of putting it. It wasn’t a rolling back of the state, although that was what was often said. It was a reconfiguration in the way in which political rule would be exercised over these domains. And it was a reconfiguration in which political rule would provide infrastructure and would require the subject to become a discerning subject of choice, and would educate the subject to be a subject of choice. Now we see all sorts of things that aim to do the same thing, which were not really dreamed of in those initial strategies but have fed off them: comparison websites, for example, run by private companies, that claim to give the subject the capacity to choose.
Of course, as you and I know, it is not so much the capacity to choose as the obligation - once you have the capacity to choose, you have the obligation to choose. You can’t just go to your doctor and say, “Doctor, I’m sick, do something, help me”, no, that’s a relationship of dependency. You’ve got to make judgements about which kind of treatment you want and you’ve got to take responsibility for playing your role, playing your part, in the choice and in carrying out the path that has been chosen. And, of course, being a market, a key indicator and driver is financial. You make the hospitals dependent on how many people want to use their services, you make the doctor dependent on how many people want to use their services. You pay them for the numbers of people that are going to use their services, you do produce a sort of quasi-market. So that those hospitals or doctors that are most popular, that provide the best service for their customers, they are the ones that are going to thrive, like your supermarket, the best supermarket will thrive. And those that produce a lousy service, well you think that people will just go somewhere else
Of course in reality it didn’t work out like this. If you are a family with four children and one of the children is sick and you haven’t got a motor car, you need to go to your nearest hospital, you’re not going to start doing the research and choosing and taking your kid somewhere 150 miles away because it’s going to give you a better service. If you go to a doctor, you basically want the doctor to give you what the doctor, the expert thinks is best – on the basis of years of training and years of experience. Further, this new system generated very significant calculative problems for these different kinds of actors, making each hospital a little calculating actor of its own so it can work out what is its market, what prices it has to charge and all these kinds of things. This became immensely difficult and whole rafts of accountants and consultants had to be employed by the hospitals – at great cost - to try and do these calculations and find the best ways of claiming to meet these targets.
In the excellent work of Michael Power on the audit society he shows very clearly what has now become rather obvious: if you say to a hospital, “your target is to get down waiting times in the accident and emergency department to below three hours”, and you are only going to get paid if you reach that target, then of course, the hospital is going to put more resources in to that and less into hip operations for the over 60’s. So the targets skewed the way in which the actors worked, because they knew where they were going to be audited. You produced a target culture, and in some cases people cheated to make sure they appeared to have reached the targets.
There is also a problem of planning in such a quasi-market. When you are running a health service in a particular area, you are concerned with not just what is going to happen today but what’s going to happen in five, ten, and fifteen years time. If you are concerned about Public Health, if you are concerned about Psychiatric Health or if you are concerned about an ageing population, you need to plan twenty or thirty years ahead in order to do that. But the market encourages a certain kind of short-termism.
So the marketization didn’t work so well, the targeting produced paradoxical outcomes, the budgeting became incredibly difficult to do, as every operation had to be given a price and this also produced more and more problems of choice. For example, suppose you can get this operation for 50 pounds in this hospital but you can get it for 75 pounds in that hospital, but the more expensive hospital has a better result rate than the cheaper one: so how do you choose?.
Some consumers took on this active patient role very enthusiastically, but that had all sorts of other effects. For example, some late stage cancer drugs, which might increase someone’s life expectancy by three months, are hugely expensive. Just this morning, there was a publicity that a particular drug cost 90 000 pounds for a year’s treatment that might increase someone with late stage breast cancer’s life by six to nine months. In a market driven economy, that is really not cost effective. But when a provider says “We are not going to provide you with that, it’s not cost effective to provide you with that” your active patient group starts lobbying and says you know: “Don’t you think our life is worth 90 000 pounds?” You get a new set of contestations growing.
I think there are all sorts of things very wrong with the system as it has emerged and even if you can call it a system, it’s more of an accident than a system! But that does not mean that the problem which was trying to be solved was the wrong problem or that the situation that there was before was perfect because it had many faults.
You have commented in some interview that you, and other researchers, tried to develop after the 70’s, a thought that could deal with the micro level of politic but also could connect it with the question of state and the economy which are so central to Marxism. Beside it, you affirmed that you were trying to offer an alternative thought that should not be Marxist but Socialist and leftist. Do you think you realized, somehow, those objectives and desires?
I think the answer to that question is no, not really. Some of us hoped that with the Blair government in the UK and the Clinton government in the United States, these ‘Third Way’ governments, that something productive would happen to the progressive thought. At their best, these ‘Third Way’ strategies and rationalities picked up some of the elements that seemed potentially productive about these new ways of thinking and tried to combine them with some rather more old fashioned notions of collectivity, solidarity and obligation. Some of us saw the possibility of a relationship between these ways of thinking that I’ve been talking about and these new ways of trying to rationalize and exercise political power.
For various reasons, whether it was the Iraq War or the Monica Lewinsky problem in the United States, whether it was the vicious right paralyzing Clinton in the United States or whether it was a failure of nerve in the United Kingdom, the hopes for that ‘Third Way’ of governing - which did appear to open possibilities of new and inventive thought - came to nothing.
At the same time these ways of analysis became rather sterile. Governmentality text books were produced, courses in governmentality studies were developed, governmentality became another academic sub-discipline.
The life went out of it, the inventivity went out it, rough and ready periodization’s that we used to hang our empirical work on - Liberalism, or Welfarism or Advanced Liberalism – were reified, and the inventivity, the creation of concepts, the empirical engagement with the politics of the present, all that seemed to fade away. Not entirely, of course, some terrific studies were produced, but for me at least, the creative moment – which was also a political moment - had passed.
The interesting thing is that I think there is a new possibility of inventiveness, but probably not in the United Kingdom, or in Europe but for those who are trying to develop these ways of thinking in Latin America, in South-East Asia, in Africa, to try and think about how conduct is conducted in these very different contexts, with their own histories, technologies, subjectivities, and their own very distinctive presents.
But to the extent that I have anything left to say on these issues, I would urge people using this work in these situations to avoid simply importing the analyses. Rather, I hope they will try to think about what the ethos was, what the spur was to doing this kind of work, what the styles of thought were that we were trying to develop. And think about what worked and what didn’t work. And then re-invent them for these different kinds of contexts.
That’s what I would hope people would do at the very different world of today - a world of globalization, a world of the Internet, a world of social media, a world with new security States. The same ethos in a different world requires not just critique or the comforting gestures of resistance, but creativity, invention, an attention to the empirical, realism about the past and responsibility for the future.
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- Publication in this collection
19 Mar 2015
15 Apr 2015