The Assault on ‘Our’ NHS!

Some blogs should be expressions of indignation, and this one certainly is. Not that being angry/passionate can be allowed to obstruct evidence-based argument. Towards the tail end of 2011 Wendy Savage and I responded to medical students moving on from campaigns against the threefold hike in student fees and the abolition of the EMS to campaign against the ConDems’ Health and Social Care Bill. Wendy ‘s resistance already had its own momentum. But I engaged too and we gave joint lectures at UCL and Imperial. Later, handed a megaphone outside a BMA gathering, I shouted that this was a Bill to be aborted not revised. It was not an option to ‘keep talking’: to compromise was to lose! In March of this year the Bill became law with the passing of the Health and Social Care Act. Its substance had remained essentially intact, the pause for further consultations the sham it was always going to be.

This is not the place for a history of the NHS, but a few comments are in order. The Bill of 1946 that led to a service available to all citizens irrespective of circumstance and free at the point of need led to the introduction of the NHS in 1948. It had cross-party origins: Beveridge was a Liberal, the wartime PM Churchill a Conservative, and The Atlee/Bevin axis represented Labour. This political consensus survived intact until Thatcher’s election in 1979. If the years 1948-74 were relatively uneventful, the years 1974-82 were years of organizational reform, and the years 1982-87 of management reform (unsurprisingly aping a corporate model). Thatcher’s promotion of a pseudo- or ‘internal’ market, installed in 1991, was as far as she could go in her deference to the market place without provoking an electoral mishap.

Major’s innovation, the Private Finance Initiative (PFI), was a far more threatening move. It was Allyson Pollock and her team who bravely constructed an evidence-base to demonstrate why. The advantage of the PFI to government was that it delegated the costs of providing new hospitals, schools and so on to the private sector, these electoral assets not appearing on its own balance sheet. The disadvantages: in the future our hospitals, schools and so on would be owned by private companies and leased back to usvia long-term and extortionate contracts. What else to expect of for-profit businesses? Chickens had eventually to come home to roost.

New Labour under Blair/Brown abolished the internal market but continued to be susceptible to markets and positively relished PFIs. For all its ‘real’ increase in spending on the NHS, the aspirations of the Tories were not set back between 1997-2010. There is a sad continuity here (neo-liberalism mark I (Tories) and II (New Labour), as Bauman put it). Following the global financial crash of 2008-9, Brown’s government signed up in mid-2009 to efficiency savings in the NHS of £15-20 billion over three years to start in April 2011. This is the context in which Cameron set Lansley loose.

But Lansley’s Bill was a shock nevertheless. Cameron had chased votes by promising no top-down reorganization of the NHS. The LibDems had campaigned under a manifesto totally at odds with what was to happen, and could only happen, with their connivance. It was a Bill, the polls told us, opposed by virtually all bodies representing health professionals as well as the public. What should have alarmed all health professionals was the ‘real’ Cameron/Lansley agenda: to ‘re-commodify health care’. It was surely hard not to grasp the subtext of the Bill’s fine-sounding clauses? Barely concealed in the rubric of ‘improving services’ was an unprecedented neo-liberal assault on the core principles and practices of the NHS. These disingenuous clauses have been interminably rehearsed so I will simply precis them here: by April of 2013 the 152 Primary Care Trusts (PCTs) would be abolished and the GPs would join commissioning consortia; these consortia would control 80% of the NHS budget; services would be purchased from ‘any willing provider’; all NHS hospitals would become Foundation Trusts by 2014; and the commissioning would be overseen by the NHS’s financial regulator, ‘Monitor’. Upfront costs would be approximately £1.4 billion (much of it for redundancies), but the reforms would cut administrative costs by a third. No significant changes were secured during Lansley’s expedient hesitation. The major private health care providers had been licking their lips; before the end of 2010 they had coalesced into a lobbying group ‘H5’ (accounting between them for 80% of private hospitals and 85% of private beds).

Let’s pause for a moment to reflect. When Thatcher was elected the NHS cost us between 5-6% of GDP and was remarkably free of bureaucracy: only 5% of the budget went on administration. Unfortunately, as US economist Galbraith argued, bureaucracy in the public sector is highlighted by media-savvy and connected vested interests while bureaucracy in the private sector remains largely ‘invisible’. Under Blair/Brown expenditure on health care rose in real terms towards the OECD average (to around 7% of GDP), but so did administrative costs (on the way to doubling). In the 1980s Thatcher called on the American Eindhoven as her adviser, so let’s look at the USA. At the time of Thatcher’s introduction of the internal market, a first step towards accommodating the private sector, US health care consumed approximately 14% of GDP, while bureaucracy gobbled one dollar in four. In short, her interventions relied on policy-based evidence, not evidence-based policy. Moreover the USA was the only ‘developed nation’ not underwriting universal care for its citizens. On the contrary, one in six had no health insurance and did not qualify for Medicaid (a federal plan for the poor) or Medicare (a federal plan for the elderly). What an exemplar! Currently, American health care absorbs 16%+ of GDP and one dollar in three is committed to bureaucracy (essentially because every intervention has to be billed and most providers are for-profit). So Thatcher/Major/Cameron are pulling the wool over people’s eyes (and disappointingly, Blair/Brown too). The Health and Social Care Act is in every sense regressive.

Back to the Health and Social Care Act. Alex Scott-Samuel, a public health physician, anticipated its outcome in a typically shrewd letter to the Guardian. In summary:

‘The NHS will be a publicly funded budget and a brand name for a subcontracting operation for competing private sector organizations, subject to European competition laws which will allow private companies to predominate over other (eg third sector) providers’.

And more:

  • The post-credit crash NHS has a more or less fixed budget, so services of ‘low clinical priority’ will cease to be free.
  • This will lead to a market for health insurance, affordable for the affluent, which will drive up costs (administrative, fees, private profits).
  • Personal health budgets will lead to personal charges as commissioning groups will operate on an individual basis in order to be compatible with the insurance companies (no more population-based pooling of risk).

This last point is vital: I’d like to think it insults those of us fortunate enough to be in good health as much as it will our less fortunate neighbours. After all, this was the point of Bevins’ NHS, the most eloquent articulation of the postwar ethos.

I participate in twitter/blog networks of like-minded pro-NHS campaigners. This blog celebrates their sharp investigative postings. PFIs have predictably led to financial distress on the part of extant providers, and this on top of a brutal inherited programme of efficiency savings. Now, eight months after the passing of the Act: (a) Cameron’s real agenda must be obvious even to those who once favoured more talking, and (b) its implementation is brazen even beyond my (sociological) expectations. Scott-Samuel’s predictions are coming to pass. But even blogs of passion should not go on too long, so here are my summary bullet-points:

  • we are experiencing an undemocratic/regressive re-commodification of our (English) health care system, bearing witness to a return to the pre-NHS health care of liberal capitalism where only the affluent are guaranteed the treatment/care they need;
  • this is a paradigmatic instance of policy-based evidence masquerading as evidence-based policy;
  • 200+ of our representatives in Parliament – or, differently put, ‘voters’ on the Bill – stand to profit personally from a shift to private, for-profit providers of health and social care;
  • political party donors are seeing a return on their investments, as are those in and around the – now more uniformly career-oriented – political class (+ their new middle-class acolytes and advisers);
  • more sociologically, these moves to destroy our NHS epitomize what in an earlier blog I called the ‘greedy bastards hypothesis’ or GBH: predatory class interests, disinhibited under post-1970s financial capitalism, buttressed by the ideology of neo-liberalism, have prevailed on the political elite to trade away our postwar entitlements as citizens under cover of a rhetoric of consumer choice.

This final point matters, and not just because I happen to be a sociologist. What I have analysed as the new class/command dynamic (see previous blogs) is at the very core of any credible attempt to understand/explain what is happening to English health care. The wealthy/powerful cannot believe what this historical moment is allowing them to do to those they purport to serve. And it’s social structures that matter, not the individuals who happen to be surfing them. Cameron/Osborne are frankly neither here nor there. Allowing for the requisite theoretical adjustments in the 150 years since Marx committed his analysis/call for action to paper, this is a form of class conflict.

This blog is also an expression of gratitude to all those fighting back. Our evidence-based, morally trumping NHS matters. So, what next?         

Twelve Favourite Living Sociologists

On twitter a few months back I ventured a list of ‘top ten’ living sociologists. What I meant of course was my favourites, meaning those who had most impressed or influenced me during my intellectual travels. Without revisiting that list I am in this blog offering for consideration a top twelve that, I guess, bears a close resemblance to my original selections. Ranking them is a step too far so there come ‘in no particular order’. Attached to each is a publication I have personally relished. I hope it goes without saying that I welcome dissent, however irrational or bombastic.

Louis Wacquant is not here as a proxy for his mentor and colleague Pierre Bourdieu. It is not coincidental, however, that he shares the latter’s virtues, at least in my estimation. Chief amongst them is his straddling of what are too often well-patrolled borders between the theoretical and the substantive. Wacquant is a reflexive practitioner. His studies, often of outsiders, from boxers to abandoned Afro-Americans subsisting within a largely subterranean network of informal markets on the outskirts of Chicago, (a) bear testimony to a pragmatic blending of methods beyond the new post-quantitative/qualitative orthodoxy of ‘mixed methods’; (b) at every juncture speak of a genuine dialectic of theory and research; and (c) present a bold case for macro-, meso- or micro-social change. And the publication of choice? It’s Urban Outcasts: A Comparative Sociology of Urban Marginality (Polity, 2008).

John Goldthorpe may be a surprise inclusion, at least for those familiar with my own efforts. After all, he is best known as an empirically scrupulous neo-Weberian researcher of social mobility in the UK, and am I not a professed neo-Marxist guilty of formulating a vulgar-sounding ‘greedy bastards hypothesis’ in relation to health inequalities? What would he think? But he is surely our premier post-war English sociologist? His contribution extends well beyond his series of studies and reflections on social mobility to encompass theoretical interventions ranging from a critique of ethnomethodology (with which I agreed) to the support of rational choice theory (with which I disagreed). The thoughtfulness, subtlety and clarity of his writing are exemplary. My favourite interjection: On Sociology (2nd ed, Stanford, 2007).

Eric Ohlin Wright’s appearance may be less surprising. He is probably best known for his – I think telling – neo-Marxist theories and studies of the continuing salience of social class in what I prefer to call ‘high’ rather than ‘late’ modernity (hindsight will adjudicate on the terminology). But he has added another string to his bow: he has proffered and interjected ‘alternative futures’. A number of sociologists have lamented the reluctance of our ‘community’ to enter this domain of non-utopian envisioning of possibilities, what Giddens has called adventures in ‘utopian realism’. Has the need to do so ever been so plain? My own, and my family’s (http//, sense of the case for an action sociology sits well with this emphasis. The chosen work is: Envisioning Real Utopias (Verso, 2010).

Manual Castells, progenitor of the ‘network society’, is someone I encountered late. Simon Williams was quicker on the draw, accenting his potential for medical sociology in my ‘Contemporary Theorists and Medical Sociology’, published earlier this year. Having dipped into his triad on the network society, I moved more recently onto his network-informed analysis of social movements. Incorporating empirical analyses of activism during the ‘Arab Spring’ via Iceland and assorted city-based occupations to resistance in Spain, his latest book captures much of the present. He portrays it as theory-lite, but I don’t see it that way. It represents a new take-off point for thinking about digital-age social movements: Networks of Outrage and Hope (Polity, 2012).

Emmanuel Wallerstein is the progenitor and principal advocate of the neo-Marxist ‘world systems theory’. I came to his largely historical work because an old friend and colleague from Emory University, Terry Boswell, who died prematurely from, but was in no way a victim of, motor neurone disease, was an enthusiastic convert (he tried to persuade Emory to recruit EW but to no avail). Wallerstein’s theory might seem dated post-1989/91, but he anticipated Marxism beyond the nation-state and points to the future. His work is a reminder that agency and culture alike are structured but not structurally determined, a favourite mantra of mine. Given his productivity and the reach of his historical sociology a choice of text is difficult, but I plump for: The Modern World System Vol.3. The Second Era of Great Expansion of the Capitalist World-Economy, 1730s-1840s (Academic Press, 1989).

Richard Sennett, cosmopolitan sociologist and occasional visitor to LSE, is one of those craftsmen he has himself written so persuasively about. He ploughs his own furrow, opting for topics that have somehow eluded others. Once he has treated them, they remain treated, inspiring colleagues to pick up and work on his themes and insights. He has moved from discourses on the hidden injuries of class to exploring singular concepts like respect and togetherness. He is currently exploring notions of politics and civil society and the creation of public spaces in the twenty-first century. The book I am choosing here has influenced my own thinking, referring as it does to our need to be pro-active and decisive in an era of almost unprecedented uncertainty: The Culture of the New Capitalism (Yale, 2008).

Zygmunt Bauman, prolific Polish émigré who came to rest at Leeds, is less known for his early work than for his profuse comments on our ‘postmodern’ present. For a while I felt he conflated a sociology of the postmodern, which was required post-1970s, with a postmodern sociology, which would have sounded the discipline’s death knell; but he righted himself. If his recent sequence of books around the notion of ‘liquid modernity’ has perhaps been too slick and speedy, they nevertheless remain replete with insights (and telling concepts). It is to one of his earlier prize-winning volumes that I turn for an exemplar however: Modernity and the Holocaust (Cornell, 1989)is a theoretically elegant, sophisticated and harrowing study of the holocaust as a twentieth-century culmination of Weber’s societal rationalization.

Margaret Archer is less widely known than others on my list, her main contributions being to the sociology of education and the critical realist theorization of the present. She owes much to Roy Bhaskar but shows a striking independence of mind. Like Goldthorpe she straddles the domains of theory and empirical research. It is her later series of books and articles – on the relations between structure and agency and on types of reflexivity – that I have found particularly illuminating. She lends substance to Bhaskar’s ‘transformational theory of social action’ via her account of ‘internal conversations’. It is something of a toss up, but largely because I have made most use of it I mention here her penultimate book: Making our Way Through the World: Human Reflexivity and Social Mobility (Cambridge University Press, 2007).            

Michael Mann is another historical sociologist committed to the ‘big picture’. Born British, he has since found a home at UCLA. He provides a frame for the understanding of the slow unfolding of types of social formation and settlement. He will remembered, no doubt, for his multi-volume tracing of human sociability; but in between this sequence he has published theoretically fine-tuned books on the post-9/11 American ‘war on terror’, fascism and ethnic cleansing. My selection is: The Sources of Social Power. Volume 2. The Rise of Classes and Nation States, 1760-1914 (Cambridge, 1993).

Bob Jessop probably owes his inclusion on my list to his continuing commitment to get to the bottom of the modern state. Beginning with Marx, he has systematically and methodically drawn on the inspiration of Gramsci and Poulantzas to fashion an all-inclusive strategic-relational theory of contemporary capitalist and non-capitalist states. In a conceptually strong series of books, interspersed with many articles, the evolution of his thought has been exposed. Very few stones have been left unturned. He also gave an excellent half-day workshop for our UCL Sociology Network earlier this year. Unsurprisingly I am citing here his latest offering: State Power: A Strategic-Relational Approach (Polity, 2007).

Goran Therborn would I suspect be on many colleagues’ short-list. He is yet another with a remarkable facility for finding and theorizing history’s patterns. His accounts of European modernity and of the Western family impress with their reach as well as their depth of learning: they are anchored in the minutiae of ordinary people’s day-to-day circumstances and decision-making. My choice of book is his The World: A Beginner’s Guide (Polity, 2011), a title that seems to have inspired rather than daunted him. It is worth recalling, however, that there is continuity through his output, the early radicalism of his seminal excursus on ideology surviving into his later more magisterial efforts.

Jurgen Habermas is quintessentially Germanic in his capacity for synthesis. His output is extraordinary, much of it as philosophical as it is sociological. His ‘theory of communicative action’ was condensed into two mammoth volumes and probably represents the culmination of his sociological work. But there was much more before and has been much more after. Of late he has been preoccupied with discourse ethics, constitutional law and Europe’s post-nationalist future. It has taken him a long way from his Frankfurt School and neo-Marxist roots; too far in my view. Admiring of his opus on communicative action as I am, it is to his early work I have retreated for a favourite contribution. It could have been his Habilitation thesis on the public sphere; but I have opted instead for the peculiarly prescient and topical Legitimation Crisis (Heinemann, 1975). It retains its bite after the global financial crisis of 2008-9.

Critical Realism and Epilepsy-related QofL

This blog builds on my previous precis of basic critical realism to offer an illustration of its potential for coming to terms with ‘interdisciplinarity’. The focus is on epilepsy-related quality of life, and my analysis draws on work conducted with Caroline Selai and Panagiota Afentouli and published as a chapter in a volume edited by Sasha Scambler and I entitled ‘New Directions in the Sociology of Chronic and Disabling Conditions’ (Palgrave Macmillan, 2010.

The concept of epilepsy-related quality of life (ERQOL) is a contested one. While some insist that there can be ‘objective’ markers of ERQOL, others argue that it is an inherently ‘subjective’ notion. Clearly objective and subjective ERQOL need not correspond: epilepsy pursuant on severe brain injury might by common consent be associated with poor objective ERQOL without this translating into a poor subjective ERQOL. Clinicians and life and social scientists are likely to agree, however, that biological, psychological and social mechanisms have a potential bearing on both objective and subjective ERQOL, even if they are likely to go on to diverge on appropriate interventions.

The causal history of ERQOL can be extremely complex. For example, deleterious effects of epilepsy can be felt in the absence of any salient biological structures or mechanisms. This is likely to occur when epilepsy is misdiagnosed: application of the diagnostic label can itself – by authoritatively foisting a new, unwelcome and stigmatising social identity on the person-cum-patient – trigger psychological and/or social mechanisms to negative effect. If on the other hand epilepsy is but one symptom of a particularly severe underlying pathology, biological mechanisms can cancel out or override the causal potential of psychological and social mechanisms (Sasha Scambler has shown this in relation to the rare juvenile Batten disease for example). Genetic predisposition and brain insult can also be mediated by psychological mechanisms that over time ‘decide’ ERQOL. The causal efficacy of psychological mechanisms like internal versus external locus of control can themselves be dependent on contexts shaped by social mechanisms, or, for that matter, contingent happenings or agency.

What these varied scenarios commend is scientific caution. Biological, psychological and social structures and mechanisms can vary in their causal efficacy from individual to individual as well as by social or cultural context. Moreover they can and frequently do interact: one genus, acting upstream or downstream, can ‘cancel out’ or ameliorate the impact of others. Critical realism, in my view, allows for this fluidity. To better appreciate why calls for some conceptual refinement. Danermark et al (2002: 55) do this splendidly:

‘The objects have the powers they have by virtue of their structures, and mechanisms exist and are what they are because of this structure; this is the nature of the object. There is an internal and necessary relation between the nature of an object and its causal powers and tendencies. This can also be expressed as follows (Collier, 1994:43): ‘things have the powers they do because of their structures … Structures cause powers to be exercised, given some input, some ‘efficient cause’, eg the match lights when you strike it’). This in turn is an example of a mechanism having generated an event. A mechanism is that which can cause something in the world to happen, and in this respect mechanisms can be of many different kinds’ (Danermark et al: ‘Explaining Society’, Routledge, 2002; Collier: Critical Realism, Verso, 1994).   

So a generative mechanism operates when it is being triggered. Unlike the internal and necessary relation between objects and their causal powers, however, the relation between causal powers or mechanisms and their effects is external and contingent. The reason for this is that, underlying phenomena in the domain of the actual, there are many biological, psychological and social mechanisms that are concurrently active. Thus ERQOL is a complex effect of influences emanating from an array of multi-level mechanisms, where some mechanisms reinforce while others frustrate others. Danermark et al (2002: 56) again:

‘Taken together this – that objects have powers whether exercised or not, mechanisms exist whether triggered or not and the effects of the mechanisms are contingent – means we can say that a certain object ‘tends’ to act or behave in a certain way’. 

Thus numerous and fortuitous circumstances can play their part in determining whether a specific causal power will manifest itself or not.

So one lesson for sociologists, if they ever doubted it, is that ERQOL cannot be understood or explained solely in terms of social mechanisms governing context (although sociology can make its own discrete and irreducible contribution). Not only do biological mechanisms typically matter, but psychological mechanisms typically condition people’s handling of biologically-induced ‘impairment effects’ (as Carol Thomas calls them) in socially-induced contexts. Further complications arise with unannounced contingency in human affairs and the play of human reflexivity and agency. In short, sociology’s research programmes on ERQOL only tell part of the story. And even genuinely interdisciplinary (biological + psychological + social) research programmes would not tell the whole story: the explanatory power generated would not be matched by an equivalent predictive power: people and their circumstances can and do defy science.

Critical realism in this connection has a threefold return. First, it recognises and allows for an adequate ontology of objects, powers/mechanisms and tendencies in open systems, and does so without falling foul of the naturalistic fallacy (namely, some form of reductionism). Second, it requires and facilitates a move beyond the ubiquitous positivistic pursuit of statistically significant associations between variables, be they biological, psychological or social or, more rarely, some combination of these. And third, it calls for methodological rigour even as it denounces positivist ‘textbook’ emphases on measurement via operationalisation and quantification using ever more advanced forms of multivariate analysis. The denunciation is not of these positivist accessories per se, but rather of the underlying assumption that phenomena can be predicted, and therefore explained, given ’empirical’ study of the ‘actual’, that is, without resort to Bhaskar’s ‘real’. The potential for experimental closure in open systems is exaggerated.

It does not follow from this advocacy of a critical realist frame that extant positivist research – quantitative, but qualitative as well -is redundant. These findings are grist to the mill, as ‘cues, in that they often favour particular retroductive/abductive inferences to ‘real objects and their causal powers/generative mechanisms and tendencies. Moreover more than science is at stake. Much research is driven by an instrumental concern to improve objective/subjective ERQOL. In this vein I end with a paragraph or two on pointers towards an intervention model. It arises out of my earlier hidden distress model of epilepsy (see my Epilepsy, Tavistock, 1989).

Using the shorthand of this blog, the hidden distress model acknowledges that biological mechanisms, extending from genetics to the neuropharmacology of anti-epileptic drugs, typically matter in relation to ERQOL, deeper understanding often mitigating epilepsy’s assault on people’s day-to-day lives via more effective treatment. But even severe biological assaults ‘may not’ be decisive for ERQOL. Psychological mechanisms typically condition people’s handling of epilepsy’s assault, and therefore its impact on ERQOL, independently of its biological severity or intractability. There is considerable scope for counselling, targeting the interface between enduring psychological traits and coping styles. Yet psychological mechanisms too ‘may not’ be decisive for ERQOL. Social mechanisms typically provide people with contexts, some of which prove decisive for ERQOL. Spontaneous reactions to a witnessed seizure can be pivotal in the long as well as the short term. Social mechanisms too ‘may not’ be compelling for ERQOL.

In line with the hidden distress model, which accorded primary significance to felt stigma and a concomitant urge to fearful secrecy and compromised aspiration, it might be suggested that what I will call, after Bourdieu, an epilepsy habitus is key. This refers to an enduring, context-induced mindset, with felt stigma at its core, which predisposes to acquiescence or passivity with regard to socially disadvantaging difference. Anticipating discrimination (enacted stigma), people with epilepsy often (learn to) do to themselves what they anticipate others will ‘inevitably’ do to them. An epilepsy habitus can form independently of either biological or psychological tendencies, although it too may lose relevance for ERQOL, for example in the presence of prepotent biological mechanisms (eg severe brain injury). Clinical and public health interventions might reasonably aim to prevent the development/grip of an epilepsy habitus.

Basic Critical Realism, ‘Interdisciplinarity’ and Health

I recently convened an afternoon workshop on ‘interdisciplinarity and health’ as part of UCL’s Behaviour Change Month. I spoke briefly about philosophy, Henry Potts about methods and Caroline Selai about applications. The ensuing discussion was lively and there will I am sure be follow-up gatherings. In this blog, the first of two, I summarize what Roy Bhaskar, its founder, calls ‘basic critical realism’, and go on to suggest that his approach offers a helpful way of thinking about and ‘framing’ attempts to do genuinely interdisciplinary research. In the second blog I will seek to apply it to a particular research topic: the varied mechanisms that shape ‘epilepsy-related quality of life’.

Bhaskar’s distinctive philosophical approach can be interpreted as emerging out of a critique of Humean empiricism in general and the regularity theory of causation in particular. Bhaskar deploys a Kantian transcendental argument to insist that, given the developments in human knowledge that have in fact occurred, there must exist real – that is, mind-independent – ‘objects’ of that knowledge, possessed of certain properties and emergent powers. This argument leads to a postulate of ontological stratification. Bhaskar contends that if, as Humean empiricism would have it,    human knowledge were restricted to atomistic events given in experience, then something akin to the regularity theory of causation would obtain. However, the world is, and must be, stratified: it is not comprised merely of events (the actual) and experience (the empirical), but also of underlying mechanisms (the real). These mechanisms can be ‘retroduced’ (that is, their existence inferred) from the experiential study of events. Mechanisms are ‘intransitive’ (that is, they exist whether or not they are detected); ‘transfactual’ (that is, they are enduring not transitory); and they govern events. This is as true for knowledge of the social as it is for knowledge of the natural world. The true objects of social and natural scientific enquiry alike are ‘real mechanisms’.

In the social world most obviously, but by no means exclusively, patterns of events tend to be ‘unsynchronized’ with the mechanisms that govern them. As Lawson puts it, this is because they are conjointly determined by various, perhaps countervailing, influences so that the governing causes, though ‘necessarily’ appearing through, or in, events, can rarely be read straight off. The governing causes, or generative mechanisms, can rarely be ‘read straight off’ because they only manifest themselves in open systems (that is, in circumstances where numerous mechanisms are simultaneously active and there is therefore limited potential for experimental closures).

Sociology differs from biology, however, in that the objects of its enquiries not only cannot be identified independently of their effects, but they do not exist independently of their effects. Furthermore, sociology must accept an absence of spontaneously occurring, and the impossibility of creating – for example, through laboratory experiments – closures. This denies sociologists, ‘in principle’, decisive test situations for their theories. Since the criterion for the rational confirmation of theories in sociology cannot – after the positivist injunction – be ‘predictive’, it must be ‘exclusively explanatory’. Thus explanation displaces prediction; and to explain a phenomenon is to provide an account of its causal history

Bhaskar’s ‘transformational model of social action’ holds that agents do not create or produce structures ab initio, but rather recreate, reproduce and/or transform a set of pre-existing structures. The total ensemble of structures is society. Thus:

People do not create society. For it always pre-exists them and is a necessary condition for their activity. Rather society must be regarded as an ensemble of structures, practices and conventions which invidividuals reproduce and transform, but which would not exist unless they did so. Society does not exist independently of human activity (the error of reification). But it is not the product of it (the error of voluntarism)’ (from Bhaskar’s The Possibility of Naturalism).

Following Margaret Archer, Sean Creaven maintains that a ‘strong account of human nature’ and of the ‘non-social subject’ is indispensable for a credible theory of social structure and human agency. He contends, again deploying a transcendental argument, that human nature and the non-social subject denote ‘an ensemble of species powers, capacities, dispositions and psycho-organic needs and interests’ that logically must exist if we are to account for the existence of human society:

At the same time as humanity’s species-being and attendant powers and capacities are transmitted ‘upstream’ into social interaction and socio-cultural relations (supplying the power which energizes the social system, constraining and enabling socio-cultural production and reproduction, and providing a certain impetus towards the universal articulation of particular kinds of cultural norms or principles), structural-cultural and agential conditioning are transmitted ‘downstream’ to human persons (investing in them specific social interests and capacities, shaping unconsciously much of their psychological and spiritual makeup, and furnishing them with the cultural resources to construct personal and social identities for themselves)’ (from Creaven’s Marxism and Realism).

So far I have noted the argument for ontological stratification and focused on sociology’s explanatory potential. It is important also to record that according to basic critical realism events are governed by mechanisms at different levels. These levels include the physical, chemical, biological and so on … to the social. Bhaskar uses the concept of emergence here. He maintains (a) that higher-order levels are irreducible to lower-order levels (e.g. we do not try and explain the power of people to think by reference to the cells that constitute them, as if cells too possessed this power); and (b) that the emergence of a higher-order level involves a specific combination of generative mechanisms at the level immediately ‘basic’ to is (e.g. biological reality is ’emergent’ from a specific interaction of causal powers internal to the chemical level).

In the second, follow-up blog I will attempt to illustrate the value of basic critical realism via an analysis of the impact of epilepsy on quality of life. I will simplify things by writing only of biological, psychological and social levels. I will go on to suggest that the impact of epilepsy on quality of life constitutes: (a) a mix of the biological, psychological and social (causality travelling both upstream and downstream); (b) the interaction of biological, psychological and social mechanisms; (c) variously and variably the ‘primary’ power of biological or psychological or social mechanisms; and (d) an outcome more accessible to a critical realist, interdisciplinary analysis oriented to open systems than to a discipline-specific positivistic variable analysis presuming the possibility of experimental closure.

I am aware both that non-philosophers may find this first part of the blog too technical and that philosophers may find it too terse. The content of the second part of the blog will be the test.

Teaching Sociology to Medical Students

I first started teaching medical students in 1975, having just taken up a part-time lecturing post at Charing Cross HMS. Much has changed in London over the period since, not least the mergers of most HMSs into four large multi-faculty institutions (leaving St George’s HMS as an outlier). Sociology teaching has changed too. In this brief blog, a contribution to discussions on twitter, I will precis my personal views on teaching sociology to medical students.

When the GMC announced its decision that sociology should be incorporated into the undergraduate medical curriculum its rationale was clear. The health of the populations doctors were being trained to serve was rooted in people’s experiences of day-to-day living, in their circumstances as well as their behaviours. Health and longevity were far from being functions of access to doctors or to health care in general. Moreover people’s behaviours were clearly ‘shaped’ – I would now say ‘structured’ but not ‘structurally determined’ – by social relations like class, status, gender, ethnicity, age and so on. This applied of course to doctors and allied health professionals as well as to patients. So it was to be sociology’s task to reveal by means of theories generated and tested by research just how this structuring worked. Topics typically included: definitions of health, illness and disease, changing causes of death and longevity by time and place, the social aetiology and courses of diseases, risk and help-seeking behaviours, doctor-patient interaction, coping and the management of long-term and disabling conditions, the ramifications of stigma and deviance, issues around dying and bereavement, evaluations of health care interventions, and the nature and effectiveness of primary, secondary and tertiary prevention and of health care systems as a whole. Sociological perspectives moved back and forth from macro- to micro-.

These foci have probably not changed too much over time, although theories and studies have evolved. But why is all this relevant to an apprentice doctor learning to detect, diagnose and manage or treat disease in an individual patient? The answer is obvious to a sociologist who sees social processes at work in the very structuring of (bio-)medicine and its preoccupation with the individual. But medical students have always asked, reasonably enough: ‘how does all this affect what I say or do when a patient comes to the surgery or clinic?’ Well a few ‘evidence-based’ tips might be forthcoming: listen to why your patient has come, join a dialogue of equals, explain any advice clearly, and so on. But much of sociology seems far removed from these individualistic encounters. This distinguishes it from most psychology, and epidemiology too deals in aggregates of individuals rather than social structures, relations and processes.

It seems to me crucial to recognise that sociology feeds less directly into clinical practice than perhaps any other discipline that students will sample in medical school. Its thrust is educational. It invites semi-detachment from personal practice and calls for a healthy dose of reflexivity. I have yet to encounter a colleague who aspires to make sociologists of medical students or doctors. The common goal is to imbue them with a sense of the context in which they will practice and of the parameters of the possible. What doctors can accomplish across the medical specialities is immense but circumscribed; and reflexivity about this is extrinsically as well as intrinsically worthwhile: it can serve as an effective ego-defence for example.

One criticism of sociological teaching is that it somehow promotes ‘left-wing’ views. My own experience is that sociologists are extremely careful to distinguish, Weber-like, between theory and data about how things are and why and moral and political stances. There are of course ready theories about why people like medical students, recruited disproportionately from the privately educated offspring of parents in well-paid professional and managerial jobs, might misdefine a sociological account of medical recruitment or class or gender-related health inequities as committed propaganda. So be it, is my response; and if they complain about bias, we fight our corner. Sociology in medical schools often educates against the grain. Extremely positive evaluations of sociology teaching could even be worrying! Talking of evaluations, I recently sought to encourage a younger colleague with three of my own, and after the same mini-series of lectures: ‘he was awesome’, ‘he was a waste of space’, ‘he never turned up’.

Sociology teaching to medical students has got more difficult in my view. It was hard to get our courses established and taken seriously in the early days. By the beginning of the 1980s, however, new textbooks like ‘Sociology as Applied to Medicine’ were available, many HMSs were providing resources for small-group teaching, and summative assessment was often by written examination and essays. There may be more choice of textbooks now, but small-group teaching has become impractical and the testing of student knowledge and understanding is typically by MCQs or SBAs, ludicrous modes of judging a critical and reflexive grasp of the social structuring of the contemporary life-course. Weberian ‘rationalisation’ has grown apace, as has the size of student intakes and the premium on space.

As for the students themselves, as American sociologists Howard Becker and co put it half a century ago, they were, and remain, intent on survival, rather like members of the French resistance during the 2nd world war. It is not easy training for medicine; and the lot of the medical student can be very unlike the university education other students experience. For many of them sociology is understandably seen as but one peripheral hurdle to be overcome, and that in the most felicitous manner possible. It is our task to make our mark as they rush past us. Fortunately we have an ally or three among our clinical and public health colleagues who typically see our students at a later stage.

Orhan Pamuk and the ‘as if’ device

I suspect I am not alone in having more ideas than I am able to follow up or write about. And I have arguably been part of a lucky baby-boomer cohort with more negotiating space than young academics have now. Anyway, too many seeds are planted, watered for a while, encouraged to grow and then abandoned. One recent idea – ‘familiarity bonds’ as protective of health in the last resort – entered the public domain recently as a ‘comment’ in the current issue of It fits in loosely with another project I am conducting with co-author Aklsel Tjora, an edited volume on ‘Café Society’.

The idea I introduce in this blog is withering for lack of TLC. Maybe a reader will water it, or even take over responsibility for its wellbeing. It occurred to me as I read Pamuk’s wonderful novel ‘The Museum of Innocence’, published in English in 2010. It concerns’ human’s ubiquitous use of ‘as if’ reasoning in the conduct of their everyday affairs.

Kemel Bey has lost his young lover Fusun to a mix of his own indecision, his pre-existing engagement, and the cultural norms of a Turkey on the cusp of modernity. Apparently abandoned, Fusun has married Feridan, with whom she is less than besotted, and lives with her parents. Kemel Bey and Fusun remain fiercely in love but are constrained by traditional conventions internalized less by Kemel Bey than by Fusun and her parents. When the former’s visits to Fusun’s family home become an addictive ritual it is apparent that, the benign but distracted Fusun apart, everybody present understands the bond between the erstwhile lovers but act ‘as if’ they do not.

The reflections Pamuk ascribes to Kemel Bey would do any symbolic interactionist proud: ‘The love I felt, like the dinner table at which we ate, was ringed with so many refinements and prohibitons that even if every fibre of me shouted that I was madly in love with Fusun, we would all be obliged nevertheless to act ‘as if’ there was absolute certainty that such a love could simply not exist. At times when this occurred to me I would understand that I was able to see Fusun not in spite of all these exquisite customs and proscriptions, but because of them’.

This is Goffman territory, and Pamuk is no less shrewd. To oil dealings with others, from family and friends, casual acquaintances and employers to business or political rivals, people learn to react to most of what is said to them ‘as if’ it is appropriate, sensible and jejune. Smooth social interaction, as Pamuk observes, requires as much. To trespass directly on Goffman’s domain, the ‘as if’ convention is a necessary condition for fruitful or effective interaction? In this brief blog it is suggested that this practical assent to the ‘as if’ rule is not just or only a prerequisite for meaningful interaction but also a device that favours interaction in line with the status quo. In other words it tends to carry ideological baggage: it is a micro-device that requires macro-sociological analysis to expose for what it is.

Without getting into the nitty-gritty of Habermas’ critical theory, his distinction between ‘strategic’ and ‘communicative’ action is relevant here. The former denotes actions oriented to outcome or results, the latter to actions oriented to understanding and consensus. When people chat in the local launderette, pub or at their bingo or book clubs, they assume they are engaged first and foremost in communicative action. But are they? Ok, maybe they may have a strategic item or two on their agendas: to talk someone into collecting the ticket monies at the next village concert for example. Habermas analyses this as a form of distorted communication. But the ‘as if’ device brings to mind an altogether more subtle form of distorted communication, Habermas’ systematically distorted communication.

Systematically distorted communication occurs when nobody attending a gathering intends to manipulate others. Rather, manipulation occurs behind everyone’s backs. So here’s a scenario. A gathering of regulars is taking place at the local pub. Those present seem a familiar and heterogeneous enough group, and most seem disengaged from politics in their own or the global village. The ‘as if’ rule is being applied. It is understood that certain topics are to be avoided or approached only briefly and with immense circumspection, especially in fields like politics, religion and so on. ‘Stances’ mitigate against sociability. Any persistent offender or social deviant is likely to be quietly put down or excluded from future get-togethers.

In the absence of second-order sociological constructs it may not be apparent that: (a) a ‘stance’ tends only to be recognised as such if it offends against prevailing – local, area, regional, national or transnational – orthodoxies, be they beliefs, attitudes or the generalised cultural norms in which these are embedded; and (b) the offence of the unsociable is to hold a minority position. To define and treat an individual as unsociable, for a de facto refusal to apply the ‘as if’ rule, is in effect to underline, ratify and police the political, religious status quo. Nobody present needs or is likely to be aware of this.

This account is obviously tentative and provisional. I wonder, however, whether it is capable of useful expansion across a range of other interactional fields, like encounters between doctors and patients, head teachers and their staff, politicians and policy advisers. Is there a sense in which what seem like basic building blocks of normal(ised) social intercourse double up as legitimating devices for extant hierarchies and structures of power? It certainly calls to mind a string of feminist arguments developed as part of the second-wave. Maybe it’s old hat? I can take it.


GBH: Greedy Bastards and Health Inequalities

Over a decade ago, in a calculated bid to rile and provoke engagement with other sociologists, I formulated the ‘greedy bastards hypothesis’ (GBH). This asserted that health inequalities in Britain were first and foremost an unintended consequence of the ‘strategic’ behaviours at the core of the country’s capitalist-executive and power elite. It is a hypothesis even more plausible in 2012 than it was in the late 1990s.

The term ‘capitalist-executive’, borrowed from Clement and Myles, contained what I subsequently called a core ‘cabal’ of financiers, CEOs and Directors of large and largely transnational companies, and rentiers. These individuals were perfectly capable of ‘conspiring’ but despite being involved in fierce competition rarely had a need to do so in the post-1970s neo-liberal era of financial capitalism. This cabal, I intimated, has come to exercise a dominating influence over the state’s political elite (that is, the upper echelons of government together with its multifold ‘new middle class’ tacticians). US historian David Landes’ once asserted that ‘men (sic) of wealth buy men of power’; and my contention was that they got more for their money post-1970s than in the postwar welfare-statist era. So the GBH charged leading capitalists and politicians with what the likes of Engels and Virschow in the nineteenth century called homicide. As Michael Marmot has more recently averred, policies can kill, and when these are reflexively enacted their architects shouldn’t be surprised to find themselves liable to prosecution in the event of a regime change.

If the GBH indicted individuals – and in a 2009 paper I cited a list of names from a column in the Guardian – this was not its primary aim. Notwithstanding allowances for charisma and the like, the stand-out wealthy and powerful are more replaceable than they would have us believe (and doubtless than they believe). As a sociologist my interest was in the social structures these individuals were able to surf while many others were not waving but drowning: the sheer heritability of wealth and power is better researched than it is grasped by the public (hence the need for ‘action sociology’). Core members of Britain’s rapidly globalising capitalist-executive are the beneficiaries of enduring relations of class. Those comprising the more slowly globalising power elite at the pinnacle of our multi-layered state reflect relations of command. My contention was and is that financial capitalist Britain is characterized by a revised ‘class/command dynamic’ whereby class interests exercise greater sway over state policy and practice than hitherto.  This strikes me as blindingly obvious.

Let anyone who doubts the thrust of this argument venture a more telling macro-analysis of the journey of the (English) Health and Social Care Bill into law in March of 2012. This Act is re-commodifying health care. Without mandate, and in defiance of unusually unambiguous comparative research, the ConDem coalition is turning the NHS over to predatory US-style for-profit companies. What better case could be made for the new class/command dynamic?

It would be convenient if type of health care organization and delivery was decisive for health inequalities, but it isn’t. Morbidity and mortality rates do not simply reflect differential access to good quality health care. Although GP Julian Tudor Hart’s ‘inverse care law’ still applies 40 years after its formulation (that is, the provision of health care is inversely related to the demand for it), it is in amongst the basic building blocks of people’s everyday lives that the explanation of health inequalities rests. I have suggested that the notion of (initially) capital and (more recently) asset flows is helpful here. These asset flows, I contend, are the media through which the class/command dynamic, via the GBH, decisively impacts on people’s health and longevity. The noun ‘flows’ is significant here. People do not either have or not have assets positive for health and longevity, rather the strength of flow of these assets varies through the life-course.

So what are these assets? I so far have listed biological, psychological, social, cultural, spatial, symbolic and material assetsl. This is not the place to discuss each in turn, but it is important to stress that a strong flow of one asset can and frequently does compensate for the weak flow of another. Examples: a strong psychological asset flow (i.e. high personal resilience) can cancel out the negative propensities of a weak flow of social assets (i.e. an absence of close-knit social networks); and a strong flow of symbolic assets (i.e. high social status) can mitigate the damage liable from a weak flow of spatial assets (i.e. living in a deprived neighbourhood). There are five points to add:

  1. the strength of flow of material assets (i.e. standard of living via personal and household income) is paramount;
  2. flows of assets tend to vary together (i.e. mostly strong or weak ‘across the board’);
  3. weak asset flows across the board tend at critical junctures of the life-course (e.g. during infancy and childhood) to have especially deleterious effects on life-time health and longevity;
  4. weak asset flows across the board, and I daresay strong asset flows across the board, tend to exercise a cumulative effect over the life-course  (negatively and positively respectively);
  5. the ‘subjective’ evaluation of the strength of an asset flow can exert an effect over and above any ‘objective’ measure of that flow (e.g. a symbolic asset flow perceived as weak relative to that enjoyed by an individual’s reference group can be injurious in its own right).

Ok, it’s complex. But I want to stress (1) here. I regard the material asset flow as vital or prepotent. To assert that it underpins all other asset flows is not to diminish the latter’s salience for health inequalities; but it is to put on record, surely the key lesson of Wilkinson and Pickett’s The Spirit Level, that a purposeful reduction in income inequality is a precondition for taking health inequalities seriously?

This last point takes us back to the GBH and the revised class/command dynamic that underwrites it. Our society, one in which income and health inequalities are rapidly rising, and in which policy-based evidence has allowed a Health and Social Care Act to deliver a proven cost-effective publicly-owned NHS into the hands of transnational profiteers, is slipping into a post-welfare-statist, neo-liberal abyss. And even my fellow sociologists are reluctant use the ‘class’ word.




Disability colloquium: declining a Tory invitation

Open Letter

Dear George Eustice,

Re – Invitation on behalf of the ‘Conservative Disability Group’ Executive Committee to attend the Third Annual Disability Colloquium to be addressed by Esther McVey, Minister for Disabled People

Thank you very much for this invitation. On reflection I have decided that the most effective way I can serve the interests of people with disabilities is by (1) declining and (2) explaining my reasons for doing so by the device of an ‘open letter’. I hope you will consider this a positive contribution to your forum.

I find the rubric of your gathering – ‘inclusion in society’ – ironic. I imagine you can anticipate why. The Treasury’s economic strategy has been to reduce the deficit by the imposition of ‘austerity measures’. These measures have impacted most significantly on those in low-income households. They have targeted the public sector in general and those in receipt of support via benefits in particular. People with disabilities have been caught up in this pincer movement. Monitoring of the practices of Atos, sponsor of the Paralympics and contracted by your government to conduct ‘work capability assessments’, has been especially illuminating. Openly pursuing an agenda to ‘cut benefits’, even the DWP noted an excess of enthusiasm, with one in five of the Atos decisions reversed on appeal. But the bottom line is that the Treasury is enacting measures ‘excluding’ people with disabilities even as you plan in your colloquium to discuss their ‘inclusion’.

Prone to evidence-based policy as I am, this could be a very long letter. However, I will content myself with three brief and readily substantiated statements as background. The first is that the richest 1,000 people in Britain have seen their wealth increase by £155bn since the ‘global’ financial crisis began. This is more than enough to pay off the entire government deficit of £119bn. So this gives us a general context.

The second is equally uncontroversial: best estimates show that the total tax gap between what is owed and what is collected is about £120bn per annum (approx: £25bn in legal tax avoidance, £70bn in fraudulent tax evasion, and £25bn in late payments). Given these remarkable figures it is ‘odd’ that the tax inspection workforce is currently being reduced and the use of tax havens glossed over.

Third, our best estimate of benefit fraud (£1.2bn annually) is by comparison ‘peanuts’.

You will forgive me for pondering too how many of the Executive Committee of the Conservative Disability Group voted for the Health and Social Care Bill that became law in March of this year. I can think of no better example of policy-based evidence delivering an undemocratic piece of legislation guaranteed to further disadvantage those unlucky enough not to inherit wealth (the principle predictor of ‘material’ success in life) plus, research tells us, sustained health and longevity.

Nineteenth-century pioneers in public health charged those who signed up to policies that led to the premature deaths of vulnerable citizens as ‘murderers’. I would be willing to accept a verdict of manslaughter. People with disabilities cast aside by Atos have died. Many more are facing futures without hope and on the cusp of despair. So while the rich prosper those less fortunate, perhaps people with disabilities above all others, bunker down to subsist.

I decline your kind invitation, in sum, because you and/or your Conservative/Alliance consociates are allowing policy-based evidence to underpin Treasury policies destined to exclude those you are inviting me to help rebrand as included.

I trust this short epistle will inform your deliberations on 13 November and thank you again for requesting my input.


Graham Scambler, Ph.D, AcSS,
Professor of Medical Sociology,
University College London.