66 The centrifugal effects of late capitalism

What we are seeing in Western healthcare systems today, is the centrifugal effect of neoliberalism, that is reshaping healthcare by de-centring it. As healthcare spins ever faster, services escape the centre and relocate at the peripheries, into communities, new localities, sometimes with new identities. The effect of this centrifugal motion has been the gradual migration of expertise to the margins. This process has accelerated rapidly in the last decade, with advances in person-centred care, the decline in professional power, and, especially, digital technologies like YouTube, and other knowledge brokering platforms. But the pace of decentralisation has become exponential with the COVID-19 pandemic, as essential services retrenched around acute care, and most other forms of healthcare escaped traditional silos and had to find new ‘asynchronous and location agnostic’ spaces ^[1], from online support services to DIY healthcare, that do not ‘expect co-presence, synchronicity, or dependency’ (ibid). This is what Dara Ivanova has called ‘placeless care’ ^[2].

The concept of de-professionalisation began to express some of this shift in the 1990s, seeing the neoliberal economic reforms sweeping through healthcare as a direct challenge to medical autonomy ^[3]. Jonathan Gabe (one of Catherine Coveney’s collaborators, above), argued that a more informed, critical public had become less inclined to be deferential to all experts, a process that had been fostered by digital media that fed on counter-narratives and subversive ideas ^[4]. Writers like Nigel Malin, Valerie Fournier, John McKinlay, and Lisa Merceau have suggested de-professionalisation is happening for a number of overlapping reasons:

• Nation states being more interested in globalisation than the domestic stability they once derived from prestige professions like medicine;
• The insistence that all healthcare practices and decisions carry the burden of cost, reducing professional clinical autonomy and control;
• An audit culture that encourages the decomposition of health work into discrete tasks, altering the indeterminacy:technicality ratio (see Chapter 5), allowing for more external interference in day-to-day work;
• The loss of exclusive access to medical knowledge with the advent of global communication technologies, and the concurrent de-mystification of healthcare work;
• The increasing focus on noncommunicable diseases and lifestyle disorders, and the commensurate decline in the idea of the heroic doctor/therapist;
• The ‘feeling’ of a loss of position, strength, or status as a result of restructuring and health service reorganisation;
• The slow decline of public trust in authority figures, amplified by ongoing reports of abuse, malpractice, profiteering, and privilege amongst healthcare professionals;
• The loss of specialist knowledge and task specificity, with increasing diversification of healthcare alliances, and pressure to adopt inter-/multi-/trans-professional working models, disrupting traditional hierarchies ^[5];
• And the replacement of specific work responsibilities with a less well-trained, more robotic or automated workforce ^[6][7][8].

Ironically, perhaps, much of the impetus for de-centralisation of health professional work has come from the sociology of the professions. Over the last 70 years, the sociologists who featured in the previous four chapters have argued that the health professions are too self-interested, and need to be reformed. The fact that ‘[w]e are on the brink of a period of fundamental and irreversible change in the ways that the expertise of the specialists is made available in society’ ^[9], would be a huge source of relief for many sociologists, if it were not for the fact that the change has been brought by late capitalism. Rather than seeing healthcare become more equitable and accessible, diverse and inclusive, late capitalism has only widened and amplified the disadvantage and poverty of access, fostered a solipsistic individualism, and transformed healthcare interventions ‘into a commodity exchangeable between consumers and [healthcare professionals] in a free market’ ^[10].

At the same time, new attitudes towards role permissiveness are creating much more fluid professional boundary definitions; new attitudes toward the body in health and illness are creating new logics of care; and new cross-sector alliances are disrupting traditional provider/purchaser binaries ^[11]. People have much more choice, and the options available to many people are much wider than they were, even a decade ago. Cultural assumptions about consumers’ subordination to medical expertise have changed markedly, ‘from patients abiding by ‘doctor’s orders’ to managing treatment regimes to fit in with their personal life’ ^[12]. And with large parts of the healthcare system sequestered into acute respiratory care during the COVID-19 pandemic, people who would normally have accessed nurses, doctors, and orthodox allied health professionals for support, have been forced to go elsewhere, showing once again that healthcare functions in an increasing number of localities beyond the reach of traditional professionals.

Cecil Helman has described this as an evolving form of health pluralism;

’In most societies people suffering from physical discomfort or emotional distress have a number of ways of helping themselves, or are seeking help from other people. They may, for example, decide to rest or take a home remedy, ask advice from a friend, relative or neighbour, consult a local priest, folk healer or ‘wise person’, or consult a doctor, provided that one is available. They may follow all of these steps, or perhaps only one or two of them, and may follow them in any order. The larger and more complex the society in which the person is living, the more of these therapeutic options are likely to be available, provided that the individual can afford to pay for them. Modern urbanised societies, whether Western or non-western, are more likely, therefore, to exhibit health-care pluralism’ ^[13].

Others have explored the changing therapeutic ‘landscape’ that all health service users and professionals now operate within. Catherine Coveney, Alex Faulkner, Jonathan Gabe, Michael McNamee, and Mike Saks have shown how porous boundaries are between formal and informal care now ^[14][15]. The study of the care of elite athletes, by physiotherapists and others conducted by Catherine Coveney and colleagues, for example, shows a remarkable hybridity, with myriad credible options now available to consumers ^[16]. Coveney et al suggest that opportunities now exist for people to take advantage of a globally connected world to build ‘variegated’ networks of support, drawn from orthodox and unconventional sources. These opportunities bring their own challenges, not least ‘the litany of other voices in therapeutic decision-making’ (ibid), which presumes a great deal about the resources available to people looking for care and support.

Thomas Friedman has suggested we are facing ‘the most profound eras of Schumpeterian creative destruction ever’ ^[17], in part because never before in the history of humanity have so many people ‘had access to so many cheap tools of innovation… and cheap credit’ (ibid). (The phrase Schumpterian’ derives from the Austrian economist Joseph Schumpeter (1883-1950), who believed economies engaged in an incessant process of annihilation and reconstruction.) The triple crosshairs of neoliberalism, globalisation, and digital disruption, have effectively led to societies all over the world throwing out the idea that elite professions should be allowed by the state and its various supporting bodies (universities, publicly-funded healthcare services, regulatory authorities, etc.) to form largely self-regulating bounded territories of professional control ^[18][19]. And so, having been ‘successful contestants in the game of modernity’ ^[20], we are now undoubtedly entering a post-professional era that ‘names an emerging if not already here progression from present-day arrangements’ ^[21].