More self-reliance, less government? Neoliberalisation in healthcare and social welfare

The Critical Ethics of Care research is interested in the study of the impact of neoliberalism in health care and social welfare. How concepts and ideas circulating in those domains, originate in, are influenced by, or are susceptible to neoliberalism.

Care ethics is concerned with caring practices in healthcare and social work ((1)). In these practices, all kinds of concepts and ideas are circulating that come from outside those domains. Concepts and ideas like the autonomous life, free market, and the supposedly withdrawing government. A political take on care ethics is interested in how such concepts and ideas resonate in healthcare and social welfare practices. We observe, for example, that assumptions derived from neoliberalism concerning independence and self-reliance do not tie in with the actual independence and self-reliance of vulnerable citizens. In the meantime, such images do inform policy and often also practice. We have good reasons to look into why neoliberalism exists, how it changes shape, adapts itself again and again, and appears in new forms. The emergence of neoliberalism is a response to a real issue and that makes neoliberal ideas and practices still attractive to politicians and administrators today. In the meantime, we as care ethicist have to look at how concepts and ideas derived from neoliberalism have an effect on actual practices. This helps us to clarify issues that professionals and their managers encounter in the practices in which they work, which they manage and for which they make policies.

Neoliberalisation through concepts and ideas

In this contribution, I will not engage with discussing the origin and development of neoliberal theory, in all its shapes, and of neoliberal practice, again in all its heterogeneity. I have learned a lot about it from the German political theorist Thomas Biebricher. The Critical Ethics of Care research network in which I participate, had a few of Biebricher’s articles translated into Dutch and we invited him for one of our meetings ((2)). More than Biebricher, however, we are interested in the study of the impact of neoliberalism on health care and social welfare. And even more so, we are interested in how concepts and ideas circulating in those domains, originate in, are influenced by, or are susceptible to neoliberalism. That is not because we think of neoliberalism as the great enemy per se. Yet we observe that concepts and ideas, that are appealing to people and also to professionals in healthcare and social work, turn out to have ‘ugly’ consequences. That makes us interested in the field of influence in which those concepts and idea that have a ‘beautiful’ side are dragged toward their ‘ugly’ side. I discuss some issues to illustrate this.

Problems and ‘solutions’

In healthcare and social work, organisations, professionals and their managers struggle with a lot of issues and concerns. In these domains, there are also a lot of ‘solutions’ offered for those issues and concerns. Not always are those ‘solutions’ based on a precise formulation, let alone an adequate analysis of the problem. The chosen formulation of the problem often largely determines what can be accepted as a solution and the solution often assumes a certain formulation of the problem.

Care for oneself

The first issue I want to discuss is the problem of how to assist people in the care for themselves. The solutions that are suggested are: promoting self-reliance, self-management, self-control, self-care. Relevant is not whether these solutions should be considered neoliberal solutions, but relevant is that they can easily be assimilated in a neoliberal way of thinking. That is because they all have a certain ambiguity which they share with the concept of freedom in general. When those solutions are introduced in healthcare and social work, they enter a field of influence, in which different forces exert influence in different, sometimes opposite directions. This field of influence is a political practice, a practice that has its bearing on the way society is ordered and in which a political struggle is going on.

The political field of influence in which every proposed solution ends up is a complex field. For the sake of my argument, I am now reducing it to a field in which every solution is pulled in two directions – with a certain dominance in one direction. Each solution then always has two sides. Those two sides are what I call: the ‘beautiful’ side and the ‘ugly’ side. Beautiful in the sense of positive, good, nice for people, just. Ugly in the sense of negative, bad, bad for people, unjust. You can also look at it differently: beautiful is idealistic, romantic, naive, say: left-wing; ugly is realistic, business-like, experienced, say: right-wing. In any case, it is too simple to say: beautiful is social-democratic, ugly is neo-liberal. Look at the history of neoliberalisation in practice. I stick to beautiful and ugly.

The beautiful side of self-reliance, self-management, self-care is: everyone can participate because everyone has equal access to resources – ‘emancipation’, you can say. The ugly side is that citizens are left to sort out things by themselves. In practices of neoliberalisation, with its focus on markets, public facilities become dismantled and the citizen has to find out whether he can indeed access the available, but not easily accessible resources. Often that is not the case.

Bridling of paternalism

The second issue is the bridling of paternalism, patronizing, and pampering by the side of professionals. The solutions are freedom of choice, autonomy and self-control. The beautiful side is: living the way that suits you, receiving the care you need. The ugly side is: if you don’t state your request for help correctly and in the others’ professional jargon, they don’t have to take responsibility and you don’t get what you need. Solidarity as a principle is being undermined: figure it out for yourself, let me know when you have a request for help and then we first have to find out who is going to pay.

Vulnerability

The third issue concerns vulnerability. In our society, vulnerability is ‘bad’, it should not be there. The solutions are: self-strength and resilience: being able to deal with contradictions. The beautiful side is: you may show vulnerability, vulnerability is considered to be a part of life and does not have to go away; we tackle social vulnerability, resilience is facilitated. The ugly side is: resilience is associated with personal performance and pride; vulnerability with personal failure and shame.

Care for one another

The fourth issue concerns care for one another. The solutions are: the ‘participation society’ (in the Netherlands) and informal care. The beautiful side – perhaps a bit romanticized – is that local communities take care of their members and much of the care is provided informally and in one’s own home. The ugly side is that care, also for elderly people with special needs and people with disabilities, moves to the private sphere and escapes both public responsibility and public control. The government withdraws and imposes sanctions on those who evade the expectation or even obligation to participate in society and have their share in informal care delivery.

Volunteering in care and assistance

The fifth issue concerns volunteering in health care and social welfare. Again, the solutions are informal care and the participation society. The beautiful side is the activation of civil society: citizens and citizens’ initiatives take responsibility for society; meaningful social relationships are promoted. The ugly side is that volunteers are utilised as a reserve workforce who can be counted on to fill gaps and cut back the deployment of professionals. It gets even worse when volunteering is required as a return for community support.

Care in the neighbourhood

The sixth issue concerns the care in the neighbourhood. The solutions here are self-strength, self-reliance and independence of citizens and neighbourhoods – that is what social district teams should promote but also assume to be present. The beautiful side is that the voice of citizens is strengthened and given priority because professionals go into the neighbourhood and speak with inhabitants. The ugly side is that professional care and assistance is withdrawn and professionals are forced into the straitjacket of a particular policy with restrictive and sometimes even humiliating rules.

The costs of professional care and assistance

The eighth issue concerns the affordability and accessibility of professional care and assistance for everyone. The solutions here are many: self-management, management of one’s own disease, competition, ‘value-based health care’, ‘shared decision-making’ and so on. The beautiful side is that care comes close to people and that that care is good enough. The ugly side is that health care and social work remain equally expensive or even more expensive, but is distributed unevenly and unequally. Those who are able to do it well – self-management, shared decision-making – receive better care. If healthcare institutions also start to focus on ‘excellent’ care, then affordability will disappear completely behind the horizon.

Political struggle

The above ambiguities in practice give rise to unexpected and inevitable contradictions of a political nature, which cannot simply be resolved or settled by struggle. For the time being, the different meanings must be balanced. And at the same time it is important, also for professionals and their managers, to investigate these contradictions along four lines.
First, analysing the problem or concern to which the proposed ‘solution’ is a response. For example, what exactly is going on with the ‘getting out of control’ costs of healthcare and social welfare? Secondly, identifying the places, forms, discourses and practices of resistance and ‘recalcitrance’ ((3)).
Thirdly, identifying workable alternative solutions that can be found, and developing and testing new solutions. Fourthly, being prepared to wage political struggles over this. The latter in turn requires the cultivation (also by professionals) of three ways of acting: (i) not going along with the neoliberal representation of things as if social problems and solutions are ‘technical’ rather than political issues; (ii) paying close attention to the phasing, degree of concreteness and effectiveness of governmental solutions for complex social problems; (iii) resisting the tendency to reduce everything to zero-sum games, in which if someone wins, someone else must lose. Healthcare and social welfare, relationally conceived, can never be zero-sum games.

Notes

  1. This contribution is an English version of the second part of my article, Timmerman, G. (2018). Meer zelfredzaamheid, minder overheid? Neoliberalisme in zorg en welzijn [More self-reliance, less government? Neoliberalism in healthcare and social welfare]. Waardenwerk, 73: 44-56. This second part was based on Baart, A. (2017). The many faces of neoliberalism: Lecture at the book presentation ‘Thomas Biebricher, Onvermoed en onvermijdelijk’ (June, 15th, Amsterdam).
  2. Timmerman, G. (Ed.). (2017). Thomas Biebricher, Onvermoed en onvermijdelijk: De vele gezichten van het neoliberalisme [Unexpected and unavoidable: The many faces of neoliberalism]. Nijmegen: Valkhof Pers.
  3. Clarke, J. (2007). Citizen-consumers and public service reform: At the limits of neoliberalism? Policy Futures in Education, 5(2), 239-248

About the illustration:
At the men’s portal of the Heddal Stave Church in Norway, built at the beginning of the 13th century, the members of the congregation are offered the two perspectives of the lost, constrained soul – in the gaping jaws of a monster, on the left side -and of the saved, free-as-a-bird soul – sharing in God’s kingdom, on the right side (photo: Guus Timmerman).

About the author: Guus Timmerman

Guus Timmerman, PhD, (1961) was trained as physicist, theologian and care ethicist. He is research fellow at the Presence Foundation and member of the programme committee of the Critical Ethics of Care research network. Together with care ethicists Frans Vosman and Andries Baart, he published recently ‘Digging into care practices’ in the International Journal of Care and Caring, and ‘In search of good care’ in Medicine, Health Care and Philosophy.
See a list of publications at: https://www.researchgate.net/profile/Guus_Timmerman

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