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The political ideologies that have been dominant in New Zealand during the 20th century and are discussed here are welfarism, (neo)liberalism and the Third Way. As regimes of truth, each in turn has made available particular subject positions for individuals as legislative processes and a growing body of knowledge about such things as economics and politics ‘conducts the conduct’ of the population (Gordon, 1991). The theoretical framework for each regime is presented briefly in this section and is followed by consideration of the spaces (or otherwise) created for an advanced nursing role by each of these regimes.

Welfarism

Social policy that promotes the well-being of the poor and disadvantaged is known as welfarism. Welfarism is defined by Heywood (1992, p. 320) as “the belief that the state or community has a responsibility to ensure the social wellbeing of its citizens, [and is] usually reflected in the emergence of a welfare state”10. Connected with welfarism are notions of social justice and the fair redistribution of wealth to the benefit of the less well-off. In New Zealand, a new regime of truth introduced by the first Labour government and enacted in the Social Security Act, 1938 marked the beginning of the modern welfare state. The Act provided full employment11 by way of a protected, state-directed economy and provided for those unable to work due to ill health or misfortune. Universally available benefits were paid from a social security tax pool to individuals who met

10 _{More specifically, Keynesian economics refers to state intervention in a country’s economy to} regulate aggregate demand and offset high unemployment. Aggregate demand is based on the macro-economic theory of John Maynard Keynes and refers to the injection of government money into the economy by an increase in public works projects (for example, constructing houses, schools, roads and hospitals), which significantly influences the grand total of all goods and services purchased in the national economy. Following World War II, most Western industrialised capitalist countries adopted these interventionist strategies in an attempt to avoid a repeat of earlier market-driven events such as the Wall Street Crash of 1929 and its sequelae of unemployment (Heywood, 1992).

11 _{In 1950 there were only twelve unemployment benefits being paid in the entire country} (Knutson, 1998). However, this may not reflect the actual number of unemployed, only those paid a benefit.

certain means-tested criteria12 and covered medical, pharmaceutical, hospital, maternity, and superannuation needs. The scheme was non-contributory, meaning that benefits were available as of right, irrespective of the amount, if any, of social security taxes paid by the recipients of the benefits (McLintock, 1966). In this way, the Act rejected the previous private model of contributions-based insurance and embraced a blend of needs and rights-based models, the latter being founded on concepts of social citizenship (P. Barnett & Barnett, 1999; Ware & Goodin, 1990).

The intellectual origins of social citizenship are in entitlements theory, “where individuals are guaranteed certain rights in society such as equality before the law and equal access to education and health care, as well as the provision of a minimum income floor” (Stephens, 1987, p. 302 – 303). Citizens, therefore, have rights, but there is a reciprocal obligation for another – in this case the state – to honour those rights (Rishworth, 1992). Welfarism as a discourse consists therefore of a coherent system of discursive practices comprising: state involvement in the economy; the assumption of state responsibility for problems of self-care; and, a system of state benefits paid to those meeting certain criteria. That the state will provide in times of individual need has become a universal expectation of New Zealand citizenship, as has the state provision of health care and education (as well as adequate housing in certain circumstances).

The new political regime of the modern welfare state is suggested by Foucault (1983b, p. 215) as the adoption of an old technique of power originating in the church, except that:

It was no longer a question of leading people to their salvation in the next world, but rather ensuring it in this world. And in this context, the word

salvation takes on different meanings: health, well-being (that is, sufficient wealth, standard of living), security, protection against accidents.

In the exercise of what Foucault terms ‘pastoral’ power, the state now cares for the community and each individual (to the grave). Pastoral power is a technique of

12 _{The means test was abolished in 1960 and in 1969 a “7.5 percent social security tax was} incorporated into the income tax schedule” (Stephens, 1987, p. 306).

governmentality having at its purpose “the welfare of the population, the improvement of its condition, the increase of its wealth, longevity, health etc.” (Foucault, 1991b, p. 100). The population is the focus of government having both an individualising power and a totalising power (Foucault, 1983b). It is used by a welfarist discourse to safeguard the economy by safeguarding the individual well- being of its subjects.

Neoliberalism

Liberalism stems from the work of Adam Smith (1776), who demonstrated that free markets and competition, without any attention of government, reduce poverty and improve the general standard of living by a phenomenon now termed the ‘trickle-down effect’ (McGregor, 2001). The dominant ideology of colonialism, a classical liberal approach to governance was the norm in New Zealand and continued until the 1930s when, in response to the Great Depression, it was replaced by the welfare state. A resurgence of liberalism then emerged in the 1970s due to the effects of rising oil prices and the war in Vietnam, as well as increased trade opportunities brought about by improved global communication and travel (Chatterjee et al., 1999). Neoliberalism, however, goes further than liberalism to shift the delimitation between state and society to a belief not only in a ‘rational’ market but to create subjects as ‘rational’ individuals, with the consequences for self-determined decisions borne by the subject (family and community) alone (Lemke, 2001).

More subtle in effect than classical liberalism, a neoliberal discourse has the state take on new tasks and functions that lead and control individuals without being responsible for them (Lemke, 2001). As such, there is a shift in subject position from the liberal “‘homo economicus’, who naturally behaves out of self-interest and is relatively detached from the state, to ‘manipulatable man’, who is created by the state and who is continually encouraged to be ‘perpetually responsive’” (Olssen, 2003, p. 199)13. Contrary to the earlier welfare period, neoliberalism renders individual subjects responsible for such things as illness, unemployment and poverty, transforming them into problems of self-care. Furthermore,

13

Homo economicus is a term suggesting one acts rationally to obtain the best possible outcome for oneself.

education and health are viewed as normal economic goods, subject to the market and not the provision of the state (Stephens, 1987). Consequently, the neoliberal ideology in New Zealand rejected the Social Security Act’s 1938 notion of social welfarism and the associated dependence of citizens on the state for services such as education, superannuation and health care.

The ideas of political writers such as Nozick and Hayek found appeal in the neoliberal concepts of “‘choice’, ‘devolution’, the ‘individual’ and ‘freedom’” (Olssen, 2000, p. 482). According to Stephens (1987), Nozick and Hayek contended the primacy of individual rights and freedom of choice over principles of equality. They viewed redistribution as a threat to those rights, although acknowledged the state’s responsibility to provide for a minimum income floor.

Potentiated by capitalism, these right-of-centre theories de-emphasised government intervention in the economy and focused instead on achieving progress and even social justice by more laissez-faire14, free-market methods. Known also as the ‘New Right’ (and sometimes the ‘Second Way’), they incorporated two important theories: Public Choice Theory, referring to the assumption that behaviour in the marketplace is mainly motivated by self-interest; and Agency Theory, referring to the cooperative relationship needed between a principal (shareholder) and an agent (manager) to maximise each other’s interests (Wright, Mukherji, & Kroll, 2001). In addition to these discursive practices, a discourse of neoliberalism is a coherent system constituted by: the withdrawal of the state from the economy; generic management principles known as managerialism, emphasising profitability and efficiency; encouraging ‘natural’ markets to compete by reducing special-interest group capture; and promoting individual autonomy in problems of self-care.

In New Zealand, and beginning in 1984 with a traditionally social democratic Labour government, widespread economic reforms informed by a neoliberal discourse were introduced as a matter of urgency (Goldfinch, 1998; Lange, 1996). The changing international economic situation related to oil production and

prices, the loss of protected trade with Britain when it joined the European Economic Union, and “massive overseas borrowing to finance new energy projects and maintain domestic spending on a comprehensive welfare state” (Knutson, 1998, p. 8). Treasury briefings to the incoming Labour governments in 1984 and 1987 proposed a radical restructure of the economy and a reduction in the government’s role in both the economy and welfare (Treasury, 1984, 1987).

The translation of neoliberal ideology into practice in New Zealand during the 1980s continued with successive National governments through the 1990s, allowing the reforms virtually uninterrupted progress (Kelsey, 1998). Lewis (2004) suggests that the purity, speed of implementation and ideological certainty with which the reforms occurred were regarded internationally as remarkable. Falling broadly into three sequential categories, the reforms increased the use of the market in the regulation of business, reformed the state sector, and redesigned the welfare state (Easton, 1994) – all of which have been documented extensively elsewhere (see P. Barnett & Barnett, 1999; Boston & Dalziel, 1992; Easton, 1994; Jesson, 1999; Gauld, 2001; Kelsey, 1998). Neoliberal welfare reform as it related to the health sector is of primary interest, however, and is discussed shortly.

The Third Way

In 1999 the Labour party campaigned on a manifesto based on the Third Way, successfully forming a minority centre-left coalition government with support from the Green Party (H. Clark, 2002). Following the trend of the British Blair government, two elections later and with new coalition partners, the Third Way as an ideology particular to the Labour party in 2007 no longer features prominently in political discussions or government policy. It is, however, discussed here because of its influence on health policy and legislation when Third Way ideas had greater currency when, for example, the New Zealand Public Health and Disability Act, 2000, and the PHC Strategy, 2001 were enacted during Labour’s first term.

On the left of the political spectrum, the ‘death of socialism’ is said to have occurred with the collapse of communism in eastern Europe and the fall of the

Berlin Wall in 1989 (Heywood, 1992). As a consequence, and due to sustained electoral failure, democratic socialist parties around the world lost intellectual credibility, necessitating the re-examination of core values and their relationship to capitalism and successful economies. An alternative ‘Third Way’ ideology began to emerge during the 1990s in the US, associated initially with the Clinton administration and then with British Prime Minister Tony Blair and German Chancellor Gerhard Shroeder and coincided with public disenchantment towards neoliberal policies (P. Barnett & Barnett, 1999). As a revisionist version of social democracy, the Third Way critiqued traditional left-wing politics and attempted to go beyond (or perhaps between) capitalism and socialism: neoliberalism and Keynesianwelfare (McLennan, 2004).

Prolific writer and Director of the London School of Economics, Anthony Giddens, popularised the Third Way movement, modernising social democracy to take into account the imperatives of “the disappearance of socialist utopias, globalisation, the development of a service economy and ageing populations” (Giddens, 2004a, p. 24). Third Way thinking endeavours to build on, rather than reverse, neoliberal achievements of the 1980s and 90s, accepting the role of capitalism in both industry and the knowledge economy (Heywood, 1992). The Third Way is, therefore, as much constituted by neoliberal discourse as it is by social democracy and welfarism.

Central to Gidden’s thesis is the realisation of ‘human potential’ as people are freed to make the most of their capabilities, moving society towards greater equality (Giddens, 2004b). Emphasising a hand-up rather than a hand-out (Huntington & Bale, 2002), the win-win purpose of Third Way welfare assistance is to support individuals’ and families’ return to productivity and usefulness in the market economy. Known as ‘ladders of escape’, this theory is not new, and in the view of Hattersley (1999), addresses neither the broader goal of redistribution, nor the supposed inevitability of economic determinism for those born to poverty.

Not claimed by Giddens – at least in 1999 – to be a fully-fledged political philosophy (Giddens, 1999), McLennan (2004) is critical of the Third Way for its lack of definition. He comments on its evolutionary nature and that it may be

more profitably thought of as ideas with “a limited shelf-life” that “serve to make things happen at a particular time” (p. 485). More cynically, Levitas (2004, p. 42) describes the concepts as deliberately “flexible”, designed to be “understood in different ways by different constituencies”. Levitas makes it clear that the Third Way is not an alternate position to neoliberalism, but “a ‘soft’ synthesis of market forces and a reliance on ‘community’ to simultaneously mop up the damage done by market forces and replace, mediate or legitimate the policing functions of the state” (p. 43). Third Way rhetoric therefore serves to reinforce neoliberal hegemony by seeking the same goals of national prosperity but achieves them via another means.

Foucault’s (1991b) notion of governmentality provides a useful tool for examining the discursive constructions of politics across the spectrum and the engagement in social ordering via public policy. According to Foucault, techniques of domination and techniques of the self connect to create subjects in

economic terms, and as “members of a population, in which issues of individual

… conduct interconnect with issues of national policy and power” (Gordon, 1991, p. 5). The political rationality of neoliberalism shifts state control onto rational individuals, shifting what were previously political and social issues to become economic and reducing state provided services such as welfare in order to increase personal responsibility for self-care (Lemke, 2001).

Conversely, the Third Way simultaneously promotes prosperity and social justice (Giddens, 2004b) by direct government intervention and serves to attach everyday living to politics, connecting health to the economy by way of a productive labour force (Gastaldo, 1997; Powers, 2003). Foucault’s notion of governmentality applies also to welfarism and Third Way thinking as subjects continue to be constituted in economic terms, but now the state assumes active involvement in the reduction of risk to society. By employing new tactics and techniques to the population, the economy of a country can develop, which in turn benefits the population. A particular technique employed by the Labour government for managing the health of the New Zealand population is the PHC Strategy (Ministry of Health, 2001b) and recurs throughout the thesis, but particularly in part three.