PROCESAMIENTO DE LA INFORMACIÓN

Those social theorists such as Bauman who recognise the existence o f a postmodern society characterised by greater political and economic uncertainty and risk typically argue that the state now responds to these more externalised risks through more subtle means of control than the top-down policies o f the past. As summarised by Lash, the social changes that have occurred are as follows:

“ I f simple modernization’s totalising inversion o f the social rights o f the Enlightenment project is the impersonality o f the bureaucratic welfare state, then its reflexive counterpart understands that welfare services are a client- centred co-production and advocates a decentralised citizen-empowering alternative set o f welfare arrangements ” (Lash: 1994:113).

Postmodemity is thus seen to mark the decline in the hegemony and universalism of science in general and of biomedical science and its power o f surveillance in particular. A picture is painted in which there is a new beginning for ‘the expert’. A health expert need not be a medical professional in the traditional sense, but someone whose knowledge is purchased by the consumer. That knowledge it is asserted may or may not incorporate the biomedical paradigm o f understanding. The expansion in the number o f ‘experts’ advising the subject about the health choices they should be making is seen to be an outcome o f a ‘free market’ o f expertise. Information about risks is provided, but the choice about what course o f action to adopt is left to the individual. However, it is acknowledged that this social process will result in different ‘expert’ groups promoting their own particular assessments o f risk (an example would be the current conflicting expert claims regarding dietary intake). This means that the

individual consumer o f expert advice can never be certain about expert knowledge, about whether one set of advice is more likely to guarantee security than another; the subject and their uncertainty remain central (this position is discussed in more detail in

Section 2.4.3 below).

But does the main threat or challenge to the continuing hegemony o f the biomedical profession within the system o f health care come from some insidious process of individualisation which is breaking the traditional sources o f power in society? Certainly, in analysing the recent history o f the British health care system in relation to this perceived failure o f the modernist project to control ‘risk’ we find that the state has been moving towards more rather than less central regulation o f the health professions. This reflects, at least in part, the ongoing attempt to regulate health care spending in the NHS through processes o f ‘efficiency and effectiveness’. Examples of this greater regulation are the development o f clinical governance frameworks, the creation o f NICE and its role in setting guidelines for the medical profession concerning the suitability o f particular drug technologies, and the move towards direct involvement in the medical profession’s self-regulatory bodies.

The traditional distinction between the work of doctors and nurses was said to be that between ‘care’ and ‘treatment’. However, this boundary is becoming increasingly indistinct as nurses take on physicians’ work, even with the tacit approval o f the profession, as described above. What are the reasons for this shift in clinical work boundaries ? First, in an attempt to reduce costs, nurse specialization has meant that a broad level o f medical knowledge is not required when limited clinical interventions are divided into a set o f discrete tasks that can be delivered as well as (but more cheaply than) by expensively trained doctors. The second reason is to make it possible to reduce junior doctors’ working hours (the 1993 ‘new deal’). The third, bearing in mind the caveats discussed in the preceding chapter, has to do with nursing’s own professionalization strategy. This has involved, amongst other factors, the adoption of systematic and distinct nursing models o f care, the move o f nursing training into the higher education sector with a concomitant widening o f nursing’s theoretical knowledge base, and the subsequent development o f ‘knowledgeable doers’.

These developments point to the historical dependence o f the medical profession upon state forms o f health care delivery. Utilising Gramsci’s conception o f ideological hegemony (discussed in detail in Section 2.5), the restructuring o f the functions o f the state which have occurred in the late modem period can be seen to reflect changes within the ‘historical bloc’ and the associated balance o f material forces. This has meant that the need to reproduce particular ideological forms disappears. In this late modem period, the post-war form o f the state in the shape o f an ideology of state welfarism could be said to constitute one such example. And with this has gone the form o f the patemalistic and altmistic doctor, to be replaced by more consumer- friendly health care practitioners. Whether there are signs o f an ending o f the traditional hegemonic role o f the doctor at the micro level, to be replaced by a more patient-centred role for the nurse in care delivery, is something which is explored in the nurse focus group discussions, the results o f which are set out in the data analysis

2.3 Professional Identity, the Organisation of Work, and