I first heard the word neoliberalism during an epistemology class as part of the first year of my PhD. I didn’t take much notice, frankly it was another long word that I just hadn’t heard before and in that class, it took quite a while to understand what any of the long words ending in *ism meant. Like yellow cars, however, I started to notice the word more and more, within student conversations, occasionally in an obscure journal paper, in the occasional Guardian article and increasingly on social media. This week I finally got around to reading ‘The Establishment’ by Owen Jones, which in many ways summarises a view of what neoliberalism is, how it has come about, implications and crucially who gains and thrives from it, and how they sustain it – the Establishment. He suggests that this isn’t some grand plan or group of leaders meeting in some smokey gentlemans club somewhere, but a mental model developed by a few outriders that prepared the way for a shift to the right, arguing that the post war consensus, i.e. The welfare state etc., needed reform and retrenching. As one of Thatchers children, the pattern was for me perhaps harder to notice, perhaps explaining why neoliberalism was I word I hadn’t heard before 2013, so normalised and prevalent were the arguments for privatisation and growing individualism, the need for accountability etc. during my education, early career and within general discourse.
Using this viewpoint, the book has made me think rather hard about what QI practitioners like myself do, and how that may or may not contribute to the ‘Establishment’ and what Owen Jones suggests it stands for. Quality improvement by its nature is about ensuring improved performance, measurement, and in many cases doing more with the same or less – many of the very thing that have grown during the era of neoliberalism. Some critics of quality improvement approaches suggest they just the latest in a long line of ways, most of which started, they argue, with Taylorism, to inappropriately standardise work (especially in healthcare) and exploit and control workers, gradually removing worker rights for flexibility and seeking ever more efficiencies and productivity improvements, that benefit the elite (establishment).
Most factories I worked in during my early career were on the brink of closure (often due to outsourcing activity, usually to Asia) or already in the throes of redundancies, which were often the programmes which I worked on to work out how a supply chain could keep working whilst production moved or the workforce downsized. The first time I work on a project involving redundancies I remember having a huge strop with my boss explaining how ‘I came to improve things, not help people lose their jobs’… I was sat down and it was explained to me that in the long run this was better, because without the restructuring there would be no factory at all, and surely some jobs are better than none. At the time, as a junior engineer, I just nodded and got on with it… time to grow up, it was my job, right? And I continued to work on improvement projects of all types. I do remember a sense of relief though on joining the NHS that now I would ‘definitely’ be improving people’s lives.
But the perspective offered in this book has really made me wonder if we are doing what we ostensively set out to do when improving quality in healthcare. Most improvement approaches define quality based on the patients view of quality (a few could be argued to use much more neoliberal view…i.e. stuff people will pay for). So, how much of improvement activity is genuinely for patients? How much improvement activity is genuine coproduction and working together with staff and patients? This to me is the hope that is offered by quality improvement approaches rather than the exploitation and standardisation that QI approaches can be critiqued as. My sense in healthcare is we are not there yet, and have quite somewhere to go.