The Sociological Analysis of the Principle of Medical Self-Regulation Part 3

Governmentality and the Revival of Liberalism

Classical liberalism emerged in the seventeenth and eighteenth centuries, through the works of a variety of writers, such as Thomas Hobbes, John Stuart Mills, Adam Smith, Thomas Locke, Jeremy Bentham and Herbert Spencer. It is possible to identify at the centre of classical liberalism the underlying concept of ‘possessive individualism’ (Macpherson 1962). Macpherson (1962) argues that for these thinkers the individual and her capabilities ‘pre-figure’ the circumstance into which she is born. In short, her talents and who she is owes nothing to society, rather she owns herself, and she is morally and legally responsible for herself and herself alone. She is naturally self-reliant and free from dependence on others. She need only enter into relationships with others because they help her pursue her self-interests. According to this viewpoint, society is seen as a series of market-based relations made between self-interested subjects who are actively pursuing their own interests. Only by recognising and supporting this position politically and economically will the greatest happiness for the greatest number be achieved. Classical liberalism is a critique of state reason, which seeks to set limits on state power.

It is against this background of the re-emergence of liberalism that sociologists concerned with the role and governance of expertise within society have recognised the importance of the work of Foucault and his concept of Governmentality in the analysis of the relationship between the professions and the state (Peterson and Bunton 1997). The work of Foucault (1965, 1970, 1972, 1977, 1979, 1982, 1985a, 1985b, 1986, 1989, 1991a, 1991b) highlights how individual subjectivities are neither fixed nor stable, but rather are constituted in and through a spiral of power-knowledge discourses. These are generated by political objectives, institutional regimes and expert disciplines, whose primary aim is to produce governable individuals (Deleuze 1988 Peters 2001).

At the end of eighteenth century onwards there was a steady growth in "the dubious sciences", what Foucault calls the human sciences, particularly new scientific disciplines, such as psychiatry. Foucault holds that a key outcome of the rise of these new sciences was the more intensive use of ‘dividing practices’ to objectify an individual and their body via systems of notation, classification and standardisation (Turner 1992). Foucault argues that through their examination and assessment techniques experts produce normative classifications for subjective positions (normal, mad, sexually deviant etc) which increasingly became inscribed within the disciplinary regimes of society’s organisational and institutional structures. There regimes spread throughout society as a whole as the dominance of the ‘pastoral power’ of Christianity started to decline and a more secular concern with ‘the conduct of conduct’, Governmentality, emerged from the sixteenth century onwards (Foucault 1991).

Foucault first published his study of Governmentality in 1979 (Foucault 1991b) and further developed it as a concept within a series of lectures given at the College de France (Burchell 1991). Foucault discusses that from around the sixteenth century onwards an ever growing number of treatises were published on the governance of the soul and the self, the family and the state. These were published against an increasingly complex background of technological development, rapid social change and political and intellectual upheaval. It should not be surprising to learn that events such as the enlightenment, the reformation, the rise of modern science and development of industrial capitalism, collectively led to a growth in the writing of treatises which sought to answer fundamental problems of rule: ‘how strictly, by whom, to what end, by what methods etc’ (Foucault 1991b: 88). Foucault notes that these treatises focused more and more upon the idea that good governance entailed ‘the right disposition of things’ and had as its aim ‘the common welfare and salvation of all’. Governance came to involve securing the security, health, welfare and happiness of the population. The "population comes to appear above all else as the ultimate end of government’ (Foucault, 1991b: 100). Over time, governance would become increasingly tied into a liberalist conception of economics. Good government was economical, both fiscally and in its use of power. Furthermore, the development of new forms of expertise, Foucault’s dubious ‘human sciences’ such as psychology, medicine and sociology, are tied up with this need to govern the population to ensure its betterment. This was because at an increasingly complex administrative and bureaucratic level the population was seen as possessing its ‘own regularities, its own rate of deaths and diseases, its cycles of scarcity, etc’ (Foucault 1991b: 90). Consequently, ‘novel forms of expertise in the fields of public health hygiene, mental health and mass surveillance emerged in concert with developing government policies and programmes.and were intimately involved in the construction of governable realms of social reality’ (Johnson, 1994: 142). The modern professions and their associated training and regulatory arrangements are emergent as an aspect of the formation of a liberal form of Governmentality that has as its target the population and its welfare, and which itself was emergent with the growth of capitalist industrial economies across Europe during the nineteenth century.

Foucault notes that two other forms of power, Sovereignty and Discipline, are tied up with the development of the power of a population-focused form of Governance, with its concern for ‘the conduct of conduct’, to enable the promotion of the security, health, wealth and happiness of individual subject-citizens. Sovereign ‘command’ power is exercised over subjects through the juridical and executive arms of government. Historically, sovereign power is related to monarchical rule, with its executive mechanisms of constitutions, laws and parliaments. Over time, these were made into more representative institutions through the development of democratic ideals, with allegiance to the monarch becoming transformed into allegiance to the rule of law (Foucault 1991b). The power of Discipline goes back to ancient religious, military and educational practices. As Foucault noted in Discipline and Punish (1977) its expansion over the population during the seventeenth and eighteenth centuries is tied up with a growing administrative and institutional need to survey and make docile individual and collective bodies. Disciplined individuals have acquired habits of action and thought which enable them to act in appropriate and expected ways and to do so through the exercise of self-control (Foucault 1977). ‘Good governance’ is about how to best align the Sovereign power of command and productive Disciplinary power in order to achieve the primary object of securing the health, wealth and happiness of the population. This is why Foucault argues that the power of Governance does not replace the power of Discipline or Sovereignty. Rather it recruits them. Indeed Foucault (1991b: 102) argues that ‘we need to see things not in terms of the replacement of a society of sovereignty by a disciplinary society and the subsequent replacement of a disciplinary society by a society of government; in reality one has a triangle, sovereignty-discipline-government, which has as its primary target the population’.

In short, the power of Governance is where ‘technologies of domination of individuals over one another have recourse to processes by which the individual acts upon himself and , conversely. where techniques of the self are integrated into structures of coercion’ (Foucault 1980: 2). Governance ‘retains and utilizes the techniques, rationalities and institutions characteristic of both sovereignty and discipline… [but it also].departs from them and seeks to reinscribe them. The object of sovereign power is the exercise of authority over the subjects of the state within a defined territory, e.g. the deductive practices of levying taxes, of meting out punishments. The objects of disciplinary power is the regulation and ordering of the numbers ofpeople within that territory e.g. in practices of schooling, military training or the organisation of work. The new object of government, by contrast, regards these subjects and the forces and capacities of living individuals, as members of a population, as resources to be fostered, to be used and to be optimized’ (Dean 1999: 12).

Liberal Government: Club Governance as the ‘Natural State’ of Things

The institutionalisation of professionalism as a self-regulatory strategy was ensured by liberalism’s focus upon what is natural and what is not. The development of modern, rational and scientific expertise is entwined with the growth of the view that personal freedom is the ‘natural state’ of humankind and minimal forms of government are the ‘natural way of things’ (Rose 1999). Governmentality seeks the optimum method by which to affect ‘at a distance’ the way individuals conduct themselves without recourse to direct forms of repression or intervention unless it is absolutely necessary (Barry, Osborne and Rose 1996). This is because the effectiveness of liberal ‘mentalities of rule’ lies in their ability to align ‘the objectives of authorities wishing to govern and the personal projects of those organisations, groups and individuals who are the subjects of government’ (Rose 1999: 48). A key method by which this goal was achieved from the nineteenth century onwards (and still today) was by harnessing the expertise of doctors, lawyers, and teachers etc ‘into the process of governing, but it did so in the institionalized forms of independent, neutral colleague associations, controlling recruitment and training, providing codes of conduct and procedures of discipline. underwritten by government in the form of official recognition of license’ (Johnson 1994: 144). The restrictive practices of professionalisms exclusive ‘club mentality’ may seem on the surface to be oppositional to liberalisms ‘free market’ political philosophy. In reality, ‘club governance’ formed an essential part of the emergence of liberal Governmentality. Indeed, the gentleman’s club was a ‘hot bed’ of commerce in Victorian society and similar to the ‘professional club’ it had clear ideas about who should get through the front door (Moran 2004). Consequently, the establishment of state-sanctioned jurisdictions for emergent professions such as medicine over the surveillance, classification and care of poor-rich, sick-healthy and mad-sane subjects, was not solely the result of successful occupational strategies of advancement based upon claims to possess esoteric expertise and an altruistic code of conduct. Rather, class and gender inequalities influenced the ‘club rule’ form that professional self-regulatory institutions such as the GMC took. While the establishment of the jurisdictions of emergent professions over particular elements of the general population was an outcome of programmes and policies that sought the legitimate expansion of the ability of government to shape and enhance the self-regulating capabilities of individuals along predetermined lines (Rose 1992 1999, Barry, Osborne and Rose 1996). This was because ‘this form of power cannot be exercised without knowing the inside of people’s minds, without exploring their souls, without making them reveal their innermost secrets. It implies a knowledge of the conscience and an ability to direct it’ (Foucault, 1982: 783). For example, over the last century, the medical profession has significantly contributed to an intensitification in the surveillance and control of the body and the self of the individual subject under the banner of maintaining the health of the population. As Armstrong (1983: 112) notes: ‘[in] the twentieth century the human body has been subjected to a more complex, yet perhaps more efficient, machinery of power which, from the moment of birth (or, more correctly, from the time of registration at an ante-natal clinic) to death, has constructed a web of investigation, observation and recording around individual bodies,, their relationships and their subjectivity, in the name of health’.

The "Enterprise Self’ of Neo-Liberal Governmentality

The focus of Governmentality is upon the role of professional expertise as a ‘socio-technical’ device through which the self-regulating subjectivity of citizens is surveyed and managed ‘at a distance’. It does not view contemporary challenges to professional privilege, such as reforms to the GMC, as being only concerned with reducing the high level of freedom from outside control that the professions have historically possessed (Johnson 1994 1995). It highlights how they are also concerned with the ultimate object of Governmentality: the population in general and the individual subject-citizen in particular. Indeed, as Johnson (1994: 149) notes, ‘government-initiated change has, in recent reforms, been securely linked with the political commitment to the ‘sovereign consumer’. In the case of reform in the National Health Service, this translates.[to a] stress on prevention, the obligation to care for the self by adopting a healthy lifestyle, the commitment – shared with the new GP – to community care’.

From a Foucauldian perspective, contemporary sociological analyses of the professions and the governance of professional expertise must be set against a background of the re-emergence of liberalisms’ ‘possessive individualism’ in the last three decades in form of the ‘enterprise self of neo-liberalist Governmentality (Rose 1996a 1999). Here, as Rose (1999: 87) notes: ‘a new relation of individuals to expertise is established, based not upon welfare bureaucracies, social obligations and the inculcation of authoritatively established norms, but upon the mechanisms of the market and the imperatives of self-realization’.

Rhodes (1994) notes that the attitude of UK government towards professionals since the 1980s has been dominated by a concern for the ’3 Es’: economy, efficiency and effectiveness. This is demonstrated by the rise of New Public Managerialism in the public sector (Pollitt 1990 1993). The growth of a rationalistic-bureaucratic managerial discourse of outcomes based transparent standard setting and performance appraisal in the health and social care arena is bound up with this. Indeed, it is often argued that a ‘new commercialised professionalism ‘ (Hanlon 1998: 54) has emerged which stresses the need for professionals to develop managerial and entrepreneurial skills (Hanlon 1994 1998). This is a result of government attempts to improve trust in public sector services by seeking to redefine professionalism so that it becomes more commercially aware, target focused and managerially accountable. In this regard, the Foucauldian viewpoint shares much in common with neo-Weberian accounts of the contemporary situation faced by the medical profession. Both hold that there has been an increase in government intervention in the public sector and in turn the work of health and social care professionals. As part of this, doctors have increasingly become entwined in a particular system of governance, namely ‘clinical governance’, which requires the medical profession work alongside management to align clinical authority with economic viability (Flynn 2002). However, authors working from a Governmentality viewpoint also see the emergence of a more economically aware form of professionalism as taking place against a background of a profound shift in ‘the nature of the present’ (Rose 1992: 161) and the way ‘[we] come to recognise ourselves and act upon ourselves as certain kinds of subject" (Rose 1992: 161). For in this way "a person’s relation to all his or her activities, and indeed his or her self, is.given ‘the ethos and structure of the enterprise form’ (Rose 1999: 138). Indeed, from a Governmentality perspective, challenges to medical autonomy in the NHS and the principle of medical self-regulation in the form of the GMC form part of a broader shift in the grounds under which the legitimate governance of the population is practiced (Rose 1999). This is due in no small part to the ascendancy of ‘the enterprise self throughout all spheres of modern social life. As Burchell (1993: 275) argues: ‘One might want to say that the generalization of an "enterprise form" to all forms of conduct – to the conduct of organisations hitherto seen as being non-economic, to the conduct of government, and to the conduct of individuals themselves – constitutes the essential characteristic of this style of government: the promotion of an enterprise culture’.

The emergence of neo-liberalism in the 1970′s re-activated classical liberalism’s concern with the liberty of the individual, advocacy of free markets and call for less direct government. It emphasised the entrepreneurial individual, endowed with freedom and autonomy, and a self-reliant ability to care for herself; driven by the desire to optimise the worth of her own existence (Rose 1993 1996a 1999). For example, the conservative home secretary, Douglas Hurd, stated in 1989 ‘the idea of active citizenship is a necessary complement to that of the enterprise culture’ (Hurd 1989, quoted in Barnett 1991: 9). Neo-liberal forms of Governmentality seek to govern through the autonomy of the governed. Citizens should be active, not passive, and democratic government must engage the self-regulating capabilities of individuals. Neo-liberal government focuses upon the use of the ‘technologies of the self’ because the ‘citizens of liberal democracy are to regulate themselves; government mechanisms construe them as active participants in their lives.Such a citizen subject is not to be dominated in the interests of power, but to be educated and solicited into a kind of alliance between personal objectives and ambitions and institutionally or socially prized goals or activities. Citizens shape their lives through the choices they make about family life, work, leisure, lifestyle, and personality and its expression. Government works by ‘acting at a distance’ upon these choices, forging a symmetry between the attempts of individuals to make life worthwhile for themselves, and the political values of consumption, profitability, efficiency and social order’ (Rose 1990: 10).

Burchell (1996: 28-29) argues that neo-liberalisms dual advocacy of the self-regulating free individual and the free market have led to ‘the generalisation of an ‘enterprise form’ to all forms of conduct’.. Similarly, du Guy (1996a, 1996b) argues that ‘enterprise’, with its focus upon energy, drive, initiative, self-reliance and personal responsibility, has assumed a near-hegemonic position in the construction of individual identities as well as in the government of organisational and everyday life. Enterprise, he argues, has assumed ‘an ontological priority’ (du Guy 1996a: 181). du Guy holds that ‘a discourse of enterprise makes up the individual as a particular sort of person – as an ‘entrepreneur of the self’ (du Guy 1996b: 11) so ‘every individual life is, in effect, structured as an enterprise of the self which each person must take responsibility for managing to their own best advantage’ (du Guy 1996b: 14) . The concept of the self as enterprise requires that the possession of an essential core self is taken as the central feature of personal identity. How else could individuals be expected to become responsible for themselves and the care of their bodies and not a burden on the state? The very notion of the enterprise self requires a political commitment to the idea that all individuals are capable of self-fulfilment. This is the core mechanism by which the self-regulatory capabilities of the individual can be enhanced and entwined with the key objectives of governance: the security, health, wealth and happiness of the general population.

Consequently, failure to achieve the goal of self-fulfilment is not associated with the possession of a false idea of what it means to be human, or that individuals do not possess an essential core self which is the ‘real’ and ‘true’ them for all eternity. Rather, it is the fault of poor choices, a lack of education or the ‘dependency culture’ created by the welfare state. It is the result of ‘learned helplessness’, which in itself can be resolved with ‘programmes of empowerment to enable [the individual] to assume their rightful place as self-actualizing and demanding subjects of an ‘advanced’ liberal democracy’ (Rose 1996a: 60)

Expert Enclosures and Technologies of Performance and Agency

The ascendancy of the enterprise self has increasingly led, as Rose (1993: 285) notes, expertise being increasingly ‘governed by the rationalities of competition, accountability and consumer demand’ Rose (1993 1996a 1999) argues that the increasing institutionalisation of expertise during the nineteenth and twentieth centuries led to expert knowledge becoming integral to the exercise of political authority. Experts gained ‘the capacity to generate ‘enclosures’, relatively bounded locales or fields of judgement within which their authority [was] concentrated, intensified and rendered difficult to countermand’ (Rose 1996a: 50). However, as a result of the rise of the enterprise self the enclosures are now being ‘penetrated by a range of new techniques for exercising critical scrutiny over authority – budget disciplines, accountancy and audit being the three most salient’ (Rose 1996a: 54). As Osborne (1993) discusses, ever since the re-emergence of liberalism in the 1970s there has been a gradual reformulation of health care governance so that ‘the field of medicine’ is, to a greater degree than ever before, simultaneously both governed and self-governing. In an attempt to promote public trust in public sector reforms, the state becomes increasingly involved in medical governance and seeks to promote greater accountability and transparency within professional systems of self-governance. To achieve these goals it adopts a strategy whereby professional expertise is increasingly subjected to an additional layer of management and new formal ‘calculative regimes’ (Rose and Miller 1992), including the setting of performance indicators, competency frameworks and indicative budget targets. Rose (1996a 1999) emphasises the enormous impact of the trend in all spheres of contemporary social life towards ‘audit’ in all its guises, with its economic concern with transparent accountability and standardisation, particularly for judging the activities of experts. This is because two technologies are central to the promotion of the enterprise self at the organisational and individual levels. A ‘technology of agency’ which seeks to promote the agency, liberty and choices of the individual as they strive for personal fulfilment, and a ‘technology of performance’ which seeks to set norms, standards, benchmarks, performance indicators, quality controls and best practice standards. These help to survey, measure and render calculable the performance of individuals and organisational structures. Dean (1999: 173) notes:

‘From the perspective of advanced liberal regimes of government, we witness the utilisation of two distinct, yet entwined technologies: technologies of agency, which seek to enhance and improve our capabilities for participation, agreement and action, and technologies of performance, in which these capabilities are made calculable and comparable so that they might be optimised. If the former allow the transmission of flows of information from the bottom, and the formation of more or less durable identities, agencies and wills, the later make possible the indirect regulation and surveillance of these entities. These two technologies are part of a strategy in which our moral and political conduct is put into play within systems of governmental purposes’.

Bound up with the technologies of agency and performance of the enterprise culture is what can be called a progressive and insipid process of ‘contractualization’. Institutional roles and social relations between individuals are increasingly defined in terms of explicit contract, or at the very least, ‘in a contract like way’. The promotion of the enterprise form involves the creation of processes where subjects and their activities are ‘reconceptualized along economic lines’ (Rose 1999: 141) Indeed, Gordon (1991: 43) argues that entrepreneurial forms of governance rely on contractualization as they seek ‘the progressive enlargement of the territory of economic theory by a series of redefinitions of its object’. Entrepreneurial forms of governance ‘re-imagine’ the social sphere as a form of economic activity by contractually: a) reducing individual and institutional relationships, functions and activities to distinct units, b) assigning clear standards and lines of accountability for the efficient performance of these units, and c) demanding individual actors assume active responsibility for meeting performance goals, primarily by using tools such as audit, performance appraisal and ‘performance-related pay’ (du Guy 1996c). Here judgement and calculation are increasingly undertaken in economic ‘cost-benefit’ terms, which give rise to what Lyotard (1984: 46) terms the ‘performativity principle’: the performances of individual subjects and organisations serve as measures of productivity or output, or displays of ‘quality’ and ‘an equation between wealth, efficacy and truth is thus established’ (Lyotard 1984: 46).

Neo-liberal Governmentality is concerned with ‘the conduct of conduct’ and seeks to govern through the autonomy of the governed. It is concerned with ”the practices of liberty’ i.e. it is concerned with practices which structure, shape, predict and make calculable the operation of freedom. This is also why the traditional ‘closed shop’ form of professionalism as a self-regulatory strategy for institutionalising expertise has been challenged by the rise of the enterprise self but self-regulatory privileges have not been completely erased. For in a very real and practical way government depends upon expertise to render social realities governable – whether it is in the field of health, education or law – through shaping the self-regulating capacity of subjectivity among all citizens, including that belonging to professionals themselves. The effectiveness of neo-liberal ‘mentalities of rule’ lies in their ability to align ‘the objectives of authorities wishing to govern and the personal projects of those organizations, groups and individuals who are the subjects of government’ (Rose 1999: 48). The ‘diagnostic truths’ and ‘recommendations for action’ provided by experts such doctors play a vital role in fostering such alignments. Consequently, from this viewpoint, the emergence of a ‘new professionalism’ within professions such as medicine is inextricably bound up with a broader shift in the nature and scope of legitimate authority and forms of governance within modern democratic liberal society. Certainly the apparent re-appropriation of rationalistic-bureaucratic ‘technologies of performance’ by occupational elites within professions such as medicine appear to belong to a particular ‘mentality of rule’ which recognises that ‘[rule] ‘at a distance’ [only] becomes possible when each [agent] can translate the values of others into its own terms [so] that they promote norms and standards for their own ambitions, judgements and conduct Rose (1999: 50). For example, a recent study of the ‘Governmentality of clinical governance’ in primary care by Sheaff (2004) found that there had been a shift towards more formal networks of collective peer review of individual doctors work practice. Primarily through the contractual use of rationalistic-bureaucratic ‘technologies of performance’ such as medical audit and evidence based medicine. Greater peer surveillance of clinical practice is justified by doctors themselves because they sought to reduce unnecessary variations in the quality of clinical care as well as minimise economic costs. This is in addition to forestalling a perceived growing threat of managerial control over medical work. The overarching outcome of this shift towards greater surveillance and control of individual doctor’s activities was an increase in the view that individual doctors could and indeed should be placed under peer surveillance and control. Hence, governing objectives for greater cost and risk containment existed alongside an increase in professional accountability, and were aligned with the medical professions self-image of itself as an independent and yet morally and socially responsible occupation.

The Contribution of the Governmentality Perspective

The Governmentality perspective makes a significant contribution to the sociological study of the professions and professional regulation. It highlights the key role professions, such as medicine, have played in the governance of the population. In doing so, it adopts a similar critical view of the emergence of professionalism as a form of regulatory control as the neo-Weberian perspective. Importantly, it reinforces the need for current debate surrounding recent challenges to the principle of professional self-regulation, to also consider the changing nature of the relationship between subject-citizens and the state, as a result of the political and economic re-emergence of liberalism since the mid to late-1970s. For the Governmentality perspective notes the ascendancy of the concept of the ‘enterprise self’ into all spheres of contemporary life. In doing so it highlights how challenges to the principle of professional self regulation and concurrent calls to reform the GMC can be seen to be directed towards the object of Governmentality – the population in general and the individual subject-citizen in particular – as much as they are the medical profession. For medicine, and indeed the health and social care professions as a whole, form but one part of a complex array of governing calculations, strategies and tactics which seek to promote the security, wealth, health and happiness of the population (Rose and Miller 1992). It is important for social scientists to recognise this. As in terms of Isaiah Berlin’s (1969) famous dichotomy of ‘positive’ and ‘negative’ liberty, although liberal mentalities may appear at first to promote ‘negative liberty’ (i.e. the personal freedom of the individual subject to decide who they are and discover what they want to be) they in reality promote ‘positive liberty’ (i.e. that is a view of who and what a citizen-subject is and should be). This carries with it the very real danger of authoritarianism (Dumm 1996).

A Critical Assessment of the Governmentality Perspective

The Governmentality perspective highlights how it is theoretically useful to collapse the ‘common sense’ dichotomy of state-profession, which often exists in sociological accounts of the professions and the governance of expertise. For neo-liberal ‘mentalities of rule’ are concerned with ‘the conduct of conduct’ as they seek to promote the autonomous self- actualised enterprising subject, who as an active citizen of a modern democracy recognises they are responsible for themselves. This means that modern government must seek to govern through the freedom and aspirations of their citizen-subjects so that they come to recognise and self-regulate their activities in such a way that they ‘naturally’ align with broader social, economic and political objectives. This requirement has led to a critical re-configuration of the legitimate grounds on which ‘good governance’ can be practiced. With the ‘field of medicine’ becoming more than ever before simultaneously ‘governed’ and ‘self-governing’ as a consequence (Osborne 1993). As illustrated by the re-appropriation by medical elites of an emergent rationalistic-bureaucratic discourse of outcomes based standard setting and performance appraisal in the face of its increasing use by ‘outsiders’, such as hospital management, to monitor the activities of doctors.

However, the Governmentality perspective suffers from two key interrelated weaknesses. First, it possesses a tendency to over state the dominance of the ‘enterprise form’ in the social, economic and political spheres, as well as the construction of human subjectivity, and so an individual’s sense of personal identity. As the topic has noted, authors such as Gordon (1987), Burchell (1993) and du Guy (1996a) hold that reforms in the public sector since the 1980s have been bound up with a political programme that is primarily concerned with the promotion of the enterprise self as an ‘ontological priority’. This is because ‘the discourse of enterprise brooks no opposition between the mode of self-presentation required of consumers, managers and employees and the ethics of the personal self’ (du Guy 1996a: 64). Thus, public sector reforms have sought to challenge the traditional work identities of public sector workers, including that of professionals. Primarily through undertaking a ‘cultural crusade’ concerned with changing ‘the attitudes, values and forms of self-understanding embedded in both individual and institutional activities’ (du Guy, 1996a: 151). For the world of enterprise valorises the autonomous, productive, self-regulating individual and requires that all workers ‘come to identify themselves and conceive of their interests in terms of these new words and images’ (du Gay, 1996a: 53). There does seem to be an element of truth in this viewpoint. However, the enterprise self, with its ‘bundle of characteristics’ such as energy, initiative, ambition, calculation, self-sufficiency and personal responsibility, is just one of an array of competing discourses and associated bundles within society. These operate within the public and private spheres on individual subjects, constructing subjective positions for them to occupy, and influence their sense of personal identity. People perform a range of identities in different places, with different people, and at different times, over the duration of their life course (Bauman 1996). As Hall (1996: 4) notes ‘identities are never unified.never singular but ..constructed across different, often intersecting and antagonistic discourses, practices and positions’. In short, the discourse of enterprise is not all consuming. Rather, it exists amongst a plethora of already existing, overlapping and frequently competing discourses. These often relate to key social categories such as gender, age, and ethnicity and so on, which act upon an individual, influence how they come to understand themselves as a particular type of subject, and consequently self-regulate their actions to produce personally desired effects (Fournier and Grey 1999). du Guy (1996a: 150) admits as much when saying ‘although enterprise prefers a tabula rasa on which to write it compositions, it actually seeks to produce its effects under circumstances not of its own choosing’. One example of a competing discourse on which the discourse of enterprise must seek to write itself with varying degrees of success is of course the discourse of professionalism. Regardless of whether or not it is called ‘old’ or ‘new’, it emphasises independence of thought and action in the name of service to others. For its sense of affiliation has not traditionally lain with bureaucratic procedures or managerial imperatives, but rather with a particular body of esoteric knowledge and specialist expertise, which belongs to a somewhat exclusive community of practitioners who possess a shared ethical code of conduct. Furthermore, the ability of professional practitioner’s ‘new professionalism’ to resist or subvert the predominately economic focus of the enterprise culture, is itself a matter for sustained empirical investigation that must include all public sector occupational groups. Kuhlmann (2006a: 222) for one believes that doctors have been able to "amalgamate managerialism and professionalism…..and [been able to] outflank tighter public control and [attempts] to create a comprehensive system of accountability". Although she acknowledges that her work is primarily focused on health care reforms in Germany, and argues that further cross-national research is needed before any firm conclusions are drawn.

The second key weakness of the Governmentality perspective is that in a practical sense professional groups and the state are different entities. It arguable that they should be treated as such if sociological understanding is furthered regarding the role institutionalised forms of expertise such as medicine play in the governance of the population. Certainly, it is often necessary for practical reasons to demarcate professional expertise from the governing apparatus of the state. Particularly when analysing empirically the affect of contemporary reforms on the principle of professional self-regulation in the eyes of professional practitioners themselves. It is the neo-Weberian ‘social closure’ perspective that is most useful here. For its account of the historical development of medicine’s ‘exclusive cognitive identity’, which underpins its ‘members only’ stance concerning the issue of who should regulate doctors, reflects the nature of the regulatory context and the form of the occupational culture of the medical profession in the Anglo-American context. As illustrated by the continued insistence by medical elites that whatever changes to the current system are introduced, they should be heavily involved in deciding if a doctor is indeed ‘fit to practice’ and should remain on the state-approved register of practitioners

Synthesising the Neo-Weberian and Governmentality Perspectives: The Restratification Thesis

Despite these two weaknesses, the value of the Governmentality perspective lies in the fact that it reinforces the need to view recent internal reforms within the professions, alongside greater external surveillance of their actions by the state, as being linked with broader changes in how ‘good governance’ is viewed and practiced within modern liberal democratic society. While as the previous discussion has illustrated, the Governmentality viewpoint shares much in common with the dominant neo-Weberian perspective in terms of how it views the regulatory arrangements surrounding the health and social care professions. Given that the neo-Weberian perspective reflects the reality of the regulatory context, as well as offers important insights into the occupational culture of the medical profession, I would argue that the Governmentality viewpoint could be used to supplement and expand upon the neo-Weberian perspective. Indeed, I would argue that synthesising these two viewpoints is a fruitful approach to adopt when analysing the regulation of medical expertise. Both argue that it is necessary to adopt a critical and historical approach when studying how professionalism operates as a regulatory strategy, as well as when exploring the reasons behind current reforms in the regulation of professional expertise. Importantly, both hold that recent challenges to the principle of professional regulation have caused professional elites to place ‘rank and file’ practitioners under greater surveillance and control, as they seek to maintain collective self-regulatory privileges. The topic noted how the Governmentality perspective argues that the ‘field of medicine’ has become more than ever before simultaneously ‘governed’ and ‘self-governing’ (Osborne 1993). This is a state of affairs conceptualised by the neo-Weberian perspective under the banner of the restratification thesis (Freidson 1985 1994 2001). The next topic discusses the development of the restratification thesis to illustrate the value of recognising this point of agreement between the neo-Weberian and Governmentality perspectives.

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