The centrality of this economic model of work should not blind us to the fact that many goods and services are still produced outside formal employment. It has been estimated for example that if unpaid domestic work was paid for at the same average rate as paid employment, then the value of this work to Britain could be calculated as 122% of gross domestic production (Guardian 1997). Most of this unpaid work takes place in families the majority of it is carried out by women as we discussed in Chapter 2.

Our role as nurses alerts us to the fragile boundary between paid employment and unpaid work, particularly where women’s work is concerned. Nurses produce a human service, but the fact that most of the tasks which we carry out in our daily employment are being carried out somewhere by an unpaid carer causes difficulties when we wish to claim special expertise and professional status. The increased throughput of hospital patients and renewed emphasis on ‘community care’ has intensified the pressures to move patients from paid to unpaid care. Ironically this is happening at a time when people often have less time to provide such care due to increased working hours. Britain has the longest working hours in Western Europe and recent surveys have shown that one-fifth of the population work more than 48 h/week (Office of National Statistics 2006). The move to informal care has been driven by the continuing pressure to contain health spending. Boundaries between unpaid work and paid employment are constantly shifting and we look in more detail at unpaid (informal) care in Chapter 2 and Chapter 10.

Much of our understanding of the division of labour is founded on Durkheim’s major work; ‘The Division of Labour in Society’ (Durkheim [1893] 1984). According to Durkheim, in pre-industrial societies, the division of labour is simple, most people are involved in similar occupations and people are bound together by shared experiences and beliefs. Work is often organized through kinship ties. Durkheim describes these close knit traditional societies as bound together by ‘mechanical solidarity’. With industrialization and urbanization comes a breakdown of traditional forms of solidarity. Modern industrial society has an extremely complex division of labour with a huge number of different work roles. This leads to a more individualistic society with many different ways of life, values and beliefs. The danger for modern society is that individualism will lead to a breakdown of social ties. Durkheim says that the problem of how to keep order in industrial societies is solved by the creation of organic solidarity. Organic solidarity is based on the acceptance of difference through a recognition of mutual interdependence. The development of highly specialized roles which are interdependent is a key feature of organic solidarity. However, the risk of a breakdown of community values (a condition that Durkheim called anomie) is always present. Durkheim saw the professions as playing a key role in maintaining a moral community in conditions of organic solidarity (Durkheim [1950] 1992). Professions are carriers of important ideals such as altruism and public service. Durkheim’s ideas about the division of labour have informed many attempts to understand role changes in contemporary healthcare (Allen & Hughes 2002).

The word bureaucracy comes from a French word referring to a kind of baize cloth used to cover desks. It means, literally, the rule of those who sit behind desks. The term bureaucracy has always had negative connotations. The most important classical sociological study of bureaucracy was by Max Weber. Weber produced a balanced account of bureaucracy highlighting both its strengths and weaknesses.

Weber thought the rise of bureaucracy was inevitable. He saw it as the form of rational administration most suited to large scale social systems. Weber saw bureaucracies as governed by instrumental rationality (rather than traditions, values or feelings) and believed that this had both strengths and weaknesses. Weber identified the following characteristics as typical of bureaucratic systems (see Gerth and Mills 1970).

Total institutions are those institutions which regulate the entire existence of those who reside in them. Residents are often cut off from the outside world. Examples of total institutions described by Goffman include asylums, prisons, monasteries, boarding schools and army barracks. Institutions for the sick are of
particular interest to us as health professionals and Goffman’s own study was of the life of inmates of a mental hospital (Goffman 1968). He describes the attributes of a total institution as follows:

Goffman’s depiction of total institutions gives us a bleak picture of the bureaucratic control of the everyday lives of individuals. His work helped to speed up the closures of large healthcare institutions such as mental hospitals. His work also influenced the attacks on state bureaucracies that have been fashionable since the 1960s. The impersonality of bureaucracy has led critics to describe it as fundamentally inhuman. These criticisms have also driven the demands to ‘modernize’ public organizations such as the NHS. Central to the process of ‘modernization’ is the demand to expose public bureaux to business values and the disciplines of the ‘market’. We must remember however that the market is also governed by instrumental rationality (the profit motive) so that markets do not necessarily rescue us from the worst features of bureaucracy. These attacks on bureaucracy ignore what Weber called the ‘ethic’ of bureaucracy; its impartiality and clear cut rules of conduct. This ‘ethic’ offers protection from cronyism, corruption and the arbitrary exercise of power (Du Gay 2000). The much criticized ‘one size fits all’ model of standardized welfare services at least offered a minimum level of equity which may be lost if ‘choice’ becomes a dominant value. Du Gay suggests that these ethical ideals of bureaucracy such as fairness, impartiality and playing by the rules are essential to democracy. We will consider next what the idea of the market has to offer.

Kahn quotes Traven’s popular novel about Mexican peasants to illustrate a critique of markets, which sees them as based on a culture of greed and a worship of money in which people have lost sight of the true value of the world around them. The ideas expressed here echo Marx’s distinction between the ‘use value’ of an object, i.e. its value to human health and happiness and its ‘exchange value’, i.e. its monetary price. These critical ideas offer us a way into thinking about what the idea of the market actually stands for.

According to Clarke (2005a) the word ‘market’ originally referred to a place where people met to trade goods. This view of a market as a place has given way to a more abstract idea of the market as the fundamental way of organizing human society (Carrier 1997). Our modern conception of the market owes much to the ideas of the classical economist, Adam Smith, who described society as regulated by the ‘hidden hand of the market’. This means that market societies are composed of millions of individual transactions, which combine to produce equilibrium if the market is left alone to regulate itself (Carrier 1997). Thus according to pro-market economists (often described as economic liberals because of their desire to ‘liberate’ the market) if everyone is free to engage in the pursuit of private profit then over time the ‘hidden hand’ of the market will achieve prosperity for all. The greatest good for the greatest number is better achieved by self-interest than by altruism (Lubasz 1992). Thus a goal of society should be to remove any obstacles to a ‘free market’ and to open as many areas of social life as possible to market mechanisms.

This idea of the market is based on two key assumptions which are contested by critics. First, the idea of the market is based on a particular idea of human nature. This is often described as the idea of ‘economic man’. This is the idea that buying and selling is a universal human activity and that the instrumental pursuit of profit (‘calculating avarice’) is a fundamental human characteristic. This is a matter of some dispute particularly amongst anthropologists who study pre-industrial societies. Thus Douglas (1992) says that market societies were relative latecomers as types of human organization. It is their dominance in the industrial West, which has led to a rewriting of our ideas about ‘human nature’. Both bureaucracies and markets are dominated by instrumental rationality in different ways (to put it simply bureaucracies are concerned with rules and hierarchies and markets with money and profits). Weber’s ideas about different types of rationality alert us to the possibility that other motivations (traditions, values, beliefs, feelings) may govern human behaviour. Traven’s depiction of the Mexican peasant at the start of this section illustrates the view that these other motivations are more desirable and authentic, and if we abandon these we become a people who ‘know the price of everything and the value of nothing’ (Oscar Wilde 1892). These issues are pertinent to an occupation such as nursing where altruism and ‘vocation’ remain important but contested ideals.

Second, the idea of the market is based on the idea that in a ‘free’ market everyone can participate on an equal footing. Our discussions of inequality in Chapter 5 and Chapter 6 will question this idea. Opponents of the market argue that markets are always shaped by structured inequalities and thus reward the rich and powerful (Carrier 1997 and Clarke 2005a). This view of markets argues that the extension of markets leads not to prosperity but to deepening inequality.

Strong ideas about the market as the fundamental form of human social life have led to a social programme which extends market mechanisms into all areas of life. The alternative view, which is that markets are just one way of organizing social life, leads to suggestions that there are some areas of social life which should be governed by other values and motivations (our personal and family life for example). Healthcare is one area where public service and altruism have been important ideals and where the role of markets has been contested (Pollock 2004). However, recent healthcare reforms in many countries have introduced market mechanisms into public healthcare systems.

Thus, the idea of the market now underpins many contemporary, taken for granted ideas in healthcare. Market ideas encourage us to see health as a commodity which we can buy and ourselves as ‘healthcare consumers’ rather than patients. It is market ideas that encourage us to believe that greater ‘competition’ and ‘choice’ will produce greater ‘efficiency’ and higher standards. These ideas assume that market motives (profit, self interest) govern the behaviours of both healthcare workers and patients. We will return to these ideas in Chapter 7 and Chapter 9.