We have written a paper on the salience of ‘muckraking sociology’ in the era of COVID which has (1) been rejected by a mainstream sociology journal, in part because it apparently doesn’t publish ‘polemical pieces’, and (2) returned to us with a request for a second set of revisions by a specialist health sociology journal, in part because it apparently requires further toning down and additional referencing. In light of these decisions and the comments of the anonymous referees – why anonymous? – we have taken the decision not to resubmit and to make our paper accessible online for anyone who is interested. People will make their own judgments on whether the paper warranted publication.
It seems to us that important issues are at stake here, and that maybe some colleagues haven’t altogether grasped, or are averse to, the very concept of muckraking sociology. Our intent was to contribute to an understanding of an emerging class-based state authoritarianism that is associated with a protracted assault on the NHS which preceded the election of Cameron in 2010 but which has gathered momentum since. We see this ‘assault’ as a predictable end product of post-1970s rentier capitalism. The paper was fully intended to provoke and to fuel resistance. This is after all intrinsic to the tradition of muckraking sociology.
While we were gratified to learn from an editor of the health journal that our paper ‘had merit’, and from a referee that we had managed to ‘improve it’ with our revisions, we are unwilling to further compromise our arguments in line with what one of us has castigated elsewhere as a ‘taming of sociology’. We find the request/requirement to produce evidence that the Conservative government (1) is actively undermining the NHS, and accelerating this process under cover of COVID; and (2) has made a catastrophic – and corrupt – mess of responding to the pandemic as little short of ludicrous. Is disseminating accounts of how things are, and why, so easily trumped by a desire for institutional and disciplinary respectability? Should we wait until the NHS has been ‘sold off’ before we elect to go public? Is governmental corruption ok? What is sociology for if it is not to expose and trigger debate and action against regressive change based on policy-based evidence? Sociology in our view is nothing if it succumbs to pressures around acceptability. We believe not only in the importance of a ‘public sociology’ but in a sociology that actively engages with contemporary issues.
We conclude by accepting that editors of journals act under constraints and that they, like those who referee manuscripts, act with positive intent. We make no special claims for our paper and readily acknowledge its imperfections, though some are perhaps a function of word limits etc. But let’s all of us be a little bolder and not stand by while valued social institutions are collapsing around us.
Graham Scambler, Benny Goodman and Miranda Scambler
SOCIOLOGY, KNOWLEDGE AND ENGAGEMENT: A CASE FOR A MUCKRAKING SOCIOLOGY OF HEALTH AND HEALTHCARE IN THE TIME OF COVID
Graham Scambler, Benny Goodman & Miranda Scambler
Abstract
We adopt the definition of muckraking advanced by Marx in his Muckraking Sociology. At its core is a commitment to social criticism via the exposure and challenging of those rhetorics that provide cover for dominant interests. Our focus is on the field of health and health care, with particular reference to the largely hidden agendas of successive Health Ministers post-2010. We present two substantial case studies. The first concerns the sustained attack on the National Health Service (NHS) with a view to replacing it with a more market-oriented system. This begins with the run-up to the Health and Social Care Act of 2012 and goes on to feature governmental action taken as a consequence of this Act, often under the public radar. The second hones in on the government’s response to the coronavirus pandemic. We argue that this reflects an ideological commitment to undermine and marketise the NHS and its public health arm. Following on from these case studies, we venture a re-appraisal of the sociological project in light of the growing need for evidence-based social criticism to examine, expose and if necessary counter a political tendency to fabricate policy-based evidence in line with the prevailing ideology.
Key words: muckraking, health policy and care, NHS, COVID-19,
Muckraking Sociology
It could be argued that in the United Kingdom (UK) we are currently facing the imminent prospect of a ‘perfect storm’ in the form of climate change, Brexit, coronavirus (hereafter COVID), economic recession and a ‘post-truth’ culture. This represents a signal challenge to contemporary sociology, yet its contributions often appear reticent in relation to: (a) the big picture (sometimes referred to as ‘big sociology’), and (b) why we are now facing this coalescing of crises. While we accept that it is important not to make undue haste with substantive research studies on topical issues like COVID ((Bell & Green, 2020; Will, 2020), we contend that tackling critical social junctions head on is intrinsic to the sociological project. In this contribution we address these issues and in doing so indicate a need to confirm the ambitions of the sociological community beyond the scholarship of its professional base to embrace a firm and unapologetic engagement with the public sphere together with creative forms of activism. It is an argument that builds on a critical realist concept of a ‘fractured society’ explicated in detail elsewhere (Scambler, 2018).
One exemplar of the kind of sociology we commend lies in the discipline’s ‘muckraking’ past. In his Muckraking Sociology, Gary Marx (1972) summarises his conception of this faded strand to the discipline. He begins by citing from the first issue of Transaction in 1963: ‘the social scientist studying contemporary problems and the complex relationships among modern men knows that he can no longer discharge his social responsibilities by retreating from the world until more is known’ (emphasis added) (Marx, 1972: 1). Setting to one side the outdated sexist language, it remains pertinent to ask if sociology in the UK is in retreat on matters of overriding public salience and concern. Muckraking research, Marx (1972: 2) pointedly insists, ‘documents conditions that clash with basic values, fixes responsibility for them and is capable of generating moral outrage.’
The term muckraking originates from ‘muckrake’, an instrument used for gathering dung into a heap. In the hands of investigative journalists, muckraking came to be identified with the uncovering and exposure of misconduct on the part of prominent individuals and the collation of incriminating evidence. Marx is worth quoting at some length here:
‘such research uses the tools of social science to document unintended (or officially unacknowledged) consequences of social action, inequality, poverty, racism, exploitation, opportunism, neglect, denial of dignity, hypocrisy, inconsistency, manipulation, wasted resources and the displacement of an organisation’s stated goals in favour of self-perpetuation. It may show how, and the extent to which, a dominant or more powerful class, race, group or stratum takes advantage of, misuses, mistreats or ignores a subordinate group, often in the face of an ideology that claims it does exactly the opposite. In pointing out a state of affairs that strikingly clashes with cherished values, muckraking research may have an expose, sacred cow-smashing, anti-establishment, counter-intuitive, even subversive quality, for it grows out of and helps sustain social upheaval and questioning. Although sociology like any other intellectual undertaking always has this potential, it is often not realised’ (Marx, 1972: 3).
He references the writings of Herbert Gans and Howard Becker, reminding us that questions like ‘whose side are we on?’ were once commonplace amongst the discipline’s leading protagonists. Maybe, Marx asks, sociology’s involvement with public issues is cyclical, or at least linked to wider social tendencies. Mannheim for example argued that systematic sociology develops when a nation begins to be unsure of itself. Marx suggests that American sociology in the 1960s (the period he is concerned with, and a product of) was much influenced by the ‘unfortunate involvement in Southeast Asia’. He notes that in 1960s America there developed a ‘reciprocal relationship’ between critical social science and social movements.
We will contend here that Marx’s portrayal of muckraking sociology has particular resonance today: cyclical or not, the time is ripe to extend the sociological project to expose and critique ideological obfuscation (Scambler, 2018).
In this paper we focus on two case studies, the first involving policy reforms affecting the NHS, and the second the response, governmental and in terms of public health and health care, to the advent of the coronavirus pandemic. We seek to show: (1) that there is a strong evidenced case that that a number of the problems that have emerged post-2010 have their roots in a flawed neoliberal ideology that reflects vested interests, and (2) that it requires a move beyond sociological scholarship towards action or muckraking sociology to mount an effective challenge to this ideology. Revealingly, we reference several examples of muckraking journalism in the course of documenting how government ministers have tackled the pandemic. In the final section of the paper we return to the issue of muckraking sociology and specify some urgent tasks confronting sociologists of health and illness in this context.
Case Study 1: The Systematic Assault on the NHS
The underlying Conservative agenda for the NHS has been clear since the governments of Margaret Thatcher (1979-1990), for all that Thatcher herself was constrained in its pursuit by a still-strong public and voter regard for the ethos and delivery of health care according to universalistic and inclusive principles (Pollock & Leys, 2004). The introduction of a makeshift ‘internal market’ via the NHS and Community Care Act in 1990, which ‘encouraged’ private providers, was as far as she could go. This half-way-house or pseudo-market sat somewhere on a spectrum between a bureaucratic command and control economy and a private free market, but it was a sign of things to come.
Of the reforms introduced by Thatcher’s successor as Prime Minister, John Major (1990-1997) the introduction of Private Finance Initiatives (PFIs) in 1992 is of special import for this paper. PFIs, which were enthusiastically endorsed by the Tony Blair/ Gordon Brown New Labour governments between 1997 and 2010, allowed for the private sector to build, and own, new hospitals and other health care facilities, which they then leased back to the NHS, often at higher rates than would have been the case with government funding and on the basis of 20-30 year deals. They appealed to successive governments because PFI building and refurbishment did not appear on governments’ books: they represented an investment of private not public monies. Predictably enough, PFIs have become major contributors to the indebtedness of many NHS Trusts. Thomas (2019) notes that PFIs have become a postcode lottery, and he estimated that twenty years after PFIs had been introduced only around £25 billion of the £80 billion expected total cost had been paid; that is, less than a third of the final price, with £55 billion still to pay. This indebtedness was exacerbated by the cuts and austerity measures following the financial crash of 2008/9.
If the future of the NHS as a universalistic and inclusive health care system was rarely challenged openly prior to 2010, a lot was happening behind the scenes. There is evidence of protracted and persistent private sector lobbying prior to the 2010 election (Leys & Player, 2011). Despite David Cameron’s (2010-2016) pre-election promise that there would be no top-down reorganisation of the NHS by a Conservative government, Health Minister Andrew Lansley, well primed by for-profit health care providers, was in fact already well advanced in his preparations for what was to become the Health and Social Care Act of 2012. This complex and far-reaching piece of legislation further opened the door to for-profit providers of health care.
It is important to acknowledge at this point that there was then and is now firm evidence that privatised health care: (i) augments costs because it requires an expanded bureaucracy that comes with contracts, billing and litigation; (ii) encourages ‘cherry-picking’, with the private sector focusing on the most lucrative work (eg hip and knee replacements); (iii) opens the way for fees to be introduced as services are cut and hospitals pushed into – often PFI-induced – debt, with for-profit companies ‘coming to the rescue’; (iv) prioritises cost of care over quality of care; (v) leads to rationing, another trigger for patients to ‘go private’; (vi) under cover of commercial confidentiality makes it impossible to properly scrutinise public spending via contracts with private providers that are primarily oriented to their shareholders; and (vii) promotes a fragmentation of health services as these are refashioned according to market principles (Scambler, 2019: 39).
But if the Health and Social Care Act – complemented in 2013 by the passing of ‘regulation 75’, which was heavily but unsuccessfully contested in 2019 – opened the door for the promotion of for-profit health care, a tranche of further intricate, extra-legal ‘devices’ have since been put in place, by stealth and under the public radar. Lansley’s successor, Jeremy Hunt (Health Minister from 2012 to 2018, and already on record as favouring NHS privatisation (see Stone, 2016), championed a series of initiatives which, whatever merits might be claimed for them, were also designed to accelerate the privatisation of health care in England. For example, a new ‘model of care’ via Accountable Care Organisations (ACOs) was introduced, and on Hunt’s watch a plan devised to ‘bundle up’ services into ‘giant contracts’ awarded by Clinical Commissioning Groups (CCGs) – and local authorities – to ACOs. ACOs comprise Multi-Speciality Community Providers (MCPs) and Primary Acute Services (PASs), which can involve private and/or public providers. ACOs can subcontract and sub-sub-contract for services. And MCP and PAS providers can form Special Service Vehicles, a device to open the door to the likes of private health insurers, property companies and investment bankers. A local service operating under the NHS brand might now be owned by an American private equity company. In fact one of the biggest general practices operators in the UK, serving half a million patients, has recently passed into the hands of the US health insurance group Centene Corporation, prompting claims of ‘privatisation by stealth’ (Kollewe, 2020). Moreover, Integrated Care Systems are about to be rolled out, combining NHS Trusts with GP services as commissioners from a single budget pot. These bodies will no longer be required to put contracts out to tender, but will instead award them directly. There is concern that these arrangements will embed the role of the private sector, but with less transparency and accountability over contracts.
Estimating the degree of NHS privatisation to date is difficult given contested criteria and issues of data access: at the time of the 2019 general election one fact-check body put it at between 7% and 22% of the health care budget (Panjwani, 2019). The Socialist Health Association (2018) has listed the multiple and varied forms that NHS privatisation can take. These include self-evident examples like the outsourcing of clinical and other services to private providers; commissioning and contracting, as when CCGs place contracts with for-profit providers; the privatisation of social care; introducing charges; and private investment, as with PFIs. But they extend to less obvious measures like selling off property, notably NHS land and facilities; trusts and spin-outs, as when parts of the NHS become private providers in their own right; regulation, as when the Department of Health/NHS England intervene to recast citizens as consumers; tariffs and targets, deployed as means to centralise and manipulate local initiatives; personalisation, for instance when ‘personal health budgets’ are used to promote privatisation; and private beds and private work, as when the NHS works with consultants to sell off beds and services.
Special emphasis must be placed on the salience of cuts for the privatisation agenda. The post-2010 Conservative-dominated coalition policy of ‘austerity’ helped legitimate legal and extra-legal change; but it also helped sow seeds of disenchantment and lowered expectations about what the NHS could deliver. Lowered faith in the NHS predictably encourages people to look elsewhere.
Scholarship, sociological and otherwise, testifies to an enduring commitment on the part of the Conservative Party, increasingly active rather than aspirational after 2010, to reform the NHS in such a manner as to replace it with a more market-orientated or Americanised alternative. It is a commitment underpinned by a network of links between right-wing think tanks like the Centre for Policy Studies, founded by Thatcher in 1974 to promote free market policies and limit the role of the state (see Slater (2018) on another right-wing think tank, Policy Exchange, and what he calls ‘agnotology’, or the intentional production of ignorance in the population). This has resulted in a generally regressive move away from a largely progressive, if imperfect, health care system to benefit for-profit providers.
Given its salience for the coronavirus pandemic (hereafter COVID), special mention must be made of public health services in the years of austerity. Though funding for the Department of Health and Social Care continued to grow through these years, budgets rose by only 1.4% each year on average (adjusting for inflation). Moreover during the last five years day-to-day spending on NHS services has been prioritised, leading to cuts in budgets for public health services as well as deterioration in NHS buildings and equipment (Ashton, 2020). According to a briefing by the Local Government Association to the House of Commons in May of 2019, the Public Health Grant paid by the government to local authorities to provide statutory public health services was reduced by over £700 million in real terms between 2015/16 and 2019/20. In addition, the Early Intervention Grant has been cut by almost £500 million since 2013. Notwithstanding a recent uplift in the Grant, public health spending is still 22% lower per head than it was in 2015/6.
To put these public health service cuts into perspective, it is important to note a number of structural changes to public health services introduced between 2010 and 2020. In 2010 Lansley, responding to Marmot’s (2010) Fair Society, Healthy Lives, proposed a new framework to tackle the social determinants of health contributing to health inequalities. Public health control would be handed back to local authorities, which would be empowered to tailor solutions to local population needs. Public Health England was established to oversee this process. These reforms were enacted in the Health and Social Care Act of 2012 discussed above.
In 2015 the Conservative Party gained majority control in government. Chancellor of the Exchequer George Osborne’s Spending Review announced a funding increase for the NHS in England, but the emphasis on social care left public health a casualty, losing £600 million in the Budget. In the same year Simon Stevens, CEO of the NHS, called for a radical redesign of prevention of ill health, and in 2016 a ‘triple prevention strategy’ was launched. The three elements were: (i) prevention programmes to target at-risk patients; (ii) a focus on the health and wellbeing of NHS staff; and (iii) a plan to create a ‘model environment’ for patients coming into contact with the NHS. The Faculty of Public Health quickly pointed to a paucity of funding. In 2018 the government announced a further cut to the budget for local authorities to spend on their public health duties (Kings Fund, 2020).
In 2019 a long-term plan set out a NHS strategy for the next 10 years. There was a strong focus on prevention, public health and health inequalities, but as the Kings Fund (2020) stressed, the public health budget had not been increased despite dire need. The plan prioritised cancer, cardiovascular disease, diabetes, respiratory disease and mental health, looking to digital healthcare solutions as well as support for people to self-manage health care through personalised plans and personal health budgets. On prevention, the emphasis was on behaviour change with regard to five risk factors: obesity, alcohol, blood pressure, smoking and diet. In September of the same year Public Health England prioritised a smoke-free society, healthier diets, cleaner air and better mental health; appended to these were a better start in life, effective responses to major incidents, reduced risk from antimicrobial resistance, predictive prevention, enhanced data and surveillance capabilities and a new national science campus.
There was a substantial gap between aspiration and practice, with regard to the NHS in general and public health in particular. The National Audit Office reported that local authorities saw a 49% real-terms cut in central government funding between 2010/11 and 2016/17 and an overall 28.6% reduction in their spending power (Buck, 2020). It should be noted at this point too that, updating the 2010 analysis ten years on, Marmot and colleagues (2020) found that people can now expect to spend more of their lives in poor health; improvements in life expectancy have stalled, and declined for the poorest 10% of women; the health gap has grown between wealthy and deprived areas; and living in a deprived area in the North East is worse for people’s health than living in a similarly deprived area in London, to the extent that life expectancy is nearly five years less (see also Hiam et al, 2020). Then came COVID.
Case Study 2: Mishandling COVID-19
The response of the Boris Johnson administration, formed in 2019, to the advent and challenge of COVID in 2020 must be rooted in the sustained ‘assault’ on the NHS and its public health arm from 2010 onwards (Ashton, 2020). Few now dispute the proposition that Johnson and new Health Minister Matt Hancock were tardy in taking the threat of COVID seriously. They were certainly handicapped by the politics of their predecessors, Theresa May as PM (2016-2019) and Jeremy Hunt as Health Minister (2012-2018). In October of 2016 a three-day dry run for a pandemic tested how NHS hospitals and allied services would cope in the event of a major flu outbreak with a mortality rate similar to COVID. The test was failed, but the results were kept out of the public domain. Ministers were warned that the UK would be swiftly overwhelmed by a severe outbreak given the shortage of critical care beds, morgue capacity and personal protective equipment (PPE) (further warnings were forthcoming in a clandestine appraisal of readiness in 2019). The lessons were unlearned: in line with the commitment to a politics of austerity, the NHS lost funding, the privatisation of services was encouraged, there were severe staffing cuts, social care was all but jettisoned, stockpiles of PPE diminished and central and local monies dedicated to public health were slashed.
COVID came to international attention with an announcement by the Chinese government on 31 December 2019 that ‘a pneumonia of unknown cause’ had been detected in the neighbourhood of Wuhan. Human-to-human transmission was confirmed on 20 January 2020; COVID arrived in Europe on 24 January; the first COVID death occurred in the UK on 6 March; the World Health Organisation (WHO) declared COVID a pandemic on 11 March; and the UK announced a lockdown – ‘you must stay at home’ – on 23 March.
Scambler (2020) comments on three aspects of the Johnson government’s response to COVID. The first of these is delay. While there are always conflicting opinions, there is something approaching a consensus amongst epidemiologists that the government was slow to respond. Ward (2020), an infectious disease epidemiologist, reports being worried in mid-February. In April she wrote:
Two months on, that anxiety has not gone, although it’s also been joined by a sense of sadness. It’s now clear that so many people have died, and so many more are desperately ill, simply because our politicians refused to listen to and act on advice. Scientists like us said lock down earlier; we said test, trace, and isolate. But they decided they knew better’.
The government went on to resist mounting public health pressure for ‘circuit-breaking’ two or three-week lockdowns to stall further waves of COVID until compelled to act, most notably in the period following the easing of restrictions over Christmas The total COVID-related mortality at the time of writing is a matter of dispute, not least because the government imposed a restrictive 28-day timescale for regarding deaths as COVID-related, but the figure of 150,000 has already been breached if mention of COVID on death certificates is used as the criterion. COVID-related deaths reported by the Office of National Statistics remain higher than those released by the government, and the number of ‘excess deaths’ indicate that England and Wales have been hardest hit in Europe (McConway, 2020).
The second aspect of the Johnson government’s response focuses on strategy. While any government would face very real difficulties formulating an effective, science-based strategy to tackle a virulent infection like COVID, it is clear that the strategy that Ward and numerous other leading epidemiologists recommended, in line with WHO advice, was not adopted in the UK (Horton, 2020b). Instead mention was made of ‘herd immunity’, namely, letting the virus work its way through a substantial proportion of the population to generate widespread immunity. Some interpreted this as a form of Social Dawinism’, or the survival of the fittest. It seemed to them as if the government was willing to sacrifice vulnerable segments of the population – notably the long-term sick and disabled and the elderly – as collateral damage. The government quickly denied ownership of such a policy, though there is speculation that it has in effect never been fully abandoned.
The rapid accumulation of COVID-related deaths in care homes during the first wave added further fuel to the fire. Horton (2020, 2020b), editor-in-chief of The Lancet, described the government’s response to COVID as ‘the biggest science policy failure in a generation’.
Independently of strategic issues, and Scambler’s third focus, is the matter of efficiency and effectiveness. There is no querying the UK government’s organisational laxity. Moreover, disturbing reasons for this are emerging in ever-increasing detail. As already mentioned, the lessons of two dry runs for pandemic preparation in 2016 and 2019 went unlearned, and in line with the government’s chosen regime of austerity post-2010, the NHS lost funding, the privatisation of services was encouraged, there were severe staffing cuts, formal social care was all but abandoned, stockpiles of PPE diminished, and central and local government monies committed to public health were slashed (see above; Scambler, 2019; Vise, 2020).
To this trio of headings might added a fourth, trust. Population and electoral trust is axiomatically a crucial factor in the effective countering of pandemics. The Johnson administration squandered the understanding, sympathy and, a by-product, ‘compliance’ of segments of the populace early on. This was not just a function of flaws around delays, strategy and efficiency. It was compounded by governmental rhetoric. People were not slow to note a yawning gap between promises and delivery. Test and trace, for example, was heralded as ‘world class’ even as it conspicuously faltered. After constantly promising the ‘ramping up of test and tract’ Hancock disguised the fact that the numbers he released included test kits posted and not used/returned, and that many swabs were unreliable and would need retesting. Nor were the commercial labs being used to run the tests sharing data with local public health groups or councils. Trust in government counsel and interventions like lockdowns was further eroded by examples of elite non-compliance, most notably involving Johnson’s advisor Cummings’ trip to Barnard Castle. The journalist Peter Oborne (2021), by no means antagonistic either to conservatism or Conservatism, goes further and painstakingly documents what he defines as a catalogue of ‘lies’ and fabrications by Johnson, Hancock and other ministers during the pandemic, with the active collusion of much of the mainstream press.
It is apparent that government’s failures manifested under these four headings owed much to its longstanding ideological commitment to reform the publicly-funded NHS, public health and social care and to deliver many of these services to for-profit companies. Already unfit for purpose by 2020, the nation’s resources for dealing with COVID were further significantly reduced by the outsourcing of a series of critically important contracts to private providers lacking both expertise and experience. Many of these were not put out to tender. Brooks (2020) writes:
‘the multibillion pound surge in outsourcing of public services during COVID-19 has attracted many headlines, but it is not just a public spending scandal. It is a vivid demonstration of our government’s inability to perform the essential roles society asks of it. Furthermore, this dependency on outsourcing to profit-driven companies undermines any promise to ‘build back better’.’
COVID, arriving in the wake of a calculated rundown of public services, has opened the door to a gold rush for government contracts. The failures with regard to private providers’ PPE procurement, not least in respect of care homes, have been well documented (Christophers, 2020). A cross-party group of MPs has castigated the government for details of hundreds of COVID PPE contracts valued at more than £5 billion, and several legal challenges by the Good Law Project are underway at the time of writing.
But it is the test and trace system that has generated the most attention and controversy. In May of 2020 Hancock appointed Dido Harding to head NHS Test and Trace, established to track and help prevent the spread of COVID in England. Box 1 summarises Harding’s ‘qualifications’ for this post and outlines some other relevant links between the Conservative Party and its beneficiaries. When, in August of 2020, it was announced that Public Health England was to be merged with NHS Test and Trace and morphed into a National Institute for Health Protection, Harding was appointed interim director of this new body.
Box 1 here
‘NHS Test and Trace’ had always been a misleading description, its orientation from the start being towards the private sector. It has provided a rich seam of profits. It remains an ongoing process, but a contract officially priced at up to £410 million was handed to Serco. Moreover it appears that: (i) the contract contained no penalty clause, meaning that even if Serco were to fail to fulfil its terms it would be paid in full, and (ii) Serco went on to subcontract contact tracing jobs to another company (PoliticsHome, 2020). Serco’s CEO is Rupert Soames, whose partner is a Conservative donor and whose brother is ex-Conservative MP Nicholas Soames. Junior Conservative Health Minister Edward Argar is a former lobbyist for Serco. In March of 2021 it was revealed that Soames had been paid £4.9 million for 2020 (Jolly, 2021).
Another contract was awarded to the French company Sitel for up to £310 million (other outsourcing giants like G4S were also to profit). Although no official figures have been given, Brooks calculates that the figures so far released by the Treasury suggest the final bill will run into several billion pounds. Additional contracts for managing the procurement of ventilators, PPE, and extending to the monitoring of contracts, have been awarded to management consultants and amount to hundreds of millions of pounds. The coordination of testing conducted by private sector staff has been overseen by consultants from Deloitte at an undisclosed cost. Junior Deloitte staff supplied to another public body, the British Business Bank, which coordinates COVID financial support packages, are reportedly costing taxpayers salaries comparable to that of the Prime Minister.
These costs have not been accompanied by efficiency. Handing the central tracing service to 25,000 people with no experience and marginal preparatory training has led to the standardisation and computerisation of processes to the point of ineffectiveness. At the time of writing, success in tracing the contacts of people testing positive is far lower in the central service than it is in the smaller number of more complex cases handled by local public health teams.
Kate Bingham was appointed chair of the government’s vaccine taskforce. A venture capitalist married to Treasury Minister Jesse Norman, she has already come under fire for insisting on hiring costly PR advisers despite a surplus of civil servants at the government’s disposal. Bingham ‘stepped away’ from her role at private equity firm SV Investors to take up this unpaid post. Two months after her appointment, however, SV Investors secured a £49 million investment into its SV7 Impact Medicine Fund from British Patient Capital, which is entirely funded by the UK government. Accounts filed with Companies House show SV Investors earned at least £1.9 million in management fees linked to its operation of the Impact Medicine Fund in 2019, before the government invested in 2020. The accounts suggest that Bingham, as one of the company’s two managing partners in the UK, receives an annual share of profits generated by SV Health Investors, implying that she could stand to benefit personally from the performance of the Fund (Elgot et al, 2020).
In the event the rollout of vaccines across the UK, overseen from within government by Nadhim Zahawi, has proved very successful. At the time of writing more than half the UK’s population has received an initial dose of a COVID vaccine. Former Chief Scientist David King – who told the Guardian ‘I am extremely worried about the handling of the coronavirus pandemic, about the processes by which public money has been distributed to private sector companies without due process. It really smells of corruption’ – has pointed out that the roll out of the vaccination programme ‘was driven through entirely by our truly national health service and GP service … yet we have persisted with this money for test and trace, given without competition, without due process … I am really worried about democratic processes being ignored’ (see Harvey, 2021). It is reasonable to conclude that while the failing test trace system misused and misled by deploying the NHS ‘brand’, the successful vaccination programme was a genuine accomplishment of the NHS.
From Scholarship to Muckraking
What is sociology to make of all this? So far we have concentrated on documenting successive governments’ policies on the NHS, public health and social care post-2010, culminating in the mishandling of COVID in 2020/21. In this section we offer a professional-cum-policy sociological analysis of these policy shifts prior to making a case for resurrecting the discipline’s muckraking tradition. We will summarise what we commend as a compelling sociological analysis in a sequence of theses.
- The extent, nature and direction of unfolding of the COVID crisis was predictable given the acceleration of material, social and health inequalities in post-1970s financialised or rentier capitalism.
This half-century has witnessed a ubiquitous ideology of neoliberalism that has ‘rationalised’ the transfer of wealth and income – and in their wake stalled growth in healthy life-years and longevity – to the advantage of the very few and to the disadvantage of ‘the many’ (Hiam et al, 2020; Marmot & Allen, 2020; Horton, 2020a). Austerity was a key political vehicle for this transfer. One of us has nominated the class/command dynamic of financialised capitalism as a major generative mechanism here (Scambler, 2018). This asserts that a fraction of the Occupy Movement’s 1%, the capital monopolists, are better placed than in the postwar years to deploy their capital to ‘buy’ sufficient state power to implement policies allowing for greater capital accumulation. A newly published account of health and health care in the USA is consonant with this thesis (Freudenberg, 2021). In the spirit of muckraking sociology, Scambler (2018) postulates a greedy bastards hypothesis, or GBH, which asserts that widening health inequalities are an unintended consequence of the behaviours of the leading capital monopolists in combination with the power elite of the state, these together constituting a capitalist governing oligarchy or plutocracy. This has led to a ‘fractured society’ (see also Monaghan, 2020). Following convincing American research, it seems likely that in the UK too the largely transnational and ‘nomadic’ capitalist class is now substantially represented within the power elite of the state, meaning that its members exercise power directly rather than merely buying it (Gill, 2018).
It is emerging at the time of writing that the class/command dynamic and the GBH are part of the explanation too for the heightened prevalence of COVID and COVID-related deaths in the UK’s BAME community. ‘Social determinants’, predictably enough, are more salient than are genetic or psychological mechanisms. Doubtless a fuller account will be possible in due course as to the relative/interacting causal contributions of the structures or relations of class, ethnicity/race, gender, age and (dis)ability to COVID-related mortality in the UK (Marmot et al, 2020a).
- The self-serving and corrupted decision-making and cronyism of the power elite of the state during COVID has brought into sharper relief the deep, structural sources of the fractured society.
One of us has likened the advent of COVID to a natural ‘breaching experiment’ (Scambler, 2020). With a nod to Garfinkel (1967), this is to suggest that by significantly disrupting the social order of the contemporary capitalist regime, COVID has exposed its contradictions and widening cracks and fissures. It is perhaps a British characteristic to transmute charges of corruption, only to readily applied to governments overseas, to those of cronyism, or even of ‘chumocracy’, at home (Conn et al, 2020). The executive editor of the British Medical Journal is more forthright, writing openly of ‘corruption’ and the suppression of science (Abbasi, 2020). In any event COVID, in partnership with other significant changes, has perhaps rendered social and political change more likely. Scambler (2020) considers four possible scenarios:
- Statist authoritarianism: this most closely approximates to a return to the status quo. It anticipates a degree of state repression to this end, with further curtailments of democratic processes and a second bout of political austerity to claw back COVID-related expenditures via a new programme of public expenditure and welfare cuts, skewed to hit the many rather than the few, together with a further tranche of privatisations.
- Proto–fascistic populism: this signals a break with conventional parliamentary politics in the wake of a COVID-precipitated crisis of capitalism and subsequent populist demand for transformative change. Twinned with Brexit, it would likely feature a platform of economic and cultural nationalism/isolationism in an England-based identity politics of white supremacism.
- Statist paternalism: this scenario sees the electoral displacement of the Conservatives by a centrist Labour administration or coalition committed to an ameliorated form of neoliberalism. Its commitment is to piecemeal social engineering.
- Radical left populism: this is also emergent from populist demand following a COVID-generated crisis of state legitimation and of capitalism itself. This time it heralds a regime oriented to left-progressive change and a reformed or post-parliamentary system of democratic politics.
Scambler’s conclusion was that the statist authoritarian scenario is the most likely, and at the time of writing movement in this direction is already discernible. Any populist swing seems likely to be regressive rather than progressive.
- Sociologists must study the COVID wood as well as its trees, and do so as a matter of urgency.
While it is appropriate and important that professional and policy sociologists address COVID with a view to better understanding and explaining it as a social phenomenon and – in alliance with colleagues from epidemiology and public health in particular – refining effective interventions, it is no less important that the bigger picture of social order and change is not overlooked. Given the neoliberalisation of universities in the UK there is a real risk that sociological attention – via its critical, public and especially its often-dormant foresight and action arms – is constrained and ‘tamed’ (Scambler, 2018). The big picture is unsettled and the future uncertain. Sociology should be seen and heard.
- Even being ‘seen and heard’ at a time national crisis is not enough, hence the emphasis in this paper on muckraking sociology. What is required is a sociological engagement that not merely exposes the enduring structural roots of what is an alarming acceleration of authoritarianism, inequity and injustice but arouses public anger and fuels movements for progressive change.
It is of the essence of muckraking sociology that it arouses passions and demands, and itself commits to, progressive interventions (action sociology). The natural experiment of COVID has laid bare a social system operating in favour of a small minority of citizens and rationalised by what Mills (1956) called their ‘higher immorality’. There is no need to write of a ‘conspiracy’ here since – another of Wright Mills’ concepts – a shared or ‘tacit understanding’ is sufficient. Ideally, sociology might extend to the framing of ‘alternative futures’, or different and better – more equitable, just and democratic – modes of institutional organisation (foresight sociology). There are already sociologists who have accepted this challenge, but few seem to inhabit the health domain. Nor are there many mainstream journalists and columnists who champion a once noble, feisty, investigative tradition, though a few have been cited here. The role of the public intellectual attracts less sympathy in British culture than in some others. But if not now, when?
Conclusion
We have argued not only that sociologists of health and health care should attend to the big picture, but that some at least of the disciplinary community of which they are part should go beyond documenting and accounting for exploitation and oppression when they find it and call it out publicly and fuel and engage with movements for progressive change (see also Scambler, 2016). The time for a muckraking sociology of health and health care has come.
Two case studies were pursued to afford substantive, illustrative material for this argument. The first focused on the reforms of the NHS by Conservative governments in the decade of austerity, while the second – necessarily a provisional and attenuated case study of a dynamic and changing political landscape – offered an account of the Johnson regime’s response to COVID in 2020. Our contention is that these provide ample evidence of the precedence of policy-based evidence over evidence-based policy, extending to an unambiguous abuse of power. A mantra or formula might read: capital buys/exercises power to frame health and health care policy in the interests of its further accumulation.
While the sociologies of health, illness, medicine and health care provide a lens through which to view society and social order and change, the reverse is no less true. Social structures and processes are revealed through health policy and practice. In this way, as reflected in our suggestion that we may well be heading for a form of statist authoritarianism, attention is directed at governance under cover of COVID. Specifically, these include: the consolidation of executive power over parliament, cutbacks on human rights, and, as we have indicated, the signing of a myriad of dubious contracts without due scrutiny or accountability.
A case might be constructed that the Johnson regime has sacrificed many thousands of lives of people known to be vulnerable, whether in care homes or in the community (Greenhalgh et al, 2020). There needs to be an ongoing dialectic between a sociology of social order and change and a sociology of health and health care. It is a dialectic that seems barely underway.
Box 1: The Rise and Rise of DIDO Harding & Co.
Harding is the daughter of John Charles Harding, 2nd Baron Harding of Petherton and the granddaughter of Field Marshall John Harding, 1st Baron Harding of Petherton. She was educated at an independent Catholic school and Oxford University.
She joined the management consultancy of McKinsey & Co in 1988, prior to holding executive posts with Thomas Cook, Manpower, Kingfisher and Woolworths, Tesco and Sainsburys. She became the first CEO of TalkTalk in 2010. She was heavily criticised when TalkTalk suffered a significant, sustained cyberattack in 2015. The attack cost the company £60 million and 95,000 customers. Harding stood down as CEO in 2017.
In 2018 Harding joined the main board of the Jockey Club, which runs many events, including the Cheltenham Festival. Public health experts were dismayed when this ‘super-spreader event’ went ahead and 250,000 people packed the terrace ‘like sardines’. Health Minister Matt Hancock, it should be noted, is the MP for Newmarket, where the Jockey Club has major infrastructural investments. It has been estimated that Hancock has received £350,000 in donations from wealthy people in the horseracing business. Before the 2019 election he announced that ‘I’ll always support the wonderful sport of horse racing.’ The Jockey Club’s premier event remains the Randox Health Grand National, and one of the Government’s most controversial contracts is with Randox. The global healthcare firm was given a £133 million deal, without advertisement or competition, to supply testing kits. Randox pays ex-Conservative MP Owen Paterson £100,000 per annum for 200 hours of work. Random’s testing kits were withdrawn on the grounds that they might be unsafe. (Monbiot, 2020).
In 1995 Harding married John Penrose, who was elected Conservative MP for Weston-super-Mare in 2005 and held junior posts in the government from 2010-2019. Penrose sits on the advisory board of the right-wing thinktank ‘1828’, which campaigns for the NHS to be replaced by an insurance system (and called for Public Health England to be scapped). At the time of writing he heads the Conservative Party’s anti-corruption team. Dido Harding was made a Conservative Life Peer in 2014.
When Harding was appointed head of NHS Track and Trace, the membership of her team was kept secret. It has since been leaked. It includes only one public health expert, but has space for a former executive from Jaguar Land Rover, a senior manager from Travelex and an executive from Waitrose. Harding’s adviser is Alex Birtles, who worked at TalkTalk with her. Subsequently, Mike Coupe, an executive at another of her old firms, Sainsbury’s, was also appointed (Monbiot, 2020).
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Graham Scambler is Emeritus Professor of Sociology at UCL and Visiting Professor of Sociology at Surrey University. He has written extensively on health and social theory. His latest books are ‘Sociology, Health and the Fractured Society: A Critical realist Account’ (2018, Routledge), and ‘A Sociology of Shame and Blame: Insiders Versus Outsiders’ (2020, Palgrave Macmillan), and ‘Communal Forms: A Sociological Exploration of Concepts of Community’ (with Aksel Tjora, 2020, Routledge).
Benny Goodman is a freelance researcher and writer, formerly a Registered Nurse and Lecturer in Adult Nursing. His interests focus on the sociology of health, including an emphasis on wider determinants of health informed by critical sociological theory.
Miranda Scambler is a Public Health Practitioner employed by East Sussex County Council. The views and analysis in this paper are a personal statement and are not intended to represent the views of her employers.