Essays on Professions (Ashgate Classics in Sociology)

ESSAYS ON PROFESSIONS

Ashgate Classics in Sociology Series Editors: Robert Dingwall, University of Nottingham, UK Alan Aldridge, University of Nottingham, UK Tim Strangleman, London Metropolitan University, UK This series is the successor to Cardiff Classics in Medical Sociology, expanding the publishing agenda of the original series to include reprints and revised editions of influential works across the discipline of sociology and collections of key articles by well-known sociologists.

Also in the series: Identifying Hyperactive Children The Medicalization of Deviant Behavior Expanded Edition Peter Conrad ISBN 978-0-7546-4518-4

A Constant Burden The Reconstitution of Family Life Margaret Voysey Paun ISBN 978-0-7546-4470-5

Sociology and Medicine Selected Essays by P.M. Strong Anne Murcott (ed.) ISBN 978-0-7546-3844-5

Essays on Professions

ROBERT DINGWALL University of Nottingham, UK

© Robert Dingwall 2008 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of the publisher. Robert Dingwall has asserted his moral right under the Copyright, Designs and Patents Act, 1988, to be identified as the author of this work. Published by Ashgate Publishing Limited Gower House Croft Road Aldershot Hampshire GU11 3HR England

Ashgate Publishing Company Suite 420 101 Cherry Street Burlington, VT 05401-4405 USA

Ashgate website: http://www.ashgate.com British Library Cataloguing in Publication Data Dingwall, Robert Essays on professions. – (Ashgate classics in sociology) 1. Professions – Sociological aspects 2. Professions – History I. Title 305.5'53 Library of Congress Cataloging-in-Publication Data Dingwall, Robert. Essays on professions / by Robert Dingwall. p. cm. -- (Ashgate classics in sociology) Includes bibliographical references and index. ISBN 978-0-7546-4614-3 1. Professions--Sociological aspects. 2. Law. 3. Medicine. I. Title. HT687.D557 2007 331.7’1--dc22 2007023736 ISBN: 978-0-7546-4614-3

Printed and bound in Great Britain by MPG Books Ltd, Bodmin, Cornwall.

Contents Series Editor’s Preface Foreword Acknowledgements

vii ix xvii

Chapter 1

The Legacy of Parsons and Hughes

Chapter 2

Accomplishing Profession

11

Chapter 3

‘Atrocity Stories’ and Professional Relationships

27

Chapter 4

‘In the Beginning was the Work…’ Reflections on the Genesis of Occupations

45

‘A Respectable Profession’? Sociological and Economic Perspectives on the Regulation of Professional Services

61

Closing the Market: Licensure and English Pharmacy 1794–1868

77

Herbert Spencer and the Professions: Occupational Ecology Reconsidered

85

Chapter 8

Professions and Social Order in a Global Society

99

Chapter 9

‘After the Fall ...’: Capitulating to the Routine in Professional Work

111

Chapter 5

Chapter 6

Chapter 7

Chapter 10

Endnotes References Author Index Subject Index

1

In Memory of Eliot Freidson: Is “professional dominance” an obsolete concept? 127 143 151 163 167

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Series Editor’s Preface Fifty years ago, sociological work on the professions lay in the doldrums. It was the era of the ill-conceived ‘trait approach’. Trait theorists saw their mission as drawing up checklists of criteria by which a profession was supposedly defined. The more points an occupation scored, the closer it came to that elusive ideal, the profession. The outcome might have been predicted, not least by sociologists themselves. Robert Dingwall characterizes the futility of the trait approach with characteristic aplomb: ‘The checklists were regularly criticized for their theoretical incoherence, their special pleading, their lack of discrimination and so on but the real blow to this approach was that people began to recognize that it did not matter very much. The really important judgements about the nature and status of occupations were made by governments, employers and clients, not by sociologists.’ This is not the only occasion in this collection where Dingwall punctures the more absurd pretensions of his contemporaries. If sociology is to flourish it has to be on the basis of imaginative but solid research, not the misplaced confidence of the technocrat, and certainly not the bombast of ideologues posing as social scientists. Dingwall does not simply demolish trait theory, he helps us to understand how it came about. In the period of social reconstruction following World War II, white-collar service occupations grew at an unprecedented rate, and this fuelled demand for professional recognition. More and more occupations claimed a status similar to that traditionally enjoyed by such the established professions as medicine and the law. Responding to this demand, trait theorists presented themselves as gatekeepers who could police access to the sacred status of profession. If they had reflected on the social context of their own professional work, they might not have been drawn into this futile activity. A striking feature of Dingwall’s work, already present in his earliest papers, is precisely his capacity to reflect deeply on the sociological enterprise itself. Far from being self-obsessed navel-gazing, it is a seriousminded endeavour to make sociology count. Dingwall’s work is full of trenchant observations that remind us of the importance of the task. Sociologists must be technically adept, but they are no mere technicians, still less technocrats. The moral seriousness both of sociology and of

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the professions themselves is a recurrent theme of the papers collected here, papers which display a rich combination of wit, provocation and erudition. Alan Aldridge Reader in the Sociology of Culture University of Nottingham

Foreword What might make the publication of a volume like this more than a simple exercise in professional vanity? There are perhaps, two answers to this question. The first, which comes perilously close to conceding its justice, is that the quirks of a career built through some lean times for UK sociology in the 1970s and 1980s mean that, although I have written a number of papers on the study of professions, relatively few people have had the opportunity to consider them as a body of work. My PhD training was in medical sociology but I have worked as much since in the sociology of law, and more recently in science and technology studies. The papers collected here were initially published in journals or edited volumes originating in the UK, the US, France and Italy, some of which circulated among economists and lawyers more than they did sociologists. While I have sometimes hoped that I might get the opportunity to distil this thinking into a synthetic book, the structures of UK academic life and the academic publishing market now make it unlikely that such an ambition can be realized. This volume, however, is an opportunity to present thirty years’ work as a whole that transcends the contingencies of its publication history. A second reason, however, may be less self-serving. In my recent acquaintance with science and technology studies, I have been reminded how far academics clean up their work for publication. If I had written my synthetic book, I would have contributed to that process. Of course, each of the papers collected here has itself been carefully constructed, often revised in response to refereeing and made to appear coherent in its own right. However, when placed together, they become markers of an intellectual journey. Each chapter bears the traces of the time and place where it was written and of its contribution to an emerging understanding. By retracing that journey, perhaps I can share something of the provisional nature of all scholarship. Perhaps I can also demonstrate something of the process of learning to write: I would like to think that each chapter is a little better crafted, as I have gained more experience. Some of the early chapters do have a clunkiness and pomposity that I would now hope to avoid. I am particularly grateful that my career crossed with that of Max Atkinson, who cared a great deal about clarity and did much to convince me that fewer words and simpler grammar almost always improve an argument.

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With the exception of the first chapter, the arrangement is more or less chronological. Chapter 1 originated at a conference in Oxford that I organized with Philip Lewis: he brought an extensive background in the study of the legal professions, while I contributed the medical sociology that I had learned in Aberdeen. Oxford’s pulling power drew a strong cast of scholars to talk about their particular studies of professions in either medicine or law and consider what could be learned from a comparative approach. However, when Philip and I started to put the papers together for publication, we discovered that the collection needed an introduction that would frame the case studies in terms of the wider project of understanding the nature and role of the professions in contemporary societies. In retrospect, I am not quite sure how I came to be the one who wrote it but it seemed to be a good place to start this volume as well, particularly as its exploration of the complementary projects inspired by Parsons and Hughes is echoed in the final chapter, written as a reflection on the contributions of Eliot Freidson, who was heir to both, in ways that have not always been recognized. Chapters 1 and 10, then, stand as the bookends to the collection, and as the opportunity to assess the arc of its approach. Chapters 2 and 3 come directly out of my PhD research. I am an accidental student of the professions. When I was an undergraduate at Cambridge (1968–71), the hot field was the sociology of knowledge, particularly when infused with the analysis of culture offered by Frankfurt Marxism. I originally wanted to write a thesis about how student teachers of history learned to teach history, seeing this as a site for exploring issues about politics and national myth-making that might lead into an understanding of the cultural roots of working-class deference. However, my undergraduate supervisor convinced me that education was not a promising field for persuading sociology departments to award me a scholarship and suggested I think about doing something on nursing instead – he had just read Olesen and Whittaker’s (1968) The Silent Dialogue and thought that it should be replicated in the UK. I trailed this idea around various departments without success until I was summoned to the MRC Medical Sociology Unit in Aberdeen. This was a strange recruitment experience. I came off an overnight sleeper train into a damp morning, where the sky was the same grey as the granite of every building in the city centre. I spent the entire day meeting staff, few of whom seemed terribly concerned about what I might actually want to do but who consistently appeared to be rather interesting people. I had a great time and the sun even appeared as I drove back to the station for the sleeper south, glinting off the flecks of quartz in the local stone and bringing a city of sparkles out of the morning’s murk. The next day, they offered me a scholarship. Some time later, I discovered that the competition had not exactly been

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fierce: even within Scotland, students preferred not to head north for their graduate work and the notion that someone from an elite English university would want to do so had piqued everyone’s curiosity. The part that I did not talk to them about was that I came from a railway background and I was well used to roaming round the UK rail network with free or heavily discounted tickets so that Aberdeen did not seem particularly remote. Of such accidents are careers made. Intellectually, Aberdeen was almost the complete antithesis of Cambridge. Where Cambridge worshipped theory and critique, Aberdeen valued empirical knowledge and understanding. Cambridge was fixated on the big narratives of macro-sociology, while Aberdeen was at the leading edge of UK micro-sociology. In fact, pretty much everything I had learned as an undergraduate was considered so much hot air by my mentors. If you look at Chapters 2 and 3, then, you will not find any trace of the student who could rattle off essays on the treatment of ideology by successive generations of Marxist thinkers. While most of my contemporaries were grappling with Althusser and the next big thing from Paris, I was steered towards symbolic interaction, ethnomethodology, Schutzian phenomenology and Goffman’s micro-structuralism – and firmly coached in the differences between them! Chapter 2 applies some of these ideas to an attempt to produce an ethnography of the vernacular use of the term ‘profession’ by the student health visitors I studied, following an agenda proposed by Becker, while Chapter 3 examines the way the health visitors told stories about themselves and other occupations as a way of locating themselves in the social hierarchies of work. Both show the influence of the ethnomethodological turn that Aberdeen field research took at that period, particularly in their emphasis on the analysis of talk, albeit limited by the technology of hand notes, rather than on its redescription in the manner of both the symbolic interactionist and Goffmanian traditions. Interestingly, neither paper draws directly on Everett Hughes’s work: some of the arguments might have been better formulated, if I had, but I did not actually read this until after I had left Aberdeen. The influence comes indirectly through the citations to Becker, Roth and Strauss, all of whom drew to varying degrees on that tradition. The ideas about the use of talk to maintain relations of exclusion and inclusion around occupations, which might today be called ‘boundary work’, were one of the few legacies from undergraduate days and an encounter with Mary Douglas’s writings. The fact that my PhD ended up being about student health visitors (public health nurses receiving post-basic education) rather than student nurses is another accident of history. Something else that no-one had told me at interview was that a previous postgraduate student had begun an ethnography of basic nurse education but had committed suicide during the fieldwork. It was never my business to know the details but there seemed

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to have been some recriminations between the Medical Sociology Unit and the Nursing School, and diplomatic relations were not good enough for me to secure entrée to my intended field site. However, there was a long history of warm relations with the Health Visiting School, which was geographically and organizationally quite separate. This offered a oneyear programme to retrain general nurses as specialist public health nurses, working mainly with pregnant women, new mothers and small children. Looking back, this was undoubtedly a more suitable project, in that it was far more manageable and conveniently time-bounded: the Unit’s Director was one of the pioneers of the UK stance that full-time PhDs should normally be completed within three years, which more or less dictates the pattern that I followed – one year to prepare and absorb the relevant literature, one year’s fieldwork and one year to write up. Studying general nurse training – then a three year course – would have raised considerable problems in deciding how to sample the student experience and to bring the fieldwork to a close. However, health visiting seemed to be a rather small and esoteric niche for the development of a career. It was, however, precisely the background that the Centre for SocioLegal Studies in Oxford were looking for when they advertised for a Research Officer. One of their senior legal academics had decided to study the use of the law in child protection and needed assistance from a social scientist who knew their way around the health and social welfare agencies involved in this process. Chapters 4 and 5 come from the thirteen years that I eventually spent at the Centre and reflect the opportunities that Oxford offered for crossing conventional disciplinary boundaries. Chapter 4 takes up some of the themes that are introduced in Chapter 3 about the idea of occupations as a folk taxonomy of work and radically extends them under the inspiration of a paper presented by Eliot Freidson at the World Congress of Sociology in Uppsala in 1978. Unfortunately, Eliot never formally published the paper, although the ideas recurred in a number of his later works. Chapter 4 develops arguments for a more historical and processual understanding of occupations through a case study of the creation of health visiting. Drawing on Freidson’s work, it argues for a more nuanced understanding of how occupations form and criticises the view that this is solely a matter of the splitting up of existing categories, as in orthodox sociological and economic accounts of the division of labour. As Freidson pointed out, work can move in and out of the market. Occupations can also be created by the fusion as well as the fission of groups of workers, an insight that came out of discussions with Mick Carpenter, who was researching the history of mental health nursing, an occupation that, like health visiting, had also been created by a process of amalgamation. The historical dimension here also acknowledges the

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seminars that I attended in Oxford’s History of Medicine Unit, which I found far more interesting than anything on offer in sociology. However, after a Christmas party awards ceremony where my colleagues presented me with the JRR Tolkien Memorial Prize for Elf Visiting, I decided that it really was time for this pony to learn some new tricks. Chapter 5 is pivotal in that respect. Where I had started with one half of Becker’s (1970) agenda to explore the use of ‘profession’ as a folk concept, I now became more interested in the other part of this agenda, namely the way in which we might specify this as an analytic concept, usable in a more technical way by sociologists. It came out of a number of conversations with Paul Fenn, who had arrived in Oxford at almost the same time as me, and at a similar career stage, with a background in health economics. Paul and I were struck by the way in which the sociological and the economic analysis of professions had converged from very different directions to see them as dangerous monopolies. We were less convinced about this, particularly when we discovered that Adam Smith had also exempted them from his critiques of guild closure of markets. Smith did not see professions as a form of market failure but as a potential solution to market failure. His basic argument was still valid as an analysis of the problems of informational asymmetry in the provision of services that were highly consequential for their users. A focus on legally-based licences to practice constituted the analytic definition that Becker was urging. The implications of this encounter with Adam Smith are further explored in Chapter 8, but I have long been grateful to the anonymous referee who encouraged us to look at Smith’s Theory of Moral Sentiments as well as at Wealth of Nations and triggered a continuing line of inquiry into the Scottish Enlightenment and its implications for the social sciences. Chapter 6 comes from the Nottingham phase of my career. You cannot set foot on the university’s main campus without appreciating the impact of Jesse Boot (Lord Trent), his family and his pharmacy business. Wherever you turn, a building or a chair is named for or endowed by one or other of these parties. The pharmacy school still enjoys a unique degree of prestige within the institution. If trying to raise a social science department’s profile, there is, then, a certain logic to considering what work could be done on social aspects of pharmacy. It is, in any case, a particularly interesting case of a near-market profession, where the concerns of trade are more evident than with many other health professions. However, the particular importance of the paper is its introduction of the distinction between demand and supply theories of professionalization that runs through the later chapters. Most writers on professions had, as shown in Chapter 5, presented them as well-organized social groups that had captured the legislative process and secured monopolies. The legally-backed licence related to occupational demand. However, pharmacy was a clear case

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where this could be questioned: a well-organized lobby had consistently failed to secure a legal monopoly until their claim coincided with a wider state interest. This suggested that we should look more closely at the circumstances under which states chose to supply monopoly licences. Perhaps it was states that captured professions… Although I had first encountered Herbert Spencer’s writings on the professions in Oxford in the early 1980s, I had not really done anything with them until Chapter 7, which was written with Michael King. Spencer has been airbrushed out of the history of sociology, although it is really impossible to understand a great deal of classic social theory without appreciating how much of it is, on the one hand, written against Spencer’s values, while, on the other, covertly appropriating much of his analysis. Nottingham was one of the few UK sociology departments where Spencer had been taken seriously until the 1970s and preserved something of that tradition. The importance of Spencer to the study of professions lies in his analysis of their role as sources of regulation operating at a distance from the state. He draws a basic contrast between militant societies, where everything is planned, directed and controlled by the state, and industrial societies, where the state has a much smaller role in facilitating the conditions for spontaneous ordering in a loosely coupled form of social organization. Such societies are, he suggests, likely to be more prosperous and more free in the long-term, because they do not carry the overhead costs of state control and because they provide opportunities for innovation and reward that are not available under central planning. Chapter 8 pulls together the themes of the four previous chapters to consider the challenges of a global society. In doing so, it makes more explicit links between the arguments derived from Smith and Spencer about the role of professions in supplying trust and confidence to otherwise unregulated markets. There is a sense in which globalization is recapitulating the 18th and 19th century experiences that were observed by these authors. Large-scale capitalism requires stabilizing elements that markets cannot easily supply without some more explicit framework of governance. That framework, however, need not take the form of a nationstate so much as an agreement between the market actors to accept the legitimacy of a particular group as suppliers of ‘certainty for all practical purposes’, whether in the form of warranting the technical feasibility of a great transnational engineering project like the Channel Tunnel or the Oresund Bridge, or of the web of associated legal and accounting transactions that bring the world’s capital to finance it. These issues of legitimacy form part of the backdrop to Chapter 9, where neo-institutionalist ideas appear for the first time. Chapter 9 was written with Kerry Kidd, whose background was in the study of English literature, in response to a challenge to explain why mediators were so

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dissatisfied with their lot, now that they were increasingly finding a secure place within the ecology of civil and family justice systems. The coorganizer of the conference where this was first presented characterized this as regret for a lost paradise, although I am not quite sure that he meant his words to be taken so literally. The chapter revisits some of the earlier discussions about occupational formation and the search for licensure, but casts these into the attempt to construct legitimacy and to align with state and market objectives in the hope of securing a market shelter. In the process, however, an occupation founded on its difference from other professions in the legal division of labour is obliged more and more to take on resemblances to them. The buccaneering days when anyone could set up their shingle and describe themselves as a mediator are fading. However, the Miltonic theme is used to question whether this is necessarily a bad thing. Does it rest on a misunderstanding of the ethic of public service? The final chapter was originally commissioned for a special journal issue in tribute to the memory of Eliot Freidson. It traces the trajectory of Freidson’s own thought and his increasing scepticism about the remedies for the failings of professional accountability that he had set out in the 1970s. Perhaps 1960s paternalism was preferable to the soulless care of 21st century health systems. The crisis of state welfare, of the benevolent partnership between professions and the state to meet the basic needs of citizens as a matter of expert and enlightened obligation, has provoked a crisis for professions. States have increasingly taken control of professions to use them as instruments for the re-education of citizens to expect less in the way of collective security and to depend more on their own self-provision. However, it is arguable that the expertise of professions remains a significant independent source of monopoly, and the uncertainty over outcomes an important basis for ethical practice. These need to be sustained as a check on the potential tyrannies of markets and capital. There is, though, a further argument, that returns to the, neglected, Parsonian elements in Profession of Medicine. Does professional monopoly rest as much on the role of physicians as control agents, policing claims to the sick role to match the carrying capacity of a society, as on expertise? What happens to this argument in societies where this rationing has effectively been abolished, or at least focussed only on those already socially excluded? If health care is less and less to do with healing the sick than with perfecting the well, do the arguments about regulation extend much beyond consumer protection, of ensuring that patients get what they think they are paying for rather than wondering whether the society can afford for them to get it at all? It is, perhaps, appropriate that this foreword finishes with a set of questions, since this collection represents an as yet unfinished project. The recent reforms of professional regulation in the UK are a powerful

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reminder both that autonomy granted by the state can be withdrawn by the state, and of the potential sources of resistance. When the state ceases to be a major purchaser of professional services, professionals can walk away from the state and create working conditions that are far less subject to proactive surveillance, even if new systems for the independent collection and investigation of consumer grievances have been put in place. Both dentists and lawyers have increasingly refused to supply their services on the terms set by the state and it is far from clear that the structural changes that have reduced the role of professionals in their own regulation will compensate for this. The New Labour challenge to professional autonomy has yet to be fully dissected and evaluated. That may well be a task for others, but I hope that these essays may offer some tools that they will find helpful in that project.

Acknowledgements

The various chapters first appeared as: 1. ‘Introduction’, pp. 1–18 in Dingwall, R. and Lewis, P.S.C., eds., The Sociology of the Professions: Lawyers, Doctors and Others, Macmillan, London 1983. 2. ‘Accomplishing profession’, Sociological Review, 1976, 24; 2, pp. 331–49. 3. ‘Atrocity stories and professional relationships’, Sociology of Work and Occupations, 1977, 4; 4, pp. 371–96. 4. ‘“In the beginning was the work ...” Reflections on the genesis of occupations’, Sociological Review, 1983, 31; 4, pp. 605–24. 5. R. Dingwall and P. Fenn, ‘A respectable profession? Sociological and economic perspectives on the regulation of professional services’, International Review of Law and Economics, 1987, 7; 1, pp. 51–64. 6. ‘Le verouillage du marché: les pharmacies anglaises dans la course à la licence 1794–1868’, pp. 15–22 in Lasselain, J., ed. Profession Pharmacien: Le Regard des Sciences Sociales, Edition Imhotep Médecine Sciences, Paris, 1995. Not previously published in English. 7. R. Dingwall and M.D. King, ‘Herbert Spencer and the professions: occupational ecology reconsidered’, Sociological Theory, 1995, 13; 1, pp. 13–24. 8. ‘Professions and social order in a global society’, International Review of Sociology, 1999, 9; 1, pp. 131–140. 9. R. Dingwall and K. Kidd, ‘After the Fall…: Capitulating to the routine in professional work’, Penn State Law Review 2003, 108; 1, pp. 67–87. 10. ‘Is “professional dominance” an obsolete concept?’, Knowledge, Work and Society, 2006, 4; 2, pp. 77–98. I am grateful to Paul Fenn, Michael King and Kerry Kidd for permission to reprint papers originally written in collaboration with them. The research described in Chapters 2, 3 and 4 was mainly supported by a PhD

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scholarship from the Medical Research Council and Chapters 1 and 5 were based on work done while employed by the Economic and Social Research Council. Chapter 9 was mainly written while a Visiting Fellow at the American Bar Foundation. I am grateful to many colleagues in Aberdeen, Oxford, Nottingham and elsewhere for their advice, comments and encouragement. They include Maxwell Atkinson, Mick Bloor, Bill Bradshaw, Joe Brodley, Mick Carpenter, Celia Davies, Gwynn Davis, Eliot Freidson, Max Hartwell, Christopher Honeyman, Gordon Horobin, Adrian James, Philip Lewis, Pat Robson, Phil Strong, David Oldman, Robert Rosen and Charles Webster.

Chapter 1

The Legacy of Parsons and Hughes Research in the sociology of the professions is, today, largely founded on the contributions of two people, Talcott Parsons and Everett Hughes. Although it is possible to identify earlier writings, these have, for the most part, been treated as of mainly antiquarian interest. Even when we come to the recent flourishing of neo-Marxist literature, we still tend to find the contributions of Parsons and Hughes as a starting-point. Parson’s general work has suffered badly from an excess of critical zeal in which the complexity and development of his thought has been obscured in an overall lambasting of functionalism. His writings on the professions, however, belong, in the main, to a pre-functionalist period when Parson’s main intellectual stimulus came from Weber rather than Freud. Two statements are of particular interest: his introduction to a translation from Weber (1964), The Theory of Social and Economic Organization, first published in 1947 but apparently written before World War II, and a paper (Parsons 1939), ‘The Professions and Social Structure’, first published in 1939. Hughes’s greatest legacy, by contrast, lies not in his own work but in that of his students, most notably Howard Becker and Blanche Greer, although Eliot Freidson, Erving Goffman and Anselm Strauss all passed through Chicago while he was on the staff. Like most of the major ethnographers in that department, Hughes had little sympathy for the grand synthetic visions of the kind that Parsons aspired to. His sociology was transmitted almost as an oral culture, which was available only at second-hand or in a rather heterogeneous assortment of papers until these were collected in a substantial and readily available format with the publication of The Sociological Eye in 1971 (Hughes 1971). Hughes too, drew from Weber but perhaps more crucially also from Simmel, whom Parsons disregarded as a microsociologist.1 Hughes’s interest in the professions also went back to the 1930s, but his thought was much less affected by the post-war intellectual fashion for Freud and displays much greater basic continuity. The starting point for Parsons’s (1968) discussion was his critique of utilitarian economics in The Structure of Social Action, first published in 1937. One of the major themes of that work was the inadequacy of the economists’ analysis of the social order of modern capitalist societies as the aggregate product of myriads of conceptually atomized unit acts, based

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on immediate calculations of maximal self-interest. How was an actor to recognize what was to count as maximizing self interest? Through the writings of Marshall, Pareto, Durkheim and Weber, Parsons sought to trace a concentration of social thought around this problem, eventually proposing his own solution, with a theoretical base in the sociology of knowledge, in terms of a socially-grounded normative order. The professions were an important empirical test for this proposition. Was their co-existence with a business economy an anachronism, given their apparent denial of selfinterest as a motive for action, or was it an illustration of an alternative approach to a shared normative end? The professions also presented a significant difficulty for Weber’s rationalist account of order in modern society. Like most of the classic sociologists, Parsons was fascinated by the fragility of social order. For him, one of the most striking features of Weber’s thought was its concern with the regulation and legitimation of the exercise of power. The selfish anarchy of the economists was held at bay by the recognition of authority, power normatively constrained and, thereby, rendered acceptable to its subjects. Weber argued that modern capitalist societies were characterized by the spread of rationality, what he termed the ‘dis-enchantment of the modern world’. In such a society authority rested on a rational-legal foundation, where the exercise of power was limited and justified by appeals to an impersonal order of generalized rules. The social organizational counterpart of this mode of authority was the bureaucracy, whose disinterested stance was underwritten by a clear delimitation of its sphere of action and its separation from the private commitments of its employees. Internally, these were reinforced by a strict system of supervision and control. Weber’s analysis offers no explicit treatment of the professions, an omission that is readily understandable in the German context: it has often been argued that the very concept of ‘profession’ reflects a distinctively Anglo-American historical experience. One might, however, propose that the professions have significant charismatic elements to their authority and organization. Many features of their relationship to society are mysterious, in the old sense of the word, and their mode of practice is highly individualized. On the Weberian model of social evolution they seem as anachronistic as on that of the classical economists. Parsons, however, recognized what is by now a commonplace: the capitalist economy, the rational-legal social order and the modern professions are contemporary historical developments. What modifications did the accepted theories require in the light of I his empirical observation? At the prompting of one of his principal Harvard mentors, L. J. Henderson, Parsons became involved in a study of medical practice in the Boston area in order to explore this question.2 Tantalisingly few details of this research have ever been published. However, medicine offered a particularly useful

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testing-ground because of its relevance to a further disagreement between Parsons and Weber over the epistemological status of natural and social science. Weber tended to argue for a break between them but Parsons took the more radical position from the sociology of knowledge, arguing for their essential continuity. In studying medical practice, Parsons could demonstrate the social foundation of its knowledge and its translation into the impersonal normative order of science. Science provided an equivalent to the legal order and a similar foundation for rational action. However, that action took place through collegial forms of organization. In fact, these are less antithetical to the notion of a bureaucracy than Parsons supposed, since he tended to elide one manifestation – the monocratic type – with the underlying ideal. Nevertheless, Parsons showed that the individualist collegial organizations of the professions and the hierarchical organizations of monocratic bureaucracy rested their authority on the same principles – functional specificity, the restriction of their domain of power, and the application of impersonal standards on a universalistic basis, without regard to the personal characteristics or circumstances of their subjects. The alleged distinction in terms of self-interested as opposed to altruistic motivation was of minor significance. What was more important was a shared orientation to ‘success’, whether material or non-material, as judged by the prevailing normative standards. These standards overrode the utilitarian calculus of the economists. The normative order was of course, a complex phenomenon. A variety of contributions might be counted as successful in ways that might or might not be merited. Other institutional spheres – family, friends, classes – might be founded on different values and embody other organizational forms with a diffuse and particularistic character, their authority spilling over an ill-defined territory in a selective and individually-responsive fashion. Social integration was always empirically problematic. In his later writings, the professions became less central to Parsons’s work, although The Social System (Parsons 1951) proposes some interesting ideas about the relations between professions and deviance. Parsons himself became more interested in unravelling the nature of the normative order of modern capitalist societies and the ways in which it was transmitted, an enterprise in which he was deeply influenced by Freudian thought.3 Hughes, on the other hand, maintained his interest in the professions throughout his career. It is more difficult to present his contribution in a synthetic fashion: like most Chicago sociologists, as Rock (1979) has demonstrated, he had less grandiose preoccupations. However, there are certain consistent themes, which may relate in part to the different

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experiences of prewar Chicago and of prewar Europe. Parsons was writing in a European tradition of conservative sociology, developed in response to the turmoil of the nineteenth-century political, industrial and economic revolutions. American sociology was a sociology of progress. Where Parsons had a deep anxiety about the apparent disintegration of social order and the collapse of its normative foundations into fascism and chaos, Hughes saw the great melting-pot of Chicago where a bewildering variety of ethnic interests were being forged into a new social order. The division of labour, then, lies at the heart of Hughes’s interest in the professions; not in the pessimistic vision of Marx and Weber but in the optimistic spirit of Durkheim and Simmel who saw its possibilities for the extension of human freedom and cooperative interdependence. The world of work was treated as an analogue to the city of Chicago urban ecology. A given terrain of demands for goods and services was divided into blocks of tasks, which might be developed, redeveloped or extinguished. These blocks had successive occupiers, competing for access and struggling to improve their status by new acquisitions or the relinquishment of less attractive properties. Some occupiers were prestigious and powerful, others disregarded. All were caught up in a constant evolutionary process as demands and technology changed, either from clients or from internal attempts to influence the market. Two concepts are particularly important in Hughes’s thought: licence and mandate. All occupations have an implicit or explicit licence to carry out certain activities that are different from those of others, in exchange for money, goods and services. It is this formalized exchange-relationship that distinguishes work from non-work spheres. If the occupation members have any sense of community by virtue of their shared work experience, they are also likely to claim a mandate to define, for themselves and others, proper conduct in relation to their work, to influence its technical content, styles of delivery and, most crucially, the patterns of public demand and response. Hughes emphasizes that both licence and mandate should be thought of in the broadest terms. Nowhere is this more true than in the case of professions, which Hughes regards as the prime illustration of the possible legal, intellectual and moral scope of a mandate. Not only do professions presume to tell the rest of their society what is good and right for it: they can also set the very terms of thinking about problems which fall in their domain. They exemplify in an extreme form the role of trust in modern societies with an advanced division of labour. The professions are licensed to carry out some of the most dangerous tasks of our society – to intervene in our bodies, to intercede for our prospects of future salvation, to regulate the conflict of rights and obligations between social interests. Yet in order to do this, they must acquire guilty knowledge – the priest is an expert on sin,

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the doctor on disease, the lawyer on crime – and the ability to look at these matters in comparative and, hence, relative terms. This is the mystery of the professions. Their privileged status is an inducement to maintain their loyalty in concealing the darker sides of their society and in refraining from exploiting their knowledge for evil purposes. It is important to emphasize that Hughes regards these features as differences of degree rather than kind, present in all occupations. In consequence, any occupation may aspire to similar privileges if it can reconstruct its licence and win acceptance of an enlarged mandate, just as the urban sociologists recognized the potential mobility routes for ethnic groups. Professionalizing occupations are a zone of transition, a point of change from which new social forms are emerging and, hence, a matter of particular interest for the sociologist. Finally, we must note that, unlike Parsons, Hughes was offering a distinctive methodology. Chicago sociology had a central belief in the importance of first-hand experience of the social world. This was never dealt with in any very systematic written fashion but formed part of the oral tradition from which students acquired a sense of research practice in the quasi-anthropological fieldwork that dominated the chronicling of interwar Chicago. This difference is important in understanding the legacies of the two men. Hughes’s students went on to produce a series of detailed ethnographies within the department’s tradition of concentrating on change as an everyday process. Parsons’s more structural approach left few guidelines for its realization in empirical study, particularly given his own failure to publish an adequate account of his research. The resulting intellectual vacuum was filled by the emergence of an empiricist methodology derived from the work of Lazarsfeld, whose old-fashioned scientism responded to the conservative climate of fifties America in its depoliticization of debate and its pretensions to objectivity. In retrospect, the two seem uneasy intellectual bedfellows linked more by their scientistic than their philosophical coherence. One might, indeed, argue that C. Wright Mills’s twin bogeys of Grand Theory and Abstracted Empiricism were able to co-exist mainly as a result of a tendency in American sociology to avoid internal conflict by a process of compartmentalization. Neither sought to occupy the territory of the other and a superficial harmony reigned. One consequence, however, was that some of the most formative writings of Hughes’s students were characterized by an explicitly oppositional stance, products of a group that often felt itself to be on the intellectual and organizational margins of the discipline. Both traditions, then, left a series of open questions. How were we to know a profession when we saw one? Parsons took the category for granted, Hughes said it was merely a question of degree. What was the relationship

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between values, organization and practice? Parsons had been very vague about the sources of values, their transmission and their internalization as regulators of work standards. He tended to play down the significance of organizational forms in favour of their pervading spirit. Hughes, on the other hand, gave more attention to organizational features. Although his own writings contain considerable discussions of the relationship between professions and moral order, the work they inspired led to a downgrading of values in favour of an analysis that often owed more to a maximal selfinterest model. Professional work and its collective forms were presented as the aggregate outcomes of everyday battles over the use of resources, the limits of task ownership and the delegation of ‘dirty work’. Crudely, one might suggest it was economics with the money left out. Finally, and most crucially, both traditions neglected the role of the marketplace and the professions’ wider contract with their society. Parsons’s repudiation of economic reasoning seems responsible for one of the most glaring omissions from his discussion of the relationship between professions and business: the monopoly power of the former. Similarly, Hughes’s disdain for the unworldliness of neo-classical economics, and his vision of sociology as a study of social forms, undermines his own remarks on the importance of exchange relationships. Competition within and between occupations is drawn around status attributes rather than financial gain. The lack of attention to exchange relationships also affected both traditions’ handling of the wider dimensions of the professions. Weber’s discussion of bureaucracy emphasizes control and supervision rather than accountability. It is, however, vital to ask where the impersonal rules come from. Insofar as they have some democratic foundation, for instance, then a bureaucracy is not just an engine of control in a necessarily oppressive sense but a device for ensuring that the popular sentiments expressed in the rules are respected by employees and clients alike. This weakness carries over to Parsons’s work and is never directly resolved in relation to the professions. Hughes does offer a way of talking about such issues in his discussion of licence and mandate. It is, however, a theme that is subordinated in later empirical work in favour of the study of intra-occupational events, partly, one suspects, as a reaction against the abstracted macro-sociology of the 1950s. Empirical work on the professions has clustered around these questions. Hughes comments several times on the avid interest of graduate students in writing about their own occupations as a means of professionalization. In some hands (e.g. Greenwood 1957) this turned into the trait approach, often mistakenly identified with Parsons, to the issue of definition. Could we list exhaustive criteria for distinguishing professions from other occupations? Other writers (e.g. Becker 1970) sought to defend profession as a non-evaluative term by identifying sociological and lay concepts. The

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former would be restricted to an analytic sense, while the latter would yield data on the rhetoric of justification current in some community. Interest in the relationship between values and institutional forms as determinants of occupational practice generated several major studies of professional socialization and countless pieces of research, of various methodological persuasions, on professional work. (e.g. Merton et al. 1957; Becker et al. 1961; Strauss et al. 1964) Finally, the reawakening of interest in political economy has led to some notable discussions of the relationship between professions and the market for their services and of their wider societal context (Johnson 1972; Larson 1977). However, the empirical base for such work has remained oddly skewed. In a review of work on American lawyers, Abel (1980, p. 335) pointed to the dearth of writing about lawyers in any critical or theoretical sense, compared with the wealth of literature on medicine. Similarly, Campbell et al. (1980, p. 9) draw attention to the discrepancy between their original classificatory frame and the available work in preparing a bibliography on the British legal profession and its work. There is a lack of basic sociodemographic data on recruitment, training and career paths. Historical work is still dominated by biographies of great men and great firms. Relatively little work has been done on the formal and informal organization of practice. How does the occupational community police itself? What is the impact of specialization on the division of labour? Where, and in what fashion, does occupational socialization occur? Where do paraprofessional workers and self-help fit? On the other hand, it must be recognized that in some respects the available work on lawyers goes well beyond traditional work on doctors. Medical sociology has had relatively little to say about the impact of the cash nexus and restrictive economic practices. It has also tended to underplay the political and community activities of doctors as topics for detailed study rather than polemic. Moreover, the concentration of sociologists on law rather than lawyers, knowledge rather than practice, has permitted a perspective on the former as a social product which medical sociologists still find difficult to sustain in relation to medicine (Dingwall 1977b). Nevertheless, one is forced to conclude that, despite a number of contributions that would be first class by any criteria, the sociology of lawyers is comparatively underdeveloped on both sides of the Atlantic. The reasons for this are both social and intellectual. We have already alluded to the critical importance of medicine as a testing ground in Parsons’s debates with Weber. It was similarly strategic for Hughes’s thought. The proliferation of specialties within medicine, the explosive growth of new paramedical occupations, the aspirations of lower-status personnel to the rewards of doctors, all constitute a vast natural laboratory for the ecological concerns of the Chicago-influenced sociologist. We must also recognize that medicine is a matter of public concern in a way

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that most law is not. The development of the modern welfare state, even if it does not directly nationalize health service provision, creates a political stake in containing premature death, disease and disability as costs to social security schemes. There has then been an investment of research funding in medical sociology that has not been paralleled in the study of law. With the important exception of criminal law-enforcement and correction, legal matters are treated as a private or corporate rather than a collective problem. Such features have interacted with the organization of academic work to create distinctive combinations of activity in the study of medicine and law on the two sides of the Atlantic. In brief, we can identify both empiricist and theoretical currents in both fields in both locations, the distinctions that Straus (1957) identifies as sociology in and sociology of medicine and Campbell and Wiles (1976) term ‘socio-legal studies’ and ‘sociology of law’. The former concentrate on the application of research techniques to questions given by the allied discipline; the latter is a more theoretical enterprise which embraces the disciplinary perspective which poses those questions as part of its own problematic. It is a distinction between working within, if not actually serving, established interests and appropriating those same interests as the subject of one’s research. In the UK the sociologies of medicine and law both grew up in the shadow of existing interests in social medicine and criminology – pragmatic, utilitarian and atheoretical enterprises. Both of these interests owed more to traditions in social administration and social biology than to the likes of Hobhouse, Ginsberg or Marshall who shared the more fundamental orientations of Continental European sociology. With the increased professionalization of British sociology in the 1960s, sociologists became less satisfied with the underlabourer role of ‘social factors in ...’ to which they had traditionally been consigned and eager to secure a share of the substantial funding resources available to their competitors. The ideas of the American sociology of deviance were imported as a spearhead in this revolution. There was, however a key difference between the two fields: criminology was a profoundly conservative discipline while social medicine’s practitioners held a strong self-image of themselves as radicals. The sociology of law, then, emerged out of a highly politicized debate while the sociology of medicine tended to retain a political consensus with social medicine and to dispute with it on predominately intellectual grounds. The American picture is rather different. From the earliest days of its establishment in the universities sociology was a strongly empirical discipline. In consequence the sociology/social administration split is not reproduced in North America and the terrains of criminology and, to a lesser extent, social medicine are occupied by sociologists. Moreover

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the sociology of medicine was at the heart of sociological development rather than being a fringe specialty, as in the UK, and there was a much weaker demarcation between the study of medicine and other areas such as deviance, work and organizations. The shape of research in the two fields, then, represents more clearly the effects of outside forces, largely the availability of funding, which in turn flows from the political visibility of health care and justice as social issues. A good deal of this is profoundly empiricist in character, but there is also a substantial body of theoretically informed empirical work. British medical sociology lies closer to this model, although periodically agonizing about its lowered indigenous prestige resulting from its lack of abstracted theorizing in the mainstream domestic tradition. After a shortlived flirtation with American writings on deviance, however, British sociologists of law gravitated towards European Marxism. Empirical concerns disappeared, particularly under the impress of Althusserianism, in favour of the armchair manipulation of closed deductive systems, where studies of historical or contemporary events entered only as vehicles for previously stipulated themes. In part this also reflects funding contingencies: medical sociology’s accommodation with social medicine meant that substantial, by sociological standards, research funds were available. The sociologists of law, on the other hand, were largely forced back onto what might be worked on alongside teaching positions. It is only comparatively recently that Britain has begun to produce a sociology of law which is capable of seeing its subject matter as a human product rather than as given a priori by the needs of capitalism. Coupled with the lack of American studies stemming from the funding market, this leaves a serious gap in our knowledge. The study of the professions is weakened by an inadequate foundation for its generalizations. The study of medicine suffers from a lack of challenge to its dominant problematic, neglecting, for instance, the study of medical knowledge. The sociology of law is biased towards the study of criminal justice, a minor part of the totality of legal activity, and decontextualized. Laws exist in vacuo without adequate appreciation of their everyday creation, recreation, translation and extension. The sociology of the professions stands at some kind of a turning point. The 1970s were invigorated by a sequence of major theoretical contributions, most notably from Freidson (1970a), Johnson (1972; 1977) and Larson (1977). Established traditions were seen to have reached the limits of their original paradigm and the research problems given within it. There does, though, seem to be a broad consensus on the key issues. First, it is clear that we need to take a very much wider perspective in attending to the historical setting of both individuals and collectivities. Professional work must be studied not just in the context of a division of labour but as

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part of a network of social and economic relations. Second, the importance of knowledge is reaffirmed. The division of labour is also a division of knowledge, with consequential implications of reciprocal dependence and vulnerability between participants. That knowledge is, moreover, a social product, reproducing and constituting a particular order. Third, and most important, is the stress on comparative empirical work. Throughout this collection, contributors, explicitly or implicitly, suggest that the separation of a sociology of professions from a sociology of occupations has been a blind alley. Rather than presupposing the sociological significance of professions as a category, we should be asking what kinds of occupations there are. Such a question can, of course, only be posed against detailed case studies of work settings, case studies, however, which, in adopting the preceding injunctions, must be grounded in a wider understanding of structural and cultural features than has previously been common. It is a time, perhaps, for paradigm evolution through research into recognized problems, rather than a continuing self-indulgence in revolutionary debate from the comfort of academic armchairs.

Chapter 2

Accomplishing Profession Our commonsense knowledge of our own society tells us that the concept of ‘profession’ is clearly central to any inquiry into the social organization of health and illness. It is, however, a concept that is notorious for the diversity of its definitions and usage by sociologists. My contention is that this confusion is the result of sociological treatments of lay social theories as impoverished sociological theorizing rather than as phenomena in their own right, to be studied in their own terms. In this chapter, I shall attempt to develop such an alternative, drawing on my work on the social organization of health visitor training. I begin by reviewing what remains the dominant contemporary mode of thinking about ‘profession’, the attribute approach, and the main criticisms of it, which one may broadly identify as structural, political and epistemological. My argument will be that each of these is, in its own way, inadequate and that we should, rather, proceed to the empirical investigations of socially distributed commonsense knowledge of social structures, abandoning any claim to legislate a correct use of the term ‘profession’, but treating it as a concept invoked by members of particular collectivities and seeking to describe its practical usage. The data were collected by participant observation of a health visiting course in a polytechnic over a period of twelve months.1 Material was obtained in lectures, tutorials and informal situations within the institution and on home visits and clinic sessions during the students’ concurrent fieldwork experience. As far as possible, field notes were recorded at the time of the observation. Sociologists and ‘Professions’ The attribute approach begins from the basic assumption that it is possible to draw up a list of fixed criteria for recognizing a profession on which there will be a general consensus. These criteria can then be used to distinguish between ‘professions’ and ‘other occupations’ in a relatively clear and unproblematic fashion. Becker (1970, p. 87) identifies the origins of this approach with a paper by Flexner (1915), which set out six criteria:

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Essays on Professions ... professional activity was basically intellectual, carrying with it great personal responsibility, it was learned, being based on great knowledge and not merely routine; it was practical, rather than academic or theoretic, its technique could be taught, this being the basis of professional education; it was strongly organized internally; and it was motivated by altruism, the professionals viewing themselves as working for some aspect of the good of society (Becker 1970, p. 88).

In reviewing this literature, Roth (1974) has catalogued a number of more recent attempts to draw up lists and shows how they are all quite different, although there are some points of overlap. But even in performing such acts of definition, it is clear that these writers are not altogether happy. Flexner qualified his whole analysis: What matters most is professional spirit. All activities may be prosecuted in the genuine professional spirit ... The unselfish devotion of those who have chosen to give themselves to making the world a fitter place to live in can fill social work with the professional spirit and thus to some extent lift it above all the distinctions which I have been at such pains to make (Flexner 1915, p. 590).

The logical outcome of this approach is that a profession is nothing more or less than what some sociologist says it is. He derives his definition from his own member’s knowledge of his society or from an inspection of some collection of data. In either case he is basically legislating a social structure by fiat, which, as we shall see, lays the definition open to the same objections as any other form of inquiry by fiat. There are, however, more conventional critiques of this approach. The classic exposition of the structural alternative is that of Freidson (1970a; 1970b). He argues that one can distinguish between adopting an ideology of professionalism, which displays the various kinds of features described by the attribute theorists and the location ‘profession’ within a given social structure. The recognition of this status is a licence of functional autonomy, secured from the state by political action, giving the profession the exclusive right to control the access to, and organization of, the tasks that constitute its work. But such structural considerations, Freidson argues, only set the broad limits of professional performances. Their details, the routine conduct of the professionals, depend upon the concrete features of their everyday work settings. One can, however, question the empirical adequacy of Freidson’s approach. The notion of autonomy is highly specific to American practice. In countries with a socialized health-care system, medical autonomy is limited by state intervention, as Gill and Horobin (1972) have noted in Britain. Yet this does not affect the societal esteem of the occupation. Because doctors work in a setting where autonomy is restricted, however much they may resent it, this does not imply that collectivity members

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at large do not continue to think of them as professionals. To invert this point, health visiting satisfies Freidson’s criteria for a profession, having independent access to and control over the content of its own work. Yet, although these structural conditions exist and health visitors describe themselves as ‘professionals’, I have no grounds for supposing that this forms an essential part of the commonsense knowledge of competent members of British society. The key weakness of Freidson’s approach it that he is trying to perform the same operation as the attribute theorists. Just as Flexner thought he had found a fundamental criterion in ‘professional spirit’, so Freidson believes he has found one in ‘professional autonomy’. He derives this attribute from his data and turns it into a primary postulate for identifying other ‘professions’ in the same way as the attribute theorists. There is a central ambiguity in his work between specifying an objective definition of ‘profession’ and examining the subjective knowledge of collectivity members. Freidson is not clear whether he wants to study a collectivity by fiat or through an analysis of the work by which its members make it real for one another. The strain is usually resolved in favour of the former. The second main line of criticism is political. This presents itself in two forms. The ‘hard’ version, for example in the work of Illich (1973), argues that the notion of profession is a concept that is used solely to achieve the successful mystification of a class interest. Such an approach, however, takes the reality of labels like ‘profession’ and ‘class’ for granted, assuming they are identifiable entities that are unproblematically recognizable. It stresses the aspect of a class in itself, whose reality may not be apparent to its members but is to the observer. It is not clear why anyone observer’s imposition of class cohesion should have priority over any other’s. The ‘soft’ version of this critique is found in the work of Parsons and Becker. Parsons (1939) notes the coexistence, in modern society, of a capitalist economic order with the development of professions, and the traditional dichotomy between analysing the motivations of capitalists in terms of selfinterest and of professionals in terms of disinterestedness. He argues that their motivations are similar, since each is searching for success, but that they are identified by different sets of imputed motives. The institutional framework of the professions is maintained by a balance of social forces rather than a belief in the importance of the professions’ social functions. Many features of this framework are common to both business and professional occupations. Parsons attempts to specify the vocabularies that are drawn upon to impute motives to professionals and businessmen: the ‘functional attributes’. This attempt has often been criticized on empirical grounds as inaccurate – that we more frequently see moral imperialism than affective neutrality and so on. I would argue that the attempt is limited rather than erroneous. The vocabularies identified by Parsons are invoked

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by some society members in bringing off their sense of location within a social structure. The social distribution of motive ascription is an important element of accomplishing a social structure. The variant on this political theme advanced by Becker (1970) derives directly from his epistemological criticism of the use made by sociologists of the concept of profession. He points out that most of the sociologists’ difficulties stem from the use of one word to do two different jobs. While lay people use the term to make moral evaluations of occupations, sociologists use it to point to an ‘objectively discriminable class of human phenomena’. Becker argues that this attempt should be abandoned and ‘profession’ treated as a ‘folk concept’: a part of the vocabulary of social analysis available to members of a collectivity. He tries to do this by treating the work of attribute theorists as data on commonsense conceptions of professional work. He concludes by considering the relation between this popular symbol and ‘what really happens’. This returns Becker to the problem of reconciling the objective social order laid down by sociologists, the reality, with the subjective order of collectivity members, the symbol. This leaves him open to the criticisms that Zimmerman and Wieder (1971) make of Denzin (1971), in particular of the interactionists’ assumption that a social world exists ‘out there’. This symbolic order remains unexplicated. Its accomplishment is treated as a fact rather than as a problem. Becker comes close to this in his treatment of ‘profession’ as a folk concept, but his discussion continues in terms that presuppose a break between the cognitive world and the social world. He remains tied to the elucidation of objective features of a taken-for-granted real world, an activity for which he can claim no special credence over any other competent member. The central problem with these attempts to define ‘profession’ is their assumption that it has a fixed meaning. On the contrary, I would argue, with Wittgenstein (1972), that words do not have fixed meanings and that the attempt to legislate meaning is unavoidably a fruitless exercise. Words do not have fixed and unequivocal uses according to some calculus of rules. Their sense is found by a process of filling in until we can say that we understand. (Understanding, of course, is not a mental process but, rather, the circumstances that allow me to justify saying ‘I understand’.) We cannot, then, define what a profession is. All we can do is to elaborate what it appears to mean to use the term and to list the occasions on which various elaborations are used. Past approaches pretend to some basic, simple super-order of super-concepts that are prior to members’ experience. But that experience ‘is in order as it is’, however vague, incoherent or whatever it may be. ‘Where there is sense there must be perfect order – so there must be perfect order even in the vaguest sentence. (Wittgenstein 1972, p. 45)’.

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How can we bring ‘profession’ back from its metaphysical to its everyday use? Some clues are provided by Moerman’s (1974) discussion of the concept of ‘tribe’ as used by anthropologists and by his native Lue subjects. He notes the difficulties presented for anthropologists by their attempts to legislate ethnicity by fiat and argues that the relevant question to ask is not ‘Who are the Lue?’ but ‘When and how are the Lue?’ He presents a list of traits that Lue invoke to identify themselves as distinct from their neighbours. Many of these are ‘objectively’ shared with these other peoples but may still be used by Lue to demonstrate their ethnicity. They identify themselves as Lue and they find the meaning of that identification by elaborating an indefinite set of criteria. Thus, I set out to examine the use of the term ‘profession’ by health visitors in relation to their own or other’s behaviour in elaborating ‘professional’ and ‘non-professional’ conduct. I then tried to sce whether members made empirical associations between this term and others, in such a way as to constitute a more or less organized sense of social structure. This involved abandoning any attempt to legislate the definition of a ‘profession’ and, instead, the study of its usage to establish the activities of health visitors as a ‘profession’ rather than an ‘occupation’. However, as the account shows, these tasks are not fully separable. As well as bringing off ‘profession’, in opposition to ‘occupation’, health visitors are also accomplishing ‘health visitor’ as opposed to ‘hairdresser’ or ‘bricklayer’. The result of this analysis was the following list, which summarizes the empirical work. This is discussed in its entirety elsewhere (Dingwall 1974). The present account will confine itself, by way of illustration, to some aspects of the personal qualities of a health visitor (Section 1) and of the relationship between health visitors and other workers (Sections 4 and 5). The Formal Scheme A field health visitor is a professional because: 1. She is a certain sort of person, in that 1.1 She has certain ambitions and is committed to her occupation. 1.2 She has certain personal qualities. 1.3 She dresses in a certain fashion. 1.4 She carries herself in a certain way. 1.5 She uses a certain vocabulary of discourse. 1.6 She uses certain kinds of transport. 2. She has autonomy in her work and knows what is best for her clients. It follows that 2.1 No other health visitors will interfere with her clients.

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2.2 No other health visitor will give her orders about her action towards her clients. 2.3 No other health visitor will give her clients advice that might conflict with hers. 2.4 She initiates her own contacts. 2.5 She is self-critical. 2.6 She enjoys her work and does not require to be stimulated to do it. 2.6.1 But she does not work to excess at the expense of her own leisure. 3. She is a member of an occupation which 3.1 Selects its recruits. 3.2 Has formal qualifications. 3.3 Is self-governing. 3.4 Has its own body of knowledge. 3.5 Has a history. 3.6 Has research done on it. 4. She has responsibility for supervising others’ work. 4.1 Clinic Attendants. 4.2 Health Assistants. 5. She is equal to all other professionals, but has a discrete area of work. Other professionals include 5.1 Social Workers. 5.2 Doctors. 5.3 Teachers. 5.4 University Staff. 5.5 Nurses. 5.6 Various Therapists. 6. She acts towards others on the assumption that they share this definition of her social location in an empirically identical, for all practical purposes, fashion. This list should not be regarded as definitive or exhaustive and the structure imposed on it relates merely to my expository convenience. Nevertheless it appears to me to represent an adequate summary of my field data. Competent performance appears to involve giving attention to those elements of this list that are relevant orientation points for the management of the presented situation. Hence we should not expect to find a complete display in anyone encounter. This summary, however, collapsing together a variety of situations, might plausibly correspond to some more or less organized interpretive scheme held by members of the health visiting community.

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Professional Qualities The group of features which constitute professional conduct in the eyes of the gatekeepers to health visiting – tutors and senior community health staff – relate to what one might call existential qualities of the individual health visitor. They are both revealed in some intuitive fashion and documented by reference to various kinds of actions on the part of the individual. In order to succeed as a student it is centrally important to establish that one is the right sort of person to be a health visitor. Academic ability is not enough. Student assessment is an evaluation of the total person as revealed in everyday activities. The relevant personal qualities may be explicitly formulated as in this extract from a lecture on health visiting practice: Some skills and qualities are required for efficient planning. For instance the skill of organization of being able to work out a method, of being methodological [sic] ... There are other qualities (a health visitor) needs such as being able to adapt to a new area, to be flexible, since anything may disrupt her plans and to have a sense of humour about this, to be realistic, since she’s not going to turn the world upside down because she hasn’t got the resources. She should be punctual and reliable and not make rash promises. She needs a sense of humour, a balanced mind and the ability to carry on in spite of obstacles.2

Other positive qualities include ambition for success as a health visitor, measured by occupation of senior posts, involvement in strategic planning and disseminating innovation, commitment to the occupation, since the decision to apply for training is taken to be a major one, confidence in one’s abilities and personal maturity. These features were also recognized by students, although they had their own accounts of the work: Clare says the attraction of health visiting is that there is no evening or weekend work. One of the others asked her if she’d said that at the interview. Clare laughed and replied ‘No. I said with all my qualifications it seemed a waste not to. Big-head!’

This of course reflects the differences in the requirements for an adequate demonstration of the rationality of their position on the part of tutors and students. Personal qualities may also be expressed in relation to negative qualities, what a professional health visitor is not. These quotations relate to discussions in the examiners’ meeting of possible failures: Miss Lane says the student’s fieldwork assessor described her as ‘shy and diffident’ but the tutors feel she lacks articulacy. Her fieldwork instructor described her as ‘passive ... absolutely non-communicative’.

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Essays on Professions The external examiner says that this student has a more plausible manner but her approach is superficial and there is an element of rigidity in doing an analysis of situations. They felt that this student’s inflexibility of attitude could be a danger in the community.

Competence develops over time as evidence is accumulated through the assessment procedures to document successful displays of professionalism by the students. The first student failed because she had been unable to produce acceptable displays. The second failed because her performances were felt to lack sincerity. This underlines my original point about the existential nature of these qualities. The performance is the person. As one tutor phrased it: We see her as a professional, a member of the health service team. When we talk of her role we are talking about the kind of person that she is.

This running-together of doing and being characterizes the other elements grouped in this section. Goffman (1971, pp. 28–82; 1972, pp. 128–130) has described something of the relevance of props as integral parts of the process of laying claim to be a particular sort of person in any particular encounter. The references made by staff to dress and to cars are instances of such usage. At the time of this research, there was some controversy among health visitors about the wearing of uniform. This was linked to changing conceptions about the proper mode of self-presentation of a health visitor and the relationship she should seek to develop with her clients. Uniforms were felt to create social distance and to imply an authoritarian personality. Abolition of uniforms was associated with progressive trends in health visiting. But not all civilian dress was equally acceptable. Trousers were disapproved of for female health visitors. Male health visitors felt required to wear jackets on duty, even on hot afternoons in Inner London. The clothing credits, which the local authority in the city where most of the fieldwork was done had substituted for a uniform, could only be spent at rather old-fashioned department stores. Similar work can be done in relation to car ownership. The specification of the social meanings of modes of transport is a large topic and I shall confine myself to two examples here. The first is from a verse in circulation in the early sixties, quoted by McQueen (1962), and the second is from a local newspaper, collected during the fieldwork: As the HV and the Midwife pedalled fiercely in the rain The School ma’am in her Austin looked upon them with disdain And the half-trained Welfare Worker ran her mini-car quite well. A full-page article (in the official magazine of the Police Federation) by a member of the Cheshire force which has decided to retire its Panda cars

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expresses regret for the backward trend. Apart from the technical advantages, he argues, Pandas raised the job ‘almost, if not financially, to the level of a profession’.3

Car ownership was a further prop in the health visitors’ claims to professional status. It was also linked with the switch from district work to practice attachment, which I discuss later. The accomplishment of health visiting as a profession also required the adoption of certain forms of communicative conduct, both linguistic and paralinguistic. Schutz (1970, p. 14) observes that: The vernacular of everyday life is primarily a language of named things and events and any name includes a typification and generalization referring to the relevance system prevailing in the linguistic in-group which found the named thing significant enough to provide a separate name for it.

One of the problems of demonstrating the identity of health visiting is its lack of such language. This reflects its interstitial position between the health and welfare services. Its vocabulary is loosely drawn from nursing, medicine and social work. There is, for example, no term to describe the persons in receipt of services. They may be referred to as ‘patients’, ‘clients’, ‘families’, ‘mothers’, ‘people’ or ‘the ladies I go to visit’. These former are commonest but enjoy no consensual status. The only exception is that there is but a single acceptable way of describing a health visitor and that is as a ‘professional’. Since the collectivity of health visitors cannot be identified in terms of the vocabulary of its natural language, the emphasis shifts to the form of their communications. They appeal to some shared sense of the appropriate language register for professionals. They should not, for example, use local dialect: Alice says it can be very patronizing for an outsider to use dialect. Miss Lane says the point is rather different. ‘We are going in as professional workers and I do honestly feel we have to be ourselves in that role’. She adds that it is wrong to adopt the client’s language but that you do have to understand it.

This point also received attention in criticisms of the students’ teaching practice and the need to select a style that was neither too technical nor too informal. In conclusion, we should also note what, following Birdwhistell (1973), we might describe as the kinesic dimension of professional performance. Birdwhistell argues that the management of body shapes and movement is a learned accomplishment that takes place inside a given cultural frame. Just as we can recognize membership of collectivities through mastery of the natural languages which bound them, so too we should be able to recognize kinesic communities bounded by learnt

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systems of body management. The present research did not investigate such phenomena in detail using some notational system, but it did turn up examples of professionalism being formulated in terms of correct and incorrect body management. One student recounted, for example, how she had been criticized on teaching practice for not looking elegant enough and for leaning on the table while talking. The assessor had said this was ‘unprofessional’. Other students had had similar experiences. Tutors drew attention to the problems involved in relating to children at their own level while trying to bring off a professional performance for parents. (Davis and Strong (1976) describe similar difficulties for other workers with children.) Body management could also be used as a discriminator between health visiting and other occupations and as a point for conflict over definitions of correct performance. The first three sections of the formal scheme list features of the qualities of performance and of the intrinsic organization of health visiting work that contribute towards the health visitors’ definition of themselves as professionals. The accomplishment of health visiting as a ‘profession’ involves its members in being certain kinds of people who carry out tasks in particular kinds of ways within a particular work setting. But a claim to professional status involves more than this. It is also the assertion of a claim to a particular kind of social location in relation to other social groups. It is to this claim that I shall now direct my attention. Professions and Other Occupations Health visitors’ claims to professional status are based upon their conceptions of the social structure of their society and of the relative placing of occupations within it. This involves the location of their occupation as equal, inferior or superior to others. This self-location may not, of course, be recognized by those others and there is no reason why it should be. The cognitive maps of social structure that are involved in performing as a competent member of an occupation are inevitably socially distributed, providing for the rationality of that occupation. This clearly offers a potential point of conflict if discrepancies are confronted and can raise questions about differential ability to enforce conceptions of social structure. These theories are described more fully elsewhere (Dingwall 1974; 1977a). Here I shall concentrate on examples relating solely to the issue of the accomplishment of health visiting as a profession. This involves, first, those groups identified as social equals. Into this category fall doctors, nurses, social workers, teachers and various types of therapist. Secondly, there are groups identified as social inferiors – clinic staff, health assistants and workers in some government services. I found no instances

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of groups regarded as social superiors. Discussion here will be confined to the first category. Occupations may be regarded as the outcome of social schemes of classification of work. The study of occupational systems is the study of taxonomies of social phenomena. We can, then, treat occupational taxonomies as we might any other folk taxonomy, examining the methods whereby categories are formulated, phenomena are recognized and assigned and the system as a whole is described and justified. Further, we can consider what is involved in maintaining the taxonomy’s orderly character, the ways in which new cases are normalized by identifying them as instances-of-a-type. This leads into problems of boundary maintenance and the methods for sustaining the integrity of the normal case. The interstitial position of health visiting in the Welfare State raises particular difficulties for such processes. It is neither entirely a health service nor entirely a social service. This gives prima facie grounds for expecting to find problems of exclusion, of defining oneself as a discrete occupation. But the groups from which health visitors wish to distinguish themselves are also those with which they rank themselves socially. Thus we might find problems of inclusion and the question of how health visitors manage to regard the occupations as the same but different. I shall, then, present a number of instances of health visitors talking about other occupations and attempt to make a number of inferences about the kind of social order which is being formulated through that talk. The relationship that health visitors formulate with respect to doctors raises problems of inclusion, of achieving recognition as social equals. As we have seen, health visitors are encouraged to define themselves as professionals and to act towards doctors on the basis of this self-definition and on the basis of defining the profession of medicine as embracing similar features, personal qualities and conditions of organization to their own and to anticipate the reciprocation of such expectations. On the whole, such expectations are frustrated. I shall, then, begin by considering the models of health visitor/doctor relations held by the respective parties and then proceed to examine the ways in which troubles arising from the discrepancies between the models are normalized. In their encounters with health visitor students, I identified two doctors’ models of their relation with health visitors. The first was held by staff from the local medical school who talked freely about changing relationships between various health workers and the emergence of a team of equals integrating both hospital and community services. They were enthusiastic about the 1974 health service reorganization.4 Their conception of the team included the possibility of an independent role for health visitors and, indeed, the possibility that the team might not be led by a doctor. They were sceptical, however, about the extent to which such views were shared

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throughout their occupation. Most of the general practitioners seemed to work with the second model. They saw the primary health care team as a group of auxiliary workers who were to be organized and directed by the general practitioner. While these workers might have skills of their own they merely duplicated in a rather partial way those of the doctor himself and were to be used strictly under his supervision. He would be responsible for the definition, allocation and pacing of the workloads. The model drawn upon by the health visitors is well summarized by Clark (n.d) in a paper that the tutors circulated to the students: Each member of the team should understand and respect the roles and functions of every other member of the team. This implies partnership not hierarchy. In particular the nurse members of the team are partners with and not ancillary to the medical members of the team. Nursing is a professional skill in its own right, requiring a specific professional preparation; doctors are not in a position to assess nursing needs or supervise nursing practice.

Health visiting had its own area of expertise in which health visitors did better than doctors and for which doctors were not competent supervisors. When groups invoking such radically different models of their proper relation come together, one might expect to find conflict. In the event, there was relatively little that I could identify as direct confrontation. The doctors assimilated health visitors to their typification of nurses and the health visitors tended to slip into this model of social relations, while recognizing its discrepancy with their preferred version of events. They relied on traditional nurses’ strategies of indirect negotiation, like those described by Stein (1968) to press policies on the doctors. Of course, they had greater resources for this than other nurses, since they had independent access to their clientele. Nurses cannot directly control the work that comes to them, other than by seeking to influence doctors, by managing information about patients, once the patient has been directed to their care. Health visitors can influence self-referral for treatment by influencing patient demands and tactics. For example, where a health visitor disagrees with a doctor’s prescribing policies she can seek to encourage or dissuade patient requests for medication. Similarly, health visitors in one area I studied coached women seeking abortions in the right ways of beating the local system, where the consultants operated a restrictive policy. Such activities, however, were tempered by the requirement to accomplish profession in respect of the public at large and to maintain the integrity of inter-professional relations to the public. As I suggest in Section Two of the list of qualities involved in accomplishing profession, it is important that the integrity of each professional’s independent judgement be maintained. Thus, although health visitors, particularly on

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district work, have a considerable store of comparative knowledge on the quality of individual general practitioners, they were unable to put this at their clients’ disposal. They sought to encourage people to patronize ‘good’ doctors but could not discourage them from going to ‘bad’ doctors. In comparing the contraceptive advice given by general practitioners and family planning clinics, for example, they would emphasize the advantages of the clinic – free supplies, specialist knowledge, etc. – rather than the inadequacies of the general practitioners. It would seem that health visitors remedy the difficulties generated for them by the discrepancy between their ‘ideal’ and ‘real’ models of social structure through their conversations about doctors. The telling of ‘atrocity stories’ is an important dimension in the constitution of the occupational group, which may be defined in terms of those to whom one tells such stories and from whom one receives them. Thus although health assistants, clinic attendants and sociologists may on occasion be allowed to listen, it is out of order for them to tell such stories. The phenomenon of story-telling has been discussed by Stimson and Webb (1975, pp. 88–112) in respect of patients. They contend that stories can be seen as devices whereby patients retrospectively give an account of their encounters with the medical profession, negotiate norms for the behaviour of patients and doctors, and redress the imbalance in the relationship between doctor and patient by allowing the voicing of complaints at a safe distance. The teller is presented as being sensible or rational in the face of the incompetence or dereliction of doctors. The rational nature of the social order is made evident, as the patient reconstructs the scene as he would have liked it to have been. I would argue that such story-telling is similarly bounded to people like oneself, but that the work which is accomplished is a common feature of everyday life. In the face of the persistent infringements of one’s rationality as a social actor which are the inevitable consequences of the social distribution of senses of social structure and the differential ability to enforce one’s own version as essentially correct, stories allow for the reconciliation of everyday affairs with one’s model of the ideal state of things and the reaffirmation of one’s rationality by one’s peers. Thus, we may find ‘atrocity stories’, ‘hard luck stories’, ‘sad tales’ and so on. Health visitors commonly tell stories about doctors, particularly in the presence of students. This would seem to involve two kinds of issues. Firstly, there is the demonstration of the rationality of one’s occupation before novices for whom such a proposition might seem questionable. Secondly, there is the transmission of the theories that are likely to be required as invocable resources if the student is to mount a competent performance as a health visitor. Over time, the students develop their own repertoire of stories. Initially, they talked about how they had successfully compensated for the deficiencies of doctors in the hospitals in which they

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had worked. As they accumulated experience in health visiting work, stories about health visitors and doctors appeared, drawing either on the students’ own experience or upon accounts transmitted by field staff. Space does not permit presentation of illustrations but the stories share the same features as those presented by Stimson and Webb, casting the teller as the active participant who sets things right despite the incompetence and idiocies of others.5 The problems posed for health visitors by nursing and social work were rather different, being problems of exclusion. Health visiting was seen as overlapping considerably with the work of each of these groups and this presented difficulties in demarcating health visiting as a separate occupation. Indeed, there were those who would argue at times that health visiting was ‘really’ social work or nursing. The present account concentrates largely on relations between health visiting and other nursing occupations – hospital nursing, midwifery and district nursing – but much of the material relating to social workers is broadly similar. There are certain differences, however, which are produced by the differing contexts in which confrontation with these groups takes place. The confrontation with social workers occurs in the setting of the everyday task performance of health visitors and the identification of health visiting work and social worker work. The confrontation with nursing occurs more indirectly, at field grade level at least, and is more in terms of the reconciliation of the students’ present with their past biographical experiences of nursing. The issue of distinguishing health visiting from nursing chiefly arose in the early weeks of the course. To some extent, it was deliberately raised by tutors in the context of reformulating student conceptions of everyday life. These conceptions may be thought of as akin to Schutz’s (1962) notion of provinces of meaning, with their own peculiar cognitive styles and socially distributed stocks of knowledge. However, I would argue that if we are to regard the reality of everyday life as constituted for collectivity members by their everyday routine actions and the recipes which enable them to produce and recognize such actions, and if knowledge of such recipes is socially distributed, then the sense of the reality of everyday life must itself be socially distributed. Since our social, as opposed to physical or temporal, locations may change infrequently or gradually, this fixity of our commonsense notions of social structures may make abrupt changes rather difficult. However, organizations, like professional schools, which specialize in changing such commonsense notions, are likely to develop routine ways of accomplishing the transition. In this school of health visiting, the tactic adopted was a reformulation of the students’ past to include it within their present. Once this had been executed the distinctiveness of the present situation was re-emphasized.

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This reformulation partly involves a manipulation of health visiting history to emphasize its association with nursing and its connection with important symbolic figures like Florence Nightingale. The concept of an ‘official history’ as a legitimation of the present state of affairs by selective attention to historical events is discussed more fully elsewhere (Dingwall 1974; 1977). For the present, suffice it to say that many other possible histories are available but that this is the particular one that occurs. The tutors at the school gave explicit attention to definitional questions, underlining the continuity between health visiting and nursing and muting the distinctions. Where these latter were discussed, tutors stressed the positive qualities of health visiting, its particular satisfactions, authority style and training rather than the negative qualities of nursing. As I found out for myself, the students were very unwilling to accept criticism of nursing. Throughout this period, however, the staff were willing to criticize nursing in other situations. With the passage of time their remarks to the students became more pointed. They criticized the rigid hierarchical structures of the occupation and the authoritarian leadership of senior personnel. Student nurses were reduced to passivity in the face of this, but arrogantly demanded, rather than sought to earn, respect from the public. Their training had low educational standards, was poorly taught and rather uncritical. Patients were reduced to objects of task performance rather than being treated as human beings with their own thoughts and feelings. This legacy from the past hampered their efforts to produce good health visitors. The health visitor students gave a similar account of nursing. This would seem to have been independently generated since it was in evidence from the beginning of the course. One must not discount the role of selection and self-selection in this but since the students found much difficulty in constructing a coherent account of health visiting and since these accounts related to reasons for leaving nursing rather than becoming a health visitor, I think we may reasonably conclude that this is what nursing is like for some of those experiencing it as an occupation.6 Accomplishing Profession This account has brought us some way from our original starting point in an attempt to provide a more adequate conceptualization of the notion of a ‘profession’. Constraints of space have obliged me in a number of places to substitute glossing for the presentation of conversational data and the analysis of its production of the order under description. It has brought this closer to an ethnography than the methodography which the purist might prefer. Nevertheless, I have sought to furnish an alternative to the legislation of social order involved in previous attempts at the analysis of the term ‘profession’. In particular, I have suggested that what we need to

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do is to examine how occupations are established as discriminable events through the interpretive work of their members and of outsiders, and how certain occupations further seek to establish themselves as ‘professions’ through certain kinds of appeals. I contend that we need to carry out further studies of what appeals are made, how they are made and in what settings they are made in such a way as to accomplish the production of an occupation as a ‘profession’ for the purposes of its members. Further, we require details of the response of other society members to such work, in the context of their own commonsense knowledge of their society and its structures, and the processes involved in acquiring and deploying such knowledge to formulate possible social realities. This points the way, for example, to studies of the transmission of social theories through education and communications media and to the use of such theories in everyday situations. The injunction is, ultimately, to take the mundane, everyday world of the non-sociologist seriously rather than to try to substitute our own versions of reality for it.

Chapter 3

‘Atrocity Stories’ and Professional Relationships This chapter’s theme is the maintenance of relationships between a number of occupations seeking to establish mutual recognition as ‘professions’ and to extract due respect from their equals and due deference from their subordinates. In the previous chapter, I argued that much of the confusion about the notion of ‘profession’ stems from attempts to legislate its meaning rather than to examine its use. I suggested, following Wittgenstein (1972), that words did not have fixed meanings but that their sense derived from the circumstances that allowed us to say that we had used them correctly. In order to examine this I took up Moerman’s (1974) discussion of the term ‘tribe’ and the similar difficulties with which anthropologists were presented. Moerman argued, in the context of his own fieldwork with a Thai tribe called the Lue, that the relevant question to ask was not ‘Who are the Lue?’ but ‘When and how are the Lue?’ Accordingly, I took from my field notes a list of features to which health visitors appealed to justify their identification of their occupation as a profession. This list made reference to the personal qualities of health visitors, their conditions of practice, the organization of their occupation, and their relation to other occupations, most notably doctors, social workers, nurses, and the auxiliary staff of general practice (receptionists, cleaners, clinic assistants). This chapter develops that discussion of inter-occupational relationships. Professions and Other Occupations We can conceive of social interaction as involving the reciprocal typification of parties to any encounter in the light of the social theories which these parties have available to them. By ‘social theories’ I mean those bodies of commonsense knowledge that we may employ in any situation to identify the sorts of persons with whom we are dealing, to make sense of their actions towards us, and to develop possible courses of action on our own behalf as the encounter unfolds. One apparently ubiquitous element of such theories is some conception of the social structure of one’s society and the relative standing of members of different occupations. Health visitors draw on such a conception in asserting their professional status

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and locating themselves as equal, inferior, or superior to other occupations. Such claims, of course, are not necessarily recognized by members of those occupations. In his study of Anglican clergymen, Moore (1974) showed how presenting oneself as a competent member of an occupational group involves drawing on a social theory to display the rational and reasonable character of that occupation. Such a theory is bound to that occupation and may, indeed, be said to constitute the occupation linking, as it does, a set of tasks by reference to its interpretive framework. In consequence, though, such theories must be socially distributed in attesting to the particular character of the occupations they subsume. Any confrontation between members of different occupations invoking theories providing different definitions of the relative standing of the occupations and/ or different definitions of the range of tasks properly the concern of each occupation contains a potential for conflict, which may raise questions about the differential ability of groups to enforce their own versions of the world. Occupations may be regarded as the outcome of social schemes of classification of work. The study of occupation systems is the study of taxonomies of social phenomena. We can treat occupational taxonomies as we might any other folk taxonomy, examining the methods whereby categories are formulated, phenomena are recognized and identified, and the system as a whole is described and justified. Further, we can consider what is involved in maintaining the orderly character of that taxonomy, the ways in which cases presented to it are handled by identifying them as falling within the boundaries of some category and outwith the boundaries of other possible categories. We may designate these as the problems of inclusion and of exclusion. Health visiting is a particularly useful occupation to study in this respect since it occupies one of those marginal positions that throw particular light on the normal state of affairs. In their work, health visitors lay claim to a set of tasks that are more closely related to the set of tasks carried out by British social workers than by any other occupation. These tasks are predominantly those of social counselling. At the same time, all health visitors are employed within the National Health Service and are, by origin, registered nurses, although their work has nothing in it which is conventionally done by nurses in the United Kingdom since there is no clinical component. Health visiting is neither entirely a health occupation nor entirely a social service occupation. This gives us prima facie grounds for expecting to find problems of exclusion confronting health visitors as they attempt to identify and maintain the discrete character of their occupation from pressures to assimilate them either into nursing or into social work by redrawing occupational boundaries and redistributing either personnel or tasks. However, those groups from which health visitors wish to distinguish themselves at one level are also those with whom they wish

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to align themselves in terms of social esteem. This suggests that we might expect to find problems of inclusion in facing the question of how health visitors manage to regard these occupations as similar, although in other ways asserting their differences.1 A common way in which these problems are rendered explicit, and achieve a partial resolution, is in the telling of ‘atrocity stories’. These critical stories play an important part in defining the colleague group, those to whom one can tell such stories and from whom one receives them. They allow for the assertion of the tellers’ social theories and for mutual support in redressing the illegitimate actions of others. The term ‘atrocity story’ was first used by Stimson and Webb (1975) in discussing the ways in which patients talk about doctors, although the sorts of account that it describes are common in much of the ethnographic literature on work. Stimson and Webb argue that atrocity stories can be seen as devices whereby patients retrospectively interpret their encounters with the medical profession, negotiate norms for the behaviour of patients and doctors, and redress the imbalance in the relationship between doctor and patients by voicing complaints, albeit at a safe distance. These stories are dramatic events staged between groups of friends and acquaintances that draw on shared understandings about the way of the world. The teller is cast as hero, in the right where the doctor was wrong and maintaining his reason despite the incompetence and dereliction of others. Through these stories, social structures and parties to them are rendered rational and comprehensible. In deriding the powerful, the teller can defend his own rational character, whether in the narrow occupational sense suggested by Moore (1974) or, more generally, against the infringements of others. Similar accounts are common. Stimson and Webb themselves cite Strauss et al. (1964) on stories in psychiatric hospitals and Roth (1963) on the stories of tuberculosis patients. More striking parallels, however, can be found in the work of Gold (1952, 1964) and Becker (1963). Gold describes how janitors gather in bars where the exchange of stories about tenants forms a major part of their conversation. In his discussion of janitors’ typifications of tenants, he is clearly tapping a similar repertoire ready for any appropriate audience. These stories too present the janitor as hero and serve to elicit reassurance from colleagues. Of particular interest to my subsequent discussion is that difficult tenants are those who are seen by the janitor to be making illegitimate attempts to control his work or unfounded claims to social superiority. Becker (1963, pp. 79–100) makes frequent reference to story-telling in his discussion of jazz musicians and many of these stories appear to centre on affirmations of the worth of the music and its players in the face of ‘square’ indifference or hostility. Again, too, we find instances centring on attempts at illegitimate control over the music or on superiority over the musician.

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It would seem, then, that atrocity stories are a good deal more common than Stimson and Webb allow in their tentative suggestion that parallels to their own stories may be found among the clients of other professionals such as lawyers. I would argue that we should expect to find such accounts wherever attempts are being made to control aspects of the life of some group by others whose justifications for such attempts are seen as illegitimate.2 It is the legitimacy of the attempt which is important. Atrocity stories are not an exclusive preserve of the powerless, although they may be more common among them. Doctors tell stories about illegitimately assertive patients as much as patients retail stories about illegitimately assertive doctors. By casting occupation members as hero, atrocity stories maintain the intrinsic worth of the teller and, by implication, his or her colleague audience. Acquiring an appropriate repertoire of such stories and being able to identify appropriate occasions for telling them are important parts of becoming recognized as a competent member of an occupation, or, more generally, any social group. Novice health visitor students, for example, still tell each other hospital atrocity stories, which Mauksch (1973, p. 823) suggests are quite common among nurses. Such stories were told in competitive story-telling sessions where each student seemed to be trying to cap the previous story by producing her own.3 These stories covered a variety of extraordinary or bizarre events like patients jumping out of windows, walking half-naked down main streets, and hanging themselves in the lavatories. As they were recounted, the teller was cast as hero in resolving these situations in the light of the obduracy or incompetence of others. I only observed these story-telling sessions in the early part of the course, before the repertoire of health visiting stories, which I analyse below, was acquired. They appeared to serve as demonstrations by the students to each other of their ability to monitor the social world as competent nurses and to formulate it into appropriate patterns. Conversely, these sessions also attested to the competence of the audience, as potential story-tellers, to listen to and evaluate stories and to produce appropriate sequels. The stories seemed to disappear as these properties became taken for granted. Such story-telling sessions appear to occur quite frequently whenever nurses who do not know each other meet. Health Visitors and Doctors Both common sense and sociological theorizing about our society tend to regard doctors as constituting the archetype of a profession. They are, then, likely to be a key reference point, especially for other health occupations claiming recognition as professions. I shall present accounts of health visitors talking about doctors and attempt to make a number of inferences

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about health visitors’ conceptions of the proper relationships between the two occupations, the extent to which these are met, and the available remedies. To anticipate a little, I shall argue that the difficulties with doctors are primarily issues of status equality, the problem of inclusion, while the difficulties with nurses and social workers are issues of demarcation, the problem of exclusion. Health visitors are encouraged in their training and by the official theorists of their occupation to define themselves as professionals and, hence, on a par with doctors. The official theorists argue that the medical profession displays similar personal qualities, conditions of work, and organization to their own and that health visitors should act towards doctors on the basis of such an assumption and should expect this to be reciprocated. This argument is summarized in a paper by Clark (n.d.) which the tutors on the health visiting training course circulated among the students: Each member of the team should understand and respect the roles and functions of every other member of the team. This implies partnership not hierarchy. In particular, the nurse members of the team are partners with and not ancillary to the medical members of the team. Nursing is a professional skill in its own right, requiring a specific professional preparation; doctors are not in a position to assess nursing needs nor to supervise nursing practice.

Elsewhere, the same author notes: The marriage between health visitor and general practitioner must be a modern marriage based on the principle of a partnership between equals, not a Victorian marriage in which one partner expected from the other obedience and servility (Clark in Bloomfield and Follis, 1974).

But this model is not shared by general practitioners (GPs). Those doctors from the local medical school who were involved with the training course were prepared to allow an independent role for health visitors. Their colleagues with whom the health visitors actually worked shared this egalitarian rhetoric but tended to treat them in practice as mere auxiliaries whose work would be strictly under the GP’s control (Mclntosh and Dingwall, 1978). One of them summarized this view in a lecture to the health visiting course: The practice consists of patients, doctors, receptionists, secretaries, health visitors, nurses, premises, equipment and records. The GP sits in the middle like a spider in his web.

In the past, these conflicts were contained by the separation of health visitors and general practitioners. Health visitors were employed by

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municipal authorities and allocated to specific geographical districts. The only doctors with whom they were required to work closely were those employed by the municipal authority in child welfare clinics who were junior members of a low-status area of British medicine. The health visitors’ practice was entirely autonomous and did not depend upon doctors’ referrals as does the work of other nurses. However, the failures of liaison between health visitors and general practitioners led to a change in the basis of work to one of practice attachment where health visitors visit on the basis of practice lists. Their work retains its autonomy and they are still employed by a separate body.4 Thus this deeply entrenched tradition of autonomy and overt claim to equality of status with general practitioners has been forced into an arena of direct confrontation with a group that espouses a totally different model of practice. There is, though, little direct conflict. Doctors tended to assimilate health visitors to the readily available typification of nurses, and health visitors slipped back into that role, at which they were experienced players. They sought to manage doctors by the use of traditional nursing strategies of indirect negotiation (Stein, 1968). They had additional resources in this compared with other nurses since their independent access to clients meant that they could influence a doctor’s practice by influencing clients’ selfreferrals. They could dissuade requests for medication, for example drugs to suppress lactation or to sedate children. They encouraged women to use the specialist municipal family planning clinics for contraception and coached women on circumventing the local medical system to get abortions. But these activities are tempered by a requirement of interprofessional solidarity. While open criticisms of doctors are readily made within the colleague group, these are not repeated to the public. Instead, health visitors point to the advantages of some courses of action, rather than the disadvantages of others. Rather than criticizing the ignorance of general practitioners on contraception, they point to the specialist interests of the municipal clinic or the fact that supplies from there would be free.5 However, it remained the case that the GPs’ control was experienced as illegitimate, although it was seldom felt to be worth a direct challenge. Apart from the success of the indirect responses, field grade health visitors felt that their administrative superiors valued practice attachment (which they equated with teamwork) so highly that they would invariably take the doctor’s side against their own staff in the event of any trouble (McIntosh and Dingwall, 1978). Health visitors are left in a vague, ambiguous, and insecure position where the worth and rationality of their occupation appears most uncertain. Atrocity stories form one of the remedies for this. At first, students are given stories by their course tutors and by their fieldwork instructors in lectures, tutorials, and case review sessions. This example is a tutor talking in a lecture about one of her former cases, a 16

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month old child of middle class parents who was unresponsive and showed slow motor development. The doctor had dismissed the mother’s worries and the tutor had been trying to get the child seen by another doctor: Finally I managed to get the child referred to the consultant audiologist with the GP’s reluctant consent – to exclude deafness. The audiologist had a long session with the mother and she talked about her problems to him. He produced a lengthy report which he sent to me and the GP. He was concerned as well and this put extra pressure on the GP to refer the family to Child Guidance ... The mother had her own problems and needs which were not being met in her marriage – It was just the start of a long story The GP wasn’t willing to see the problem and get involved He was very glad to get a health visitor to keep people out of the surgery. She came in to see the doctor a lot and had great faith in him but always went away dissatisfied. She required very lengthy sessions every time.

I then began to record students repeating stories that they had been told by instructors, or tutors, to other students. This extract is taken from a student’s presentation of a case to a tutorial group of about ten students and a course tutor. All the speakers are students. Caroline: Why is the youngest child at risk? Rosemary: He’s retarded with a neuromuscular disorder. Pat: When was this found out? Rosemary: The health visitor was worried quite early on, but the GP poohpoohed it until after the developmental assessment.

This is a useful indication of how short stories may be. Rosemary’s is reduced to a single sentence. What distinguishes this from a simple complaint is the choice of vocabulary. Rosemary has selected a dramatic word in ‘pooh-poohed’ which has clearly discrediting connotations. She is not merely saying that the GP disagreed but that he was culpably wrong and, moreover, that the health visitor was demonstrably right. Finally, one gets students telling stories of their own, as I shall illustrate in discussing social workers in the next section. These stories present the health visitor as the active character who triumphs over the incompetence or foolishness of others. There is derision of the illegitimate claimant of superiority, the doctor who ‘pooh-poohed’ a health visitor’s suggestion and the doctor who wanted a health visitor attached so that he could keep people out of his surgery (even though the account offers the possibility of the patient being over-demanding of surgery time). The group’s ideas about correct performance are reaffirmed. Doctors should accord a more equal role to health visitors and not dismiss their opinions lightly. At the same time the tutor’s story shows the tactical

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response to opposition should be one of quiet persistence rather than direct confrontation. If problems in the health visitors’ relationship with doctors stem from their assertion of an equality of status in respect to differentiated work, the problems with social workers and other nurses are more of demarcating between their respective zones of competence. In the former case a sharp distinction has come to be blurred; in the latter a blurred distinction is sharpened. Health Visitors and Social Workers If we look at what actually happens in a household during a visit from a health visitor and from a social worker it is very hard for the observer to identify any significant difference in the form or content of the two occupations’ work. Both of them are attempting to give social counsel or exert social control in contexts defined by state legislation. Their occupational theories and vocabularies of motive are very similar. Fashions in each tend to be rapidly mimicked by the other. I turned up many instances of confusion between the two groups among both clients and other related occupations. Thus in both training and practice, a major problem in maintaining the identity of health visiting is to find a way of distinguishing between the two occupations. Health visitors make few appeals to the content of their work as a discriminator, except insofar as they have some special skills in relation to medical problems. Instead, they tend to talk more in terms of the organization of their work. Health visiting is presented as essentially longterm preventive work with the general population while social work deals with crises in the lives of people who are social ‘problems’. However, even this distinction is difficult to maintain since health visiting and social work are in direct competition for clients in areas where visiting is necessarily long-term, notably the chronically sick and the elderly.6 The working definition of ‘health’ in health visiting is that of the World Health Organization, ‘a state of complete physical mental and social wellbeing’. Some respond to this vagueness of classification by trying to annihilate the boundary between the two occupations and to insist that health visitors are social workers. This is particularly popular among occupational theorists like the college tutors and the local Medical Officer of Health (MOH) who was, at that time, director of the public health services: Tutor: (The health visitor) is really a medical social worker. It’s a pity we can’t use that title.... Medico-social worker would be ideal. Student: Social workers might object ...

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Tutor: We should have got there first. City MOH: Health visitors are social workers with a nursing background ...

But such an option is not available for field staff. They are faced every day by the distinction between the two occupations. Social work is organized through a separate department of the municipal authority with whom the field staff must negotiate for resources ... This is complicated by a series of policy decisions by central government which have allocated most of the relevant financial and statutory resources to social work. Social workers were rapidly becoming an all graduate occupation and, particularly at the time the research was carried out, enjoyed superior pay and conditions.7 Health visitors have become increasingly dependent on a group whose social prestige has been rising, to considerable degree, at their expense. As a consequence, we can see a coalescence of the twin problems of exclusion and inclusion and the use of atrocity stories to remedy them. In order to establish their difference from social workers and to assert their own worth, health visitors concentrate on appeals to the quality of their respective services. This allows them to assert that there is something distinctive about health visiting and that, although they may be less wellpaid and have a less prestigious qualification, they are still as good as, if not better than, social workers. Critical stories about social workers seem to be a staple topic of conversation among qualified health visitors. Unlike the hospital stories I described earlier, these stories gave no evidence of disappearing with acquaintance although, as the last example cited below suggests, they may become highly truncated. This, I suggest, underlines the role which stories may play in defining a colleague group, a point to which I shall return later. Health visitors’ stories present social workers as slow, as lacking in practical knowledge and, in consequence, as guilty of making erroneous motive imputations and questioning medical judgements, as having a slack attitude towards confidentiality, and as being both possessive about clients and unpopular with them. The following examples were all collected in the presence of students: One of the fieldwork instructors told us about a social worker who had complained to her about a family not knowing how to boil bones for stock. She thought this was quite ridiculous when you considered all the problems the family had. Fieldwork Instructor: When I rang about this hoist, the social worker said ‘I’ll have to go round and assess the need for a hoist’ ... I thought it was a bit of a cheek. Telling a trained nurse that. I said, ‘The need is quite clearly proven.’ He was probably a probation officer or something. I wouldn’t dream of trying to tell him about his work.8

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This last example amplifies Stimson and Webb’s point about the degree to which stories trade on shared knowledge. Within a group of storyexchangers it may be necessary only to mention key elements of a story to get the relevant response. Just as before, we see a pattern of students being coached into telling comparable stories and, eventually, producing them independently. An example of this is Keith’s story told to other students: We were up in (a ‘rough’ social housing area) yesterday while a social worker was in the same house and we were ushered in and treated like royalty and the social worker got really ratty. She (the client) fetched us chairs and sat us in front of the fire and offered us tea and he was sitting there saying, ‘I’m only doing my job’. The woman was quite aggressive anyway but this was just her manner. I could notice the difference right away, we were really accepted.

These stories need not be thought of as ‘factual’ accounts. They are elements of the oral culture of a group that epitomize aspects of that culture. In this sense they are rather like proverbs or parables. They play on discrepancies between the ‘real’ and the ‘ideal’. However, they may play an important role in relation to the transmission of a group’s culture to newcomers. These stories present a version of events that students are required to master and use in order to achieve recognition as competent members of the group. They are also available to serve as orienting principles for relations between members of one group and members of another. In this respect, stories may become self-fulfilling. The presentation of a history of strained relations may lead health visitors to be suspicious of social workers who in turn reciprocate such suspicion. I have no direct evidence from my own work of this mutual discrediting, but it has been clearly documented in British inquiries into cases of children who died as a result of abuse or neglect. Social workers had refused to take health visitors’ views seriously and health visitors had been left in the dark about social workers’ actions. Such problems are not necessarily inevitable, though, as we can see by looking at the relationship between health visitors and nurses. Health Visitors and Nurses The nursing occupations – hospital nursing, midwifery and district nursing – represent the opposite pole to social work in the demarcation question. Although a direct connection is less than fifty years old, health visiting is

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now treated as a nursing occupation for most purposes, and all health visitors are registered nurses. The extent to which health visitors are still nurses, given that they do nothing which is – to common sense – nursing work is an issue for many of them. However, with the partial exception of district nurses, who give basic nursing care in the community, health visitors have fewer direct confrontations with other nurses in their everyday work than they do with social workers or doctors. Thus, the problem of exclusion is more a question of facing their own pasts than with present work. The issue of distinctions between nursing and health visiting arises most critically in the first few weeks of the training course. To understand this, we need to look briefly at Schutz’s (1962, pp. 207–259 and 340–347) discussion of transitions between provinces of meaning. He argues that the world we experience is divided into finite provinces of meaning, each with its own particular cognitive style, so that shifts between provinces are experienced as shocks. One province of meaning, that of everyday life, and its cognitive style, the natural attitude, is experienced as paramount. This reality is developed out of the shared access of members of a society to stocks of knowledge that allow them to define events as typical, usual, and routine. While elements of this knowledge may be held in common by all or most members of a given society, others may be socially distributed between different groups and individuals. But this implies, as Schutz does not recognize, that the sense of the reality of everyday life must also be socially distributed. It may appear relatively fixed since our social locations may change only slowly or only seldom, but this fixity may make change more difficult. Migrating from one area of a province of meaning to another is a more radical phenomenon than our everyday excursions into the provinces of sleep or prayer or whatever. It can produce a permanent change in the nature of everyday life itself. Organizations like training schools, which specialize in facilitating such migrations, develop routine ways of easing the process. In this instance, the college tutors try to redefine the students’ past to include their present situation to maximize continuity. This bridge is then allowed to fall away and the distinctiveness of the new occupation is emphasized. The stories here are rather different. With a few exceptions, which I will deal with shortly, they were only told in the college. Since field health visitors have little contact with hospital nurses, they face few problems in maintaining the boundaries of their work. The stories that are in circulation are used in two different ways. The college tutors and some of the field service management do face a problem of resisting illegitimate control. At the time this research was carried out, a major health service reorganization was bringing all nursing under a single management, and community nurses were worried that their service would be dominated by the hospital side. Their criticisms of hospital nursing reflected their assertion of the

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difference between their own occupation which they presented as having high educational standards, a maximum of autonomy for field staff, and a relaxed style of management in contrast to the poorly taught, authoritarian, and petty hospital workers. While health visitors respected their clients as people because their management treated them like people, nurses reduced patients to objects because they themselves were so treated. Although these stories were told to students, most of the examples I collected were told directly to me and seemed to be related to the use that these groups envisaged for the research. The project was invoked on occasion to assert the professional standing of the occupation and was seen as one way of defining and establishing the worth of health visiting. The prevalence of these stories in conversation with me suggests a hope that the research might be capable of helping to sustain the independence of health visiting and its right to a continuing autonomous existence. The students produced stories couched in rather similar terms, but they seemed to be doing a rather different kind of interactional work.9 They presented some graphic accounts of life as a hospital nurse. This student is talking about the creation of difficulties in labour by the expectations of hospital staff: During her midwifery training Gillian was with a mother in labour. She was sitting there holding the mother’s hand when a very large Jamaican staff midwife came in and struck her a blow which knocked her across the room. Gillian calmed down the mother who was very frightened and asked the midwife to come outside. The midwife said that mothers in labour were often very strong and violent and that since a midwife’s hands were her fortune it was hospital policy not to hold the hands of mothers in labour in case their fingers got broken. Gillian said this was absolute nonsense and that not being allowed to hold the hand of a mother in labour was the height of inhumanity. If that was the hospital policy, she was going to see matron in the morning and do something about it.

The students presented an image of hospitals as institutions that dehumanized both staff and patients. They were dominated by routine and arbitrary discipline. There was a strong feeling of social isolation as a consequence of the irregular and uncertain working hours and the difficulty of making relationships with outsiders. This was reinforced by public attitudes, treating male nurses as homosexuals and female nurses as promiscuous, and by the degree to which the occupation provided a haven for ‘cranks’. These accounts, too, can be seen as a form of self-defence against perceived attempts to exert illegitimate control. In particular, they offer a way of defeating the pressures for commitment to which lower members of both nursing and health visiting are subjected. The discrepancy between

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the manifest commitment of senior and junior staff is quite marked. Few junior staff have any orientation towards their work as a career, with its implications of vertical progress. For the younger ones, work occupies an interim period between school and family-building. One finds the same ‘touristry’ in Britain that Pape (1974) describes for America. For older women, their work is ancillary to their family life. It may bring fortuitous extra income and offer added interest to their life, but it is not central to their plans. Consequently, student life at the school of health visiting and subsequent practice was marked by a stance of ‘getting through’, of doing what was necessary to be regarded as competent without exerting oneself to do more. These stories about nursing offered a way of displaying this by dissociating the teller from the capricious interventions of authority or the absurdities of excessively keen colleagues. As in the stories cited earlier, the teller appears as rational and other parties as fundamentally irrational. At the time when these were recorded, health visitor students had not yet acquired a vocabulary for telling stories in the context of their own work. This seems to come after qualification and further experience of practice, although this study did not investigate this area in any detail. There is, however, one important caveat. The municipal public health service I was studying was rather unusual in that it did not at that time provide a district nursing service. Responsibility for basic nursing in the home was contracted out to a voluntary agency. Health visitors had no direct competition from any other nursing group in their everyday work. In another area where I carried out fieldwork, though, the two groups, district nurses and health visitors, were combined in the one department, as is more usual. Here the administration centred on the nurses’ home and was dominated by a ‘home guard’ (Habenstein and Christ, 1963) of district nurses.10 In this locality, I found the same kind of stories that I have noted for social workers and doctors, taking up themes of illegitimate control. I suspect that my lack of such accounts reflects a peculiar feature of the locality I studied and that they may be very common. Health Visitors and their Subordinates So far I have concentrated on the relations between health visitors and those whom they regard as their social equals. In this section, I want to turn to those whom they regard as their inferiors and to look at some problems in this relationship. In some instances we shall find the occurrence of stories relating to illegitimate control and in others we shall note their absence. The relationship between health visitors and their inferiors revolves around the maintenance of the health visitors’ dominance and its acknowledgement in deferential conduct by the other party. ‘Deference’, here, is broadly conceived, following Goffman (1956), as a general form

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of recognition of another’s interactional claims and a pledge of support for their self-presentation. In this particular case, health visitors need to secure certain kinds of goods, services, and information from other parties without being called upon to breach the boundaries of professional conduct by returning favours. If we take those involved with other organizations first, these fall into two main groups. The first group can be divided into those who accept health visitors’ claims without question and those who require legitimation. The former were entirely drawn from members of voluntary organizations who had a relatively undifferentiated conception of the health and social services and were ready to ascribe the right to nonreciprocal actions to anyone embraced by the aura of social esteem which attaches to those services. The latter included agencies that had little direct contact with welfare services and for whom those services could offer no relevant favours. They required some establishment of professional standing by the health visitor to offer what assistance they could. One example given by a health visitor was the Post Office: (They) can be difficult but when they know you’re a professional person and not just a nosy neighbour they sometimes bend the rules a bit.

The second group, including the municipal education and housing departments and the Supplementary Benefits Commission, who administer national social security payments, was much less cooperative. This group was composed of agencies that have close relationships with the health and social services. Health visitors often have data potentially relevant to them. Maintaining nonreciprocal service flows was quite difficult, and we find further instances of atrocity stories about the treatment of health visitors by these agencies. By denying access to relevant services or demanding reciprocal favours, the personnel of these organizations were seen as trying to exert an illicit influence on health visiting. Health visitors’ social theories provide them with a conception of themselves as professionals. The theories of uncooperative agency personnel, as of doctors and, probably, social workers, do not recognize that claim. Hence, they see no reason to behave towards health visitors in a different fashion to that which they would adopt for laypersons. Such a theory is based on a more detailed knowledge of health service organization than the knowledge of the citizen in the street. That response can probably be seen more clearly in the former group of agencies who either accord an undifferentiated recognition of health workers as a morally special kind of people deserving special treatment or are ready to accept that health visitors could fall into the category of professionals if they can substantiate that claim with appropriate appeals. In this, they resemble health visitors’ responses to groups like teachers, physiotherapists, occupational therapists,

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and the like. These have not been discussed in detail here but, broadly, each group offers the other tentative recognition and a working relationship is bargained for (Dingwall 1974a, pp. 319–323). Where such a consensus cannot be created, we find the actions of other groups interpreted in the light of health visitors’ social theories as attempts to secure illegitimate control over an autonomous profession. The importance of a detailed knowledge of health service organization can also be seen in considering health visitors’ relationships with practice and clinic ancillary workers. In his analysis of the power of lower-status personnel, Mechanic (1968, pp. 415–432) notes how ancillary workers can manipulate the access of other groups to the resources under their control in accordance with their conceptions of the legitimacy of the request for access. In this case, such conceptions are derived from traditional social theories about the hierarchy of health service occupations, which may be sustained by observations of doctor–health visitor encounters and by the direct loyalty that practice ancillary staff owe to the doctor who employs them. Health visitors’ requests may be defined as illegitimate and refused, giving health visitors the view that ancillary staff are illegitimately attempting to control them. Predictably, this generates atrocity stories. Examples which I collected included stories relating to receptionists refusing to accept, or failing to pass on, urgent messages for attached health visitors, about manufacturers’ samples being distributed on the basis of ideas about practice hierarchy rather than need and of deliberate harassment. A case in point related to a receptionist refusing to loan spare chairs from her office for a well-baby clinic and then making booking patients go through the crowded waiting room being used for the clinic to the ‘official’ hatch rather than dealing with them at the office door in the entrance hall. Accomplishing Profession This chapter has described an interactionally based approach to interprofessional relationships. I have argued that securing social recognition as a profession involves asserting claims to a certain relationship with other occupations. These claims involve establishing exclusive claims to a particular area of work and inclusive claims to a particular relationship of symmetrical respect with other occupational groups who are recognized by the claimant as ‘professions’. Such claims form a particular aspect of a general relationship between social theories and social action. Social theories are drawn on to find the sense of other peoples’ actions towards us and to produce action that we expect others to find sensible. Since these theories are necessarily socially distributed, reflecting each individual’s unique intersection of biological and social

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experience, there are, inevitably, discrepancies in all interaction. Where little is at stake or the differences are negligible, a working consensus may easily be reached. Where, however, there are more serious problems like those of occupational boundary maintenance, self-defence, or a zero-sum game of status recognition, we need to examine the power relationships involved. In particular, we must ask which party to any given encounter controls access to social or physical resources desired by the other. This can allow that party to establish their social theory as an enforceably correct one. They can define what is to count as a ‘true’ description of reality for that encounter. But where this occurs, and if such enforcement is regarded as illegitimate, we may expect to find atrocity stories used as a remedial device. The use of the term ‘atrocity’ should not be allowed to mislead us into thinking that some disaster must necessarily lie at the heart of the story. The choice of a dramatic term reflects the dramatic character of the account by which a straightforward complaint or slight is transformed into a moral tale inviting all right-thinking persons (the audience) to testify to the worth of the teller as against the failings of the other characters in the story. The data cited in this paper suggest that stories may be used in two ways. Firstly, they may be used to bind a group together through the exchange of common problems and the mutual reaffirmation of their troublesome nature. The group can defend the essential rationality of its unifying theory despite any particular attempt to discredit it. In binding the group together, there are clear restrictions on who may tell stories. While others, such as a participant observer, may be permitted to listen, they are not permitted to recount stories of their own. It was impermissible for me, for example, to tell atrocity stories about nursing. A mark of the acquisition of competence by novices seems to be the ability to tell appropriate stories at appropriate times. In this usage, atrocity stories may be told at any time when a majority of the audience are occupational members or candidate members. The second, and related, way in which atrocity stories may be used is at an individual level, as Moore’s work implies, to assert the reasonable character of an individual. In this study, I made little use of formal interviewing, but stories occurred frequently in interview-like conversations with students, tutors, and other participants in the training process. Here, the stories take on a slightly different character in their appeals to anyone’s standards of reasonable conduct as the teller contrasted the rationality of their part in the process, or their station in life, with the implied or stated positions of others. Stories are directed in a similar fashion towards novices as a depiction of the performance requirements of the work and the obstacles that lie in their path. They form a peculiarly dramatic part of the oral culture of the occupation.

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This analysis is clearly capable of wider application. I have said nothing here about stories concerning clients, which Zimmerman’s (1969a; 1969b) work suggests are not infrequent. This area deserves a fuller treatment in its own right, but, in fact, health visitors seem to tell rather few client atrocity stories, probably because they have few resources which clients might try to manipulate them for. It is also true, of course, that this analysis need not be restricted to the study of occupations. Although most examples seem to have been collected in such contexts, similar accounts, as Stimson and Webb’s work on patients suggests, could well occur in talk about sex, ethnicity, class, or any other social division. The general use of the atrocity story to defend rationality under threat would seem to be a profitable topic for future ethnography.

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Chapter 4

‘In the Beginning was the Work…’ Reflections on the Genesis of Occupations A curious omission from the sociology of work and occupations is what would seem to be one of the most basic questions: when is an occupation an occupation? While there have been recent attempts to explore the issue by examining the history of census categories (Hakim 1980; Davies 1980), these represent the end-point of the process at which new occupations receive official recognition and legitimation. This chapter will discuss how occupations form and come to be recognized as such. The creation of health visiting between 1850 and 1919 will be taken as a case study. Occupations Occupations may be thought of as units in folk taxonomies of work. Like any other classificatory scheme, they offer a way of organizing some area of the social world and rendering it familiar, predictable and manageable. The term ‘occupation’ is used as a device under which particular social actions can be collected and co-ordinated: [A]n occupation is a more-or-less standardized one-man’s part in some operating system [which] cannot be described apart from the whole. A study of occupations, then, becomes in part a study of the allocation of functions and the consequent composition of any given occupation (Hughes 1971, p. 292)

Like any other social term, however, the meaning of ‘occupation’, or any more specific lexical substitute, is ultimately indeterminate. There are two basic ways in which its referent may alter: as a result of changes in social relations or as a result of changes in the material base. The former might include the delegation of ‘dirty work’ to a subordinate occupation, the acquisition of tasks from a competitor or the application of Taylorist principles of managerial rationalization. I have pointed elsewhere to the analogies between Hughes’s sociology of work and Chicago urban ecology (see Chapter 1). We might, then, think of these as processes of

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urban flight, of gentrification or of city planning. Material changes stem from alterations in the physical environment or in technology, rendering some tasks obsolete and creating others. Our urban analogies might be the exhaustion of a mineral deposit and the abandonment of a settlement to leave a ghost town or the invention of reinforced concrete, which made possible entirely new kinds of building. New occupations can arise from either of these processes. Hughes (1971, pp. 304–10 and 338–47) took medicine as his principal natural laboratory, noting the repeated downward delegation of medical tasks to paramedical occupations which, in turn, delegated to semi- or unskilled subordinates of their own. Similarly, Bucher and Strauss’s (1961) discussion of segmentalization incorporates the impact of technical change. Former colleagues in a single segment find that their work has become too disparate for a single device to co-ordinate and split into distinct specialties. Some of these, like dentistry, may go on to become, in effect, autonomous occupations with their own internal segmentalization. The dominant model throughout is one of occupational development as a process of fission. In this respect, the Chicago sociology of work lies squarely in a mainstream tradition. Whether their theories are ultimately derived from Marx, Weber, Durkheim or Simmel, most sociologists subscribe to a view that, as societies develop, work becomes more complex and the division of labour more specialized through the dissection of occupations. Various writers differ on the motors that drive this process, and the desirability or otherwise of the human effects, but the basic proposition is unquestioned. Like all great ideas, this account of the evolution of the division of labour has the virtue of simplicity. However, this very simplicity may well make a note of caution appropriate. After all, much the same might have been said of traditional sociological accounts of the evolution of the family before the advent of modern historical demography revealed their insubstantial empirical foundations. It may, therefore, be useful to consider the thesis in the light of an account of the genesis of a particular occupation for its consonance with detailed historical data. Health visiting is a good case for this because its emergence takes place during a reasonably well-defined period of the nineteenth and early twentieth century for which written documents exist. It is sufficiently distant to give the perspective of history but not so removed as to present difficulties in access to material or in recapturing the interpretive understandings of a radically different culture. The initial choice of dates rests partly on evidence of linguistic usage and partly on the occupation members’ own selection in their official histories. Although antecedents have been identified in organized home visiting schemes as far back as the middle of the eighteenth century, there is general agreement among health visiting writers that their occupation originated in Salford in 1867

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when the Ladies’ Sanitary Reform Association appointed its first paid employee. Contemporary accounts, however, actually describe her as a ‘sanitary woman’ or a ‘mission woman’. The Oxford English Dictionary dates the first usage of ‘health visitor’ to 1901 and three years later the Report of the Interdepartmental Committee on Physical Deterioration uses quotation marks around the term, which we may take to imply that it is still a neologism. The main occupational association, the Health Visitors’ Association, actually began life in 1896 as the Women Sanitary Inspectors’ Association and did not introduce ‘Health Visitors’ to its title until 1915. A national certificate was first established in 1919, the end of our proposed period, although uncertified practitioners could still be employed by public authorities until 1928 and by voluntary agencies, contracting to provide public service, until 1948. While any choice of dates must have an arbitrary quality, it does not seem unduly nominalist to suggest that in 1850 there is no occupation recognizable as health visiting and that by 1919 such an organized group of workers could be said to exist. Proto-Health Visiting 1850–1904 There is a sense in which health visitors have always existed. Every community has some members who act as sources of knowledge or advice on particular topics. Thus, those who have successfully raised families or avoided serious illness may share the supposed secrets of their success. While this task may be carried out for material gain, the rewards may be primarily symbolic in the status and deference that accrue to them from the recognition of their superior expertise. Part of the task may include home visiting within a pattern of kinship, neighbourhood or feudal obligations. As such, there are still large numbers of people doing ‘health visiting’ in a way that no society member would recognize as their occupation. The difference is effectively defined by Freidson (1978) in his discussion of four ideal types of market in which labour may be performed: the official, where the labour is legally recognized and included in official measures of production; the criminal, where labour is illegal and unrecognized; the informal, where labour is unrecognized and may, as a result, be technically illegal, as in large areas of the ‘black economy’; and the subjective, where the labour is not part of any system of economic exchange although symbolic, and occasionally material, rewards may accrue. This kind of voluntary or self-help activity falls within his definition of the subjective economy, on the borders between work and leisure. Such services may make a significant contribution to economic and social welfare but are officially invisible because their exchange value is not realized. While we may be able to analyze them as hobbies, pursuits, interests or reciprocal

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role-obligations, a discussion in terms of occupations would seem rather unintelligible. At some point towards the end of the eighteenth century, however, such elemental voluntary relationships began to be perceived as insufficient for the maintenance of a successful and well-ordered society. Donajgrodski (1977) notes how this gave rise to a concern about the foundations of social order, which is, of course, partly visible in the very emergence of sociology as a discipline, and the adaptation and rationalization of existing beliefs and practices about the proper relations between social classes. The result was the formulation of a theory of social policing, which rested on two assumptions: first, that social order was the product of a common morality which was sustained by its diffusion throughout the institutions of a society, such that its promoters should attend not merely to law enforcement but to the active dissemination of a normative code through religion, education, housing and public health policy, and regulated leisure; and, second, that, left to themselves, the poor were likely to form normless or perverted social systems or be led astray by agitators, outcomes which could only be prevented by personal contact with the moral example set by the better-off, contact which was therefore a, sometimes uncomfortable, civic duty. Home visiting or home inspection can be seen as an integral part of these developments. It provided for that immediate and direct social contact between members of different classes, which realized the obligations of the one and uplifted the other. Thus health visiting should properly be analyzed not as a phenomenon sui generis but as one among a number of experiments including urban missionary and temperance movements and the voluntary philanthropy usually identified with the Charity Organisation Society and regarded as the ancestor of modern social work. Given the emphasis placed by official historians on the role of the Manchester and Salford Ladies’ Sanitary Reform Association (later the Ladies’ Health Society) in founding their occupation, this seems to be an appropriate starting point for a more detailed analysis. The justifications quoted in the occupation’s accounts relate to the scheme’s endurance – there is an unbroken organizational continuity to the present day – and its vision of the worker as an adviser and counsellor rather than a home nurse (McEwan 1957, pp. 19–30; McQueen 1962). The Ladies’ Association was formed as an offshoot from the (allmale) Manchester and Salford Sanitary Association, itself founded in 1852. The male organization was one of a number of similar societies established after the 1848 cholera epidemic to press for the extension and active enforcement of sanitary legislation and to work voluntarily for the amelioration of urban conditions. The explicit motivation of these societies was the indiscriminate nature of the threat from epidemic disease, which

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was thought to demand community-wide action to search out and eliminate potential reservoirs of infection. Some of these were structural, requiring the intervention of sanitary inspectors to enforce building and other regulations. Others were failures of household management or personal hygiene requiring practical instruction or intervention (Longmate 1966). Little is yet known about the early history of this Association. An interest in medical police was, however, well established in Manchester and proposals for the instruction of the poor in their own homes had been in circulation when the first Board of Health was established there by Thomas Percival and his associates in the 1790s. Apart from its civic activity in pressing for the vigorous enforcement of sanitary legislation, the male organization is known to have distributed handbills and posters through workplaces. On a purely speculative basis, one might suggest that both the civic and the work sphere were defined at the time as masculine domains so that actions within them would have a limited chance of affecting the feminine realm of the home and domestic hygiene. A ladies’ visiting society would be an obvious development as a way of disseminating enlightened thought on household management. On its formation in 1860, then, the objectives of the Ladies’ Association were to undertake voluntary home visiting among the poor, distributing health tracts and temperance literature and offering advice on domestic management and child care. What tends to be regarded as the dramatic transformation took place in 1867, when the annual meeting resolved to employ a ‘sanitary woman’ to assist the ladies1. She is conventionally regarded as the first paid health visitor. The duties of this ‘mission woman’ are described in the 1868 annual report: Whitewash pails and brushes were placed at her disposal to lend and also chloride of lime for the purification of the air in the rooms of those who were suffering from fever. She had not only given instruction in common sanitary rules but she would herself wash and make comfortable a sick person whom she might find neglected or dirty, thus encouraging those who were around to follow her example by showing people how to do what was needful in the best way.

With the support of the Medical Officer of Health for Salford, the meeting decided to appeal for funds to employ a second such woman (Langton 1963). By 1890, there were fourteen of these visitors. In that year, Manchester Corporation took over payment of the salaries of six of them, in exchange for the right to call on all for service. Shortly afterwards, probably in 1894, Salford came to a similar arrangement (McEwan 1957; McQueen 1962). The account presented to the Interdepartmental Committee on Physical Deterioration in 1904 shows that there were then thirty-two lady

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supervisors and twenty-three paid employees. Of the latter, sixteen worked in Manchester, eight paid by the Corporation and eight by the Society, the remainder being in Salford. This evidence describes them equally as ‘health visitors’ and ‘sanitary mission women’ (Report II. Qs 5722,72524,7262-3). With the formation of the Ladies’ Association, we have already come a long way from the subjective economy of voluntary assistance. The ladies are engaged in voluntary work, which is better analysed as part of what Freidson calls the informal economy. Here, while the activity itself is legal, transactions are unrecognized and unregistered in official descriptions of the production of goods and services. The medium of exchange may be cash but it may still reflect the reciprocal obligations of the subjective economy. Now, however, these seem to be experienced in a less personal form as role-related or collective duties that can be subjected to collective rather than individual determination. Visiting societies changed the task from an element of personal exchange into an informal occupation on a regular, albeit part-time and unpaid basis, organized through a centralized institution that set impersonal criteria for need and allocated service. The question still remains, though, as to why paid labour should have been introduced, thereby bringing health visiting into the officially recognized labour market, even if not yet creating an identifiable occupation. Some clues to a possible answer can be found in the evidence to the Interdepartmental Committee. One suggestion, in a remark by Mr Horsfall of the (male) Manchester and Salford Sanitary Association, is that ‘it was found that more constant work was needed than ladies could give’ (Report II, Q. 5715). More pertinent, however, may be the material on the division of labour between the lady volunteers and the paid women. Mr Horsfall goes on: the sanitary mission women give the whole of their working time to visiting the houses and making friends of the people, giving advice and reporting any defects in the houses – anything that is alterable in the habits of the family each mission woman reports to the lady who is in charge of the sanitary district; and in time of infection when any disease is about they supply them with carbolic acid and things of that kind, and other disinfecting agents given gratuitously .... Then the ladies – some of them – have mothers’ meetings not on religious lines but on sanitary lines ... (Report II, Q. 5717).

He noted that the main constraint on the expansion of the service was the lack of suitable volunteer lady supervisors rather than of paid women. Mrs Worthington, of what was by now the Ladies’ Health Society, elaborated on this account in describing the division of labour between herself and Mrs Bostock, a paid worker, in the South Ancoats district:

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The chief part of the work is done by Mrs Bostock in her house to house visitations. My own part is chiefly collecting such of the women as we can for mothers’ meetings, which we find an extremely useful organisation. We use these very much to prepare public opinion .... I began talking on the question of consumption years ago, before there was any systematic consumption work, and it made it easier for Mrs. Bostock to do it. She had very little difficulty in getting admitted into the homes because a notion had spread abroad of what it meant (Report II, Qs 7221, 7225).

Between them, Mrs Worthington and Mrs Bostock, who also gave evidence, draw a clear picture of the health visitors’ work. Their districts were said to cover the greater part of the working-class areas of Manchester and Salford. The health visitors lived in their districts and visited every house regardless of circumstances. Mrs Bostock had lived in South Ancoats for fourteen years and was responsible for 1500 households. Although most of the Committee’s questions concerned aspects of maternal and child welfare, both women stressed that these only formed a part of their duties, although increasing as a result of the particular interests of the current MOH. The Committee also quote ‘a recent report’ of the Ladies’ Health Society as stating that, in that year, health visitors had made 30,364 visits and reported 1,500 cases of insanitary conditions to the sanitary inspectorate: In addition to teaching personal and household cleanliness and giving advice and sympathy, much practical help is given in ways such as giving food and clothing to especially needy families, finding work for men and women, getting recommendations for different hospitals and institutions, sending children into the country or the seaside, making the beds of sick patients and cleaning their houses .... The women in the district are shown the evils of dirt and the dangers of living in unhealthy dwellings; they are taught to prevent the spread of disease and the laws generally which will enable them and their families to lead moral and healthy lives (Report I, p. 58).

There was, however, a substantial class difference between the voluntary and the paid workers. In the course of an exchange with Mr Legge and Mr Fitzroy for the Committee, Mrs Worthington described the sort of women who were being employed. (Mr. Legge) What sort of people do you get for this 16s a week – it is getting increasingly hard to get the right kind. What sort do you get – people who have some other money as well, I suppose? – No, in many cases not, in most cases not. The mere fact that they know what it means to live on 16s a week gives them a very great power.

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In her evidence, Mrs Bostock stated that the range of wages in her district was 16s to 25s a week (Report II, Q.7502). The position is summed up in a contemporary reference from the Lancet to the paid workers as: superior women belonging to the classes among whom they work ... [with] a fellow feeling and more thorough understanding of the difficulties ... the failings and the sorrows of the poorer classes than women brought up in greater refinement and luxury would have (Smith 1979, p. 1l5).

While paid staff might have been introduced because the scale of the work and the commitment involved were thought to require a labour discipline that would be inappropriate for voluntary workers, we would still have to explain why this particular pattern of recruitment developed. One possible argument would relate it to the nature of the tasks involved. By 1867, the ladies would presumably have had a clear idea of the limited potential of purely verbal instruction, however delivered. In the available data, there is considerable stress on the use of teaching by example after 1867. The duties may well have expanded, then, into areas that were more ‘properly’ the sphere of a domestic servant than a lady. The logical response would be to recruit from that class, working under lady supervisors on the model of the Victorian household. This would account for the constraint on expansion of a lack of lady supervisors perceived by Mr Horsfall at a later date. It would also be consistent with Carpenter’s (1977, pp. 167–8) thesis about the adoption of the Victorian household division of labour as a model for the organization of hospitals. In effect, then, we are treating these particular proto-health visitors as a special kind of domestic servant who provides a service for economic reward but is only a member of a discrete occupation in the most minimal sense. This model was already established when, during the late l880s and the 1890s, some MOHs began to become more interested in preventive work through education as much as in environmental action and the public health service as a whole acquired new duties in respect of infant welfare. Its gradual municipalization was the local response to a set of concerns that, elsewhere, led to the development of an alternative model for the occupation.

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I have discussed elsewhere these concerns over the quality of the reproduction of the working class in examining the circumstances surrounding the appointment of the 1904 Interdepartmental Committee (Dingwall 1977c). In that paper, I argued that evidence to the committee showed four specific sources of anxiety: the rise of international economic competitors, the development of an indigenous socialist movement and the physical, mental and moral unfitness of the working class for either manual labour or military service. These anxieties were accentuated by the falling birth rate. If there were to be fewer children born to the working class, then it was necessary to be more concerned about those who were produced. That earlier discussion followed Gilbert’s (1966) arguments in emphasizing the role of the Boer War in crystallizing these problems. It would be wrong, however, to suppose that they did not exist before that time. The birthrate had been falling for at least a decade and there had been prolonged economic difficulties and civil unrest. One of the most marked features of the Report of the Interdepartmental Committee is the ambivalence towards Germany. The Germans are the great commercial rivals and, already, seen as potential adversaries in war. At the same time there is much admiration for their success in curbing internal dissent by social legislation and municipal action. Several witnesses refer to the Elberfeld scheme where voluntary visitors took responsibility for household visiting in districts of a city with the overall support and guidance of a municipal secretariat. Mr Horsfall, indeed, claimed this as a model for the original Manchester and Salford scheme, although this is chronologically unlikely. Directly or indirectly, this pattern of municipal initiative, often in partnership with volunteers, was adopted by a substantial number of local authorities around the turn of the century. In order to provide the municipal input, the MOHs turned to the staff already available to them. In Manchester and Salford they assumed direction of an existing service. In some areas like Huddersfield they used women doctors as Assistant MOHs (Parton 1981). Most commonly, they seem to have lighted on female sanitary inspectors who were already an organized group with a national certificate awarded by the Royal Sanitary Institute and an occupational association. Moreover, they were engaged on relevant work in the enforcement of the Infant Life Protection Acts of 1872 and 1897, which provided for local authorities to regulate the conditions under which children were privately fostered. This involved them in the regular visiting of homes in workingclass districts both to discover unlicensed minders and to inspect those who were registered. Worcestershire had employed ‘lady health missioners’, under the direction of the MOH, since at least 1898 and now had five who visited homes where there were young children ‘to school the parents in regard

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to feeding, clothing and the rearing of children’. They were paid 35–40s a week (Report II, Qs 6610-21, 6629-32). There were five male and two female sanitary inspectors in Preston, directing the work of volunteers. Longton and Burslem each had one woman sanitary inspector (Report II, Qs 3242-6,9193-6). Birmingham had advertised for six ‘women visitors’ in 1899, to be uniformed corporation employees at 25s a week. By 1904, they were being described as ‘lady health visitors’ and at least some of them were trained nurses (Report II, Qs 3156-62; Smith, 1979, p.l15). The focus of their work was somewhat different from that of the original Manchester and Salford scheme. Mrs Greenwood, a sanitary inspector from Sheffield, gave evidence to the Interdepartmental Committee.2 Her work, under the direction of the MOH, included visiting every house where a birth was registered in three districts of the city to advise on infant feeding, delousing and home safety. There was an effective division of labour between male inspectors engaged on structural examinations and enforcement and the women who were doing home visiting and advisory work. This division, she argued, should be formally recognized by their reconstitution as separate services. She stressed, however, the need to recruit women with an adequate social and educational background, contrasting her work with that of her assistants, lower-middle-class women with a board school education (Report II, Qs 8089-8418). This would seem to imply that the female sanitary inspectors saw themselves as a cut above the sort of person employed in Manchester and Salford, ladies rather than women. From other sources, it is also dear that there was an increasing emphasis on training and certification. The Liverpool Ladies’ Sanitary Society, for instance, set up a school in 1894, which trained women for posts as ‘health inspectors’ (Smith 1979, p. l15). The net effect appears to be a shift to recruitment from a different social stratum, Mrs Greenwood and her colleagues do not seem to come from the respectable working class like the original Salford sanitary woman but from some sort of upper-middle-class background, They arc more like the voluntary workers and, while engaged in home visiting, seem to have discarded some of the more practical elements of the work. Where volunteers are used, they are now subordinated to paid women of their own class rather than supervising their social inferiors. By 1904, although the word ‘health visitor’ has just about entered the language, one still cannot discriminate an occupation to which it refers. What we have, rather, is a patchwork of local responses to commonly experienced social problems. Although there is considerable overlap in the actual content of the work, women are being recruited from a variety of sources in different relationships to the official labour market. Some of them are moving from the informal to the official economy, like Miss Nolan-Slaney who had been a voluntary worker before becoming one of the

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first paid Birmingham visitors. Some, like Mrs Greenwood, are gradually dividing themselves off from a mainstream of sanitary inspection in a process of segmentalization. Others, like Mrs Bostock, are adapting the model of domestic service to novel tasks. Occupational Coalescence 1904–1919 All of these options were laid out in evidence to the Interdepartmental Committee in 1903–4. At first sight its response appears to be unequivocal. Health Societies on the lines of the Manchester and Salford Ladies’ Health Society should be formed all over the country. Enough has been said of the value of the system by competent judges to justify the Committee in urging upon every locality the adoption of similar methods.... There is no step, in short, towards training mothers in personal, domestic and infant hygiene with which it cannot be made to contribute (Report I, pp. 59, 90).

On further consideration, however, the situation seems more complex. What is being enforced is the post-1890 Manchester and Salford model, which lies much closer to the female sanitary inspector pattern.3 The Committee emphasizes the partnership between municipal and voluntary effort. The system has the advantage of linking individual and philanthropic effort with municipal responsibility, in a way that regularises the one while energising the other, and appears to give to each its proper influence in dealing with social wrongs, at the same time tending to check the overlapping and misdirection so often characteristic of purely charitable impulse (Report I, p. 59).

The organization of the service was to be the responsibility of local government staff, channelling and harnessing the enthusiasm of volunteers. It may also be relevant to note that the passages dealing with health visiting come immediately after a paragraph urging local authorities to upgrade the quality of midwifery practice, particularly ‘as women trained under the [1902] Act take the place of the illiterate, incompetent persons that very generally look after the poor ...’ (Report I, p. 58). If one actually examines the references made to the Manchester and Salford scheme by witnesses from other parts of the country, it is clear that the details were not widely known although its general nature was reasonably well comprehended.4 One is tempted to conclude that the attention devoted to it owes much to the experience of one of the Committee members, Dr Tatham, as an MOH in the area at the time of the partial municipalization of the service between 1890 and 1894. The model

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is not one of an autonomous voluntary agency employing relatively poorly educated working-class women so much as a partnership between educated municipal officials and volunteers, with the latter in a subordinate role. Although by 1905 about fifty local authorities were employing a variety of paid workers on health visiting duties, a consensus on the most relevant training was slow to emerge. The 1909 order, under the London County Council (General Powers) Act 1908, which permitted the boroughs to employ health visitors, specified that they could have either (a) a medical degree; (b) full nurse training; (c) the Certificate of the Central Midwives Board; (d) some nurse training and the Health Visitor’s Certificate of an organization approved by the Local Government Board; or (e) previous experience with a local authority. The Local Government Board recommended in 1916 that health visitors should have two qualifications from: nurse training, a sanitary inspector’s certificate or a CMB Certificate. After 1918 the Board only made grants towards the salary of local authority employees who had a qualification under the 1909 LCC Order. Finally, in 1919, the newly created Ministry of Health issued regulations for health visitor training courses whose certificates became a prerequisite for local authority employment after 1 April 1928. We should not be misled by this educational heterogeneity, though, to suppose that an important amount of consolidation was not going on. Perhaps the most important effect of the increasing emphasis on qualifications was the gradual exclusion of working-class women. After Manchester municipalized the whole of its service in 1907, only trained nurses were appointed for instance (Simon 1938, p. 210). Speeches in the Local Government section of the Women’s Congress at the 1910 JapanBritish Exhibition depicted health visiting as an occupation which was particularly suited to educated middle-class women. It is also arguable that this class difference was relevant to the initial resistance of the Women Sanitary Inspectors’ Association to the recruitment of health visitors. This diminishes after 1908 when the Royal Sanitary Institute introduced an examination for them and courses were mounted at centres like Bedford College for Women and Battersea College of Technology. These moves, in effect, produced the reconstitution of sanitary inspection that Mrs Greenwood had urged on the Interdepartmental Committee. By 1909, the WSIA seems to have absorbed health visiting to the degree that it is actively campaigning for improved pay and conditions. Those who have been absorbed, however, seem to be those who are most like the existing sanitary inspectors in terms of class and education. Miss NolanSlaney, who had moved from Birmingham to Croydon, was, for instance, a member of the WSIA by 1906. At the same time, it appears that a nursing background was beginning to predominate as a primary qualification for those who were being recruited.

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Two factors seem to be relevant to this process. Firstly, there is the degree to which health visiting was a delegation of ‘dirty work’. Although women doctors were sometimes employed on household visiting, it is not clear that this was ever seen as a particularly appropriate use of their skills. The work was neither clinical nor epidemiological and fitted neither the hospital nor the public health model of practice. Even in Huddersfield, perhaps the most celebrated doctor-based scheme, it seems that the greater part of the visiting was actually done by voluntary workers under the supervision of an Assistant MOH (Parton 1981). Although there is a dearth of research on sanitary inspectors, they seem to have developed as one type of lay auxiliary to the MOH, searching out nuisances defined by their medical superior. If a new type of auxiliary was needed to work on female issues, then it could well seem logical to draw on the trained nurses who were already well established in that role within the increasingly prestigious hospital sector of health care. Alongside this demand factor, we must note the limited supply of professionally educated women. There were probably too few female sanitary inspectors to form the nucleus of an occupation. In 1906, the WSIA had just sixty-three members, all drawn from the London area. Although it made strenuous efforts to recruit nationally, membership built up very slowly and even this brought in people with prior nursing backgrounds. Miss Cooper-Hodgeson, later to be Superintendent Health Visitor for Durham County Council, who joined in 1908, was, for instance, a trained nurse and midwife as well as having certificates in sanitary inspection and health visiting. There were few women doctors and the new class of midwife produced under the Midwives Act 1902 would not yet have been available in any numbers. Even there, Donnison (1977) has pointed to the way in which general nurses came to form the occupational leadership and a major source of post-1902 recruitment. It might be necessary to explain why certified teachers were not drawn in but one would need more data on the relative labour markets for them and nurses. Certainly, Celia Davies has suggested, in a personal communication, that the market for trained nurses was slackening from the mid-1890s as the opportunities for private practice became saturated and the hospitals became increasingly dependent on cheaper student labour. After about 1909, the nursing press was regularly carrying articles on the attractions of health visiting as a job for nurses. The imagery of coalescence in the title of this section is deliberate. It simply does not seem adequate to characterize the processes described here solely in terms of fission. While there are plainly fissile elements, I would argue that we need to introduce at least two other concepts if we are to develop a more exhaustive account. The first of these is that of occupational fusion. Piecemeal local initiatives developing various models

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of work organization in different relationships to the official market are brought together under a single device, a process which gradually imposes a greater homogeneity in the range of actions reconcilable with any such cover term. (Bittner 1965; Dingwall and Strong 1985). The second is borrowed from geography, the notion of occupational capture. Here the longest-established or most politically influential occupation with a stake in some area of human activity absorbs nascent, or sometimes even established, adjacent groups. Nursing is a particularly good example of this not only in its capture of health visiting but in its annexation of asylum attendants and midwifery (Adams 1969; Donnison 1977). There can, of course, be difficulties in maintaining such gains; witness the continuing struggles between nursing and social work over ownership of the care of the elderly and the mentally handicapped, for instance. Occupational Careers This account is obviously limited in its reliance on publicly available material and its details must remain open to revision and correction as a result of further work on primary sources. Nevertheless, I would contend that the account offered here does illuminate some neglected issues in the sociology and social history of occupations. While parts of health visiting can be derived from the fission of tasks collected together by the devices, ‘Medical Officer of Health’ and ‘sanitary inspector’, other parts are plainly brought into the official economy de novo. These are tasks performed within the subjective economy, which Freidson (1978) suggests may be both the cradle and the grave of occupations. Many traditional crafts have disappeared into this realm, to be perpetuated as pastimes rather than for economic reward. Conversely, other tasks, like home visiting, have been brought out of this zone to receive official recognition and sanction. As Hughes (1971, p. 287) observed, occupations are ultimately constituted by the legitimation of their covering devices through the grant of a licence, not necessarily in a narrow legal sense but in terms of the right ‘to carry out certain activities rather different from those of other people… in exchange for money, goods or services’. With health visiting, as we have seen, this process takes place over a period of some fifty years as subjective tasks are first organized into informal occupations and then brought into the official economy as they become the preserve of paid workers. Obviously, further comparative studies are needed if we are rigorously to specify the conditions under which such a process takes place as opposed to more traditional accounts. It seems arguable, however, that these conditions are particularly likely to prevail in the personal services. As the description implies, these are tasks which, at least in the first instance,

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any human being may perform for another. What parent has not ‘nursed’ a sick child? Who has not ‘caseworked’ a depressed friend? Which of us has not ‘advocated’ a disputed course of action? All of these activities may be carried out in the subjective or informal economy as much as in the official. As they are translated into the market, their organization into occupations depends upon assembling skills which all society members possess to some degree into intellectually or practically defensible units. Thus it might be particularly interesting to compare health visiting and social work whose unification is achieved over a much longer time-span but along an apparently identical route. Why do the various voluntary and paid groups in health visiting fuse so much more quickly? This would also allow us to ask questions about the conditions for occupational capture. Why was health visiting annexed by nursing while its near-relatives in social work remained independent? The thesis might be further developed by looking at the development of manual occupations in the same period. Electricians might be a good example. Here is an occupation that arises in the nineteenth century out of technological rather than social change. What is the impact of that different starting point? A greater attention to such questions might also allow us to develop the study of official histories as ideological forms. Official histories can be thought of as akin to tribal myths whose key elements are fixed but evolve in the telling to reflect changing contemporary debates.7 Whittaker and Olesen (1964, 1967) have shown how Florence Nightingale has been used as a symbolic legitimation of radically different philosophies of nursing as the concerns of occupational leaders have changed and been reflected in the products of their official historians. The same is true in the present context: Florence Nightingale’s contribution is strongly emphasized, although her only close association was with an apparently less than successful scheme in Buckinghamshire in the early 1890s and she actually refers to the need to create ‘a new profession for women’ as lady health missioners rather than defining this as a branch of home nursing. One might also ask why contemporary health visitors make so much of their descent from the working-class employees of the Salford ladies rather than the educated middle-class radicals who seem historically more genuine antecedents. Finally, we must not ignore the practical benefits of such studies at the boundary of sociology and social history. If we need to create several million jobs in the next decade, then an understanding of occupational lifecycles might actually help us to identify and nurture prospective sources of employment in a much more sophisticated fashion than the blunderbuss approach of many labour economists. A detailed investigation of the subjective and informal economies may have much more to commend it than the use of public sector employment as a vast programme of outdoor relief. What is needed, perhaps, is a restatement of the truism that

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occupations have careers just as much as individuals. The joint task of the sociologist and the social historian is to develop the combination of narrative and analysis which allows us to see those careers as typifications in the way that sociologists now tend to think of individuals’ careers.

Chapter 5

‘A Respectable Profession’? Sociological and Economic Perspectives on the Regulation of Professional Services There is an unresolved problem at the heart of both the economic and the sociological study of the professions. Are these occupations simple monopolies whose anticompetitive effects distort the social and economic organization of a society or are they institutions which have developed for public interest reasons and should be preserved? This chapter reviews the treatment of the professions in contemporary social science. It begins by discussing the current orthodoxy, which emphasizes their anticompetitive effects, and some of its recent critics. It is argued that both of these neglect the critical role of professionalization in maintaining trust or confidence in the workings of the market under the conditions of a complex modern society. If this is accepted, then new directions are implied in both academic study and policy debate. The Real and Effectual Discipline The difficulties which professions raise for social scientific analysis were recognized by Adam Smith in The Wealth of Nations (first published in 1776). One of the most enduring features of this work is Smith’s rigorous critique of occupational monopolies. He rejected the argument that these were necessary to regulate the quality of the service being offered: The real and effectual discipline which is exercised over a workman is not that of his corporation but of his customers. It is the fear of losing their employment which restrains frauds and corrects his negligence. An exclusive corporation necessarily weakens the force of this discipline (Smith 1976a, I, p. 144).

Smith uses the professions, however, to discuss the adverse effects of excessive entry. Lawyers and physicians, whose training was not subsidized to any significant extent, enjoyed incomes which reflected the

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size of their human capital investment, the uncertainty of the trade and the risks of the work. Clergymen suffered from the misguided public and private provision of ‘pensions, scholarships, exhibitions, bursaries, etc.’, which attracted more recruits to the occupation than the demand for its services could sustain and destroyed the prospects of those who undertook the training at their own expense, ‘the competition of the poor takes away the reward of the rich’. This surplus of educated labour flooded into the profession of scholarship with similarly destructive results. If lawyers and physicians received a comparable degree of support for their training, the same consequences would follow, ‘to the entire degradation of the now respectable professions of law and physic’. In his phrasing here Smith hints at a difference in his attitude to the professions which is marked in other ways. He wonders if it is ‘indecent’ to compare the wages of a curate with those of a ‘journeyman in any common trade’. He notes the extrinsic rewards so that the ‘respect paid to the profession makes some compensation even to (the clergy) for the meanness of their pecuniary recompense’. Moreover, he accepts eighteenthcentury professional education at face value and makes no mention of it in his attack on the apprenticeship system in other trades, as a restraint on the practice of skills which could easily be taught within a few weeks. Smith’s hostility to combinations, as obstructions to the free movement of labour does not, then, extend to the professions. He appears to accept the restrictions on entry and competition as necessary to secure what he considers to be a proper reward for members of these occupations. Indeed, it would seem that the problem for the clergy is that entry is insufficiently limited. His justification has, in the words of one recent writer, ‘perplexed many economists’ (Whitfield 1982, p. 225). We trust our health to the physician; our fortune and sometimes our life and reputation to the lawyer and attorney. Such confidence could not safely be reposed in people of a very mean or low condition. Their reward must be such, therefore, as may give them that rank in the society which so important a trust requires (Smith 1976a, I, p. 118)

Perhaps as a result of this perplexity, the orthodox contemporary economic position simply disregards Smith’s caution and treats professions as a particularly powerful type of restrictive combination, cartels backed by licensure laws (e.g. Friedman and Kuznets 1945; Kessel 1958; Moore 1961; Friedman 1962; Lees 1966; Forgotson and Cook 1967; Hodgson1977) To summarize their analysis, these writers argue that market-division strategies, restrictions on entry and advertising, and licensure create opportunities for professions to raise their incomes above the rate which would prevail under perfect competition, The weakening of competitive pressures means that innovation and technical progress are slowed or

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distorted. The nature and organization of services are shaped by producer interests rather than client demand. Lees’s (1966, p. 28) verdict is typical: Getting rid of the medieval guild system and the producer privileges of mercantilism were essential pre-conditions of more rapid economic advance and greater equality of opportunity. The modern professions embody those same notions of conservatism, status and privilege which it was the abiding achievement of 18th century thought and 19th century capitalism to destroy.

Few go quite so far as Friedman (1962) in proposing the outright repeal of licensure laws and the exposure of the professions to the full rigours of antimonopoly legislation. Nevertheless, the general drift is to assert that client interests would be better served by a weakening of professional monopolies. Comparable arguments can be found in the writings of sociologists influenced by Marxist traditions in political economy. As Freidson (1982, p. 45) has pointed out, these share with the neoclassical approach an ideal of a fluid division of labour with free movement between tasks, ‘to hunt in the morning, fish in the afternoon, rear cattle in the evening, criticize after dinner without ever becoming hunter, fisherman, shepherd or critic (Bottomore and Rubel 1963, p. 111)’. The main difference is the extent to which this movement is induced by the signals of the price system or by some other, usually unspecified, means of coding social needs. Larson (1977, pp. xvi–xvii), for instance, analyses professionalization as a deliberate strategy to obstruct the free movement of labour and induce or accentuate social inequality. I see professionalization as the process by which producers of special services sought to constitute and control a market for their expertise. Because marketable expertise is a crucial element in the structure of modern inequality, professionalization appears also as a collective process of upward social mobility... [the] constitution of professional markets inaugurated a new form of structured inequality.

The development of modern professions, since the mid-nineteenth century, can be regarded in such accounts as a service-sector equivalent of the attempt by corporate capital to enlist the state in regulating markets to restrain competition. This analysis can be used to introduce a further development to the cartelization theory of professions by incorporating it into the demand side of the economic theory of regulation (Stigler 1971). Insofar as licensure confers benefits on producers there is always likely to be a substantial number of groups that would like to achieve its protection. Grafted on to the principle of rent-seeking behaviour is a recognition that the process of cartelization is facilitated if the coercive power of the state can be

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harnessed to support it by a licensing regime. Plainly, however, producer groups do not invariably succeed in this objective. Hence, in addition to the factors which determine whether producer groups can form effective cartels by private means – such as the scale of coordination and policing costs, and the homogeneity of producer interests – there are also factors which determine how well these would-be licensees are able to influence the political process in order to obtain favourable regulation (Posner 1974). The manner in which pressure groups seek to secure legislative favors through the ‘political market’ is the subject of a well developed branch of the economic analysis of public choice (Buchanan 1975; Peltzman 1976; Tullock 1982). The sociological approach being discussed here tends to see the supply of licensure as the result of market imperfections. Two of these are particularly important. The first is an imbalance between the cohesiveness of producers and consumers in professional services. Larson (1977) contrasts the success of medicine, dealing with a dispersed and individualized clientele, and the failure of engineering, facing organized corporate interests. The second is the extent to which a state is not democratic, which neoclassical economics might render as an imperfection in the market for votes. It seems to be implicit that transparently anticompetitive special interest protection will not be acceptable to a democratic legislature. Licensing is analyzed as a way of extending privileges to certain groups in order to co-opt them to the task of repression or to the production of legitimating ideologies which mask the undemocratic organization of the society. We shall argue below that this approach may understate the extent to which professional licensure is a theoretical solution to certain organizational problems which are intrinsic to any complex society, despite the particular historical experience of certain Western countries. Our next step, however, is to review other economic analyses of professional services. The Public Interest Identifying the importance of supply-side factors in licensing leads naturally to the examination of public interest approaches to the professions. The success or failure of cartelized occupations in attracting favourable regulatory concessions may depend upon broader governmental perceptions of social efficiency. Certainly the lasting nature of these concessions in the face of obvious alternatives in a market economy suggests this as a possible explanation. There are always profits to be made from eliminating market imperfections so that a persistent failure to do this implies that there are actually efficiency gains being made (Thurow 1975). What might these gains be?

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Until quite recently, the consensus among economists would have been that a competitive market in professional services would achieve an equilibrium at which the quality of the service was socially optimal. Consumers would choose among competing suppliers in such a way that the equilibrium price for each incremental unit of quality reflected its marginal valuation. Since the publication of Akerlof’s (1970) paper on qualitative uncertainty, however, there has been some debate as to whether the informational problems involved in determining quality levels lead to the market’s failure to achieve socially optimal standards. Akerlof’s argument, subsequently formalized by Leland (1979), is based on the assumption that consumers of some commodities are less good than producers at discovering the quality of the product. If we take the example of health care, this arises from the fundamental difficulties in testing diagnostic and prescriptive abilities (until it may be too late!) given the complex relationship between inputs and outputs. Similar questions arise in law where clients cannot easily establish in advance whether a lawyer has successfully arranged their affairs so as to avoid potential problems. If such problems do arise, they may have devastating effects on the life, reputation or property of the client. As a result of this informational asymmetry, producers are unable to signal differences in their relative quality to consumers. The market price will reflect only the average quality level so that high-quality producers will be driven out of the market, or will reduce their quality of service. In turn, this will lead to a reduction in the average level of quality perceived by consumers, a further consequent reduction in market price and yet another dilution of quality, the process continuing in a downward spiral. Leland has attributed this failure of the market to a simple externality: high-quality producers must share the returns from a higher price with all other producers and do not, therefore, receive their full contribution to social welfare. Suboptimal levels of quality result from private benefits falling below social benefits. This failure of individual actors freely to arrive at an aggregate outcome which they all desire is an example of a multi-person prisoner’s dilemma (Schelling 1974). A variety of collective responses may be in order as ways of resolving this dilemma. First, society could subsidize suppliers of professional services so that the supply price would draw high-quality practitioners into the market. This might be the simplest interpretation of Smith’s argument or J.S. Mill’s (1926, p. 404) remark that ‘such persons are more trustworthy if paid highly in proportion to the work they perform’. The more we pay professionals the more likely it is that they will provide us with high standards of care. However, the appropriate size of such a subsidy would be difficult to determine without detailed knowledge of supply and demand schedules. Moreover, it assumes that individual suppliers cannot adjust

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their quality of service subsequent to the receipt of subsidy. The net effect may well be simply to shift the whole supply curve so that the same quality as before is now offered at a higher price. This has particular force given some of the findings on supplier-induced demand and output restriction which suggest that professionals aim for a target income and work/leisure trade-off, adjusting their activities to yield these (Evans 1974). Alternatively, penalties might be imposed on individuals who do not pursue quality improvements (Blair and Kaserman 1980) or entry to the profession restricted to those meeting minimum quality standards. Both of these entail the creation of a regulatory body capable of judging quality, where consumers are not, with discretion to license only those suppliers who meet minimum standards. This will raise both average quality and price and attract more high-quality suppliers. Pre-entry licensing is, of course, vulnerable to the arguments we have used against subsidies. It assumes that subsequent behaviour will not be affected when, as we have seen, there are strong incentives to do so. The regulation of professional conduct ex post by an external regulatory agency administering prescribed standards of behaviour might be seen as a viable alternative, but it is clear that anything involving an external regulatory body is vulnerable to the quis custodiet problems so effectively satirized by Benham and Benham (1980). Who is to regulate the regulators? The same arguments apply against Friedman’s (1962) suggestion that, in the absence of licensure, private organizations would develop to certify suppliers of professional services. Even if there is post-certification monitoring of behaviour, consumers have to determine which private evaluation agency they can trust. Do they purchase advice from evaluators of evaluations? Where does this potentially infinite regress stop? The problem of informational asymmetry is shifted rather than abolished. That problem might be reduced by imposing a self-regulatory regime and requiring the profession itself to control service quality, whether by pre- or post-entry means. This, of course, takes advantage of the fact that it is members of the profession who have the greatest capacity to recognize low standards, although, it must be noted, they do not necessarily have the greatest opportunity (Freidson 1975). Against this solution, we may also note its reliance on the assumption that the professions will not abuse their privilege by accepting the rewards of their monopoly without enforcing correspondingly high standards. If it requires time and effort to provide a high-quality service, there will be a consistent incentive for members to cheat. Indeed, this incentive may take a collective form such that self-regulation specifies a minimum standard rather than one which is socially optimal, in the sense that it would be sufficient to avoid, as far as practicable, information deficits and externalities.

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This is the crux of the matter. If informational asymmetry is significant, then noncooperative behaviour will lead to low salaries and low standards. At the same time, cooperative behaviour leading to a high wage, highquality agreement will be vulnerable to cheating by virtue of that same asymmetry, because of the difficulty of detection. If imposed regulation, whether external or internal, can be made successful, it is unnecessary. Such regulation would rely on an efficient review mechanism which, if accurate, could simply be conveyed to consumers who could then choose the quality of service they were willing to pay for. Klein and Leffler (1980), for instance, argue that information about the quality of suppliers of medical services exists and is not costly to obtain so that a competitive equilibrium can be achieved without regulation by licensing. The penalty for low standards is a lower income. The public interest school maintains that quality review is both difficult to accomplish and costly to pass on to consumers so that certification is relatively ineffective. Restriction of entry by licensing is seen as the only means by which optimal standards of quality can be maintained. While the monopoly approach argues that entry restriction results from collective rent-seeking behaviour on the part of occupational groups, the public interest school accounts for it in terms of a collective occupational interest in improving standards of quality as well as remuneration. But what each of these analyses fails to confront is the question of the persistence and stability of entry restriction. What is it that prevents pressures from potential entrants from building up to an intolerable level? What is it that ensures that cartel members do not dilute quality to such an extent that public concessions are withdrawn? In the traditional economic analyses of professional licensing, the crucial answers to these questions refer back to the coercive power of the state, legislating for impenetrable entry barriers, and of the cartel itself, ensuring that individual members fear its sanctions should they act in a way that jeopardizes the retention of their collective privileges. We have, however, already argued that the power of the state to supply licensing will be restricted by other pressures than those from the cartel itself. We have also argued that the very nature of the informational problems which lead to a public interest in restricted entry may also defeat any attempts at self-regulation, especially within a cartel comprising a large number of independent practitioners. Moreover, the proposal that this prisoner’s dilemma can be resolved in the long run through repeated playing cannot apply here because of the discontinuous but highly consequential nature of most private transactions with professionals. In the remainder of this paper, we shall attempt to approach the prisoner’s dilemma by a different route, albeit one which is seldom travelled by game theorists. Their classic dilemmas only arise because of the difficulties which are placed in the way of coordinating actions (Schelling 1971).

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Typically analysts have attempted to devise solutions by focusing on the manipulation of pay-off matrices through external sanctions but, in principle, there is no reason why, if we discover a real world dilemma, we should not also consider the means by which players can be encouraged to trust each other and to forego the possibility of extracting the last quantum of self-interest in favour of a socially preferable outcome. As Arrow (1963, p. 966) has observed, in discussing the market for medical care: Delegation and trust are the social institutions designed to obviate the problem of informational inequality. The general uncertainty about the proposals of medical treatment is socially handled by rigid entry requirements. These are designed to reduce the uncertainty in the mind of the consumer as to the quality of the product insofar as this is possible. I think this explanation, which is perhaps the naive one, is much more tenable than any idea of a monopoly seeking to increase incomes. No doubt restriction on entry is desirable from the point of view of the existing physicians, but the public pressure needed to achieve the restriction must come from deeper causes.

In other words, the social institution of ‘delegation and trust’ acts to facilitate a collectively rational outcome. Why this is so, and the organizational means by which it can be achieved, form the subject matter of the remainder of this paper. The Problem of Order Our starting point is the sociological critique of utilitarianism, which remains the philosophical basis of most contemporary economics. The classic expression of this critique is to be found in Parsons’s (1968) major work, The Structure of Social Action, first published in 1937. He points out that the utilitarian tradition’s treatment of action has an inherent tendency towards atomism. It concentrates on the analysis of conceptually isolated acts, which are aggregated solely by reference to the individual actor who is producing them. In his view, the only utilitarian to see clearly the implications of this approach for the modelling of social organization was Hobbes. Human beings, in Hobbes’s analysis, were the servants of their passions, the ultimate ends of action. But these, in themselves, were random and their pursuit was always likely to result in conflict. In the absence of any other restraint, people would adopt the most efficient available means of achieving these ends, means which would inevitably give priority to force and fraud. The result would be chaos. Hobbes sought to avoid this by the fiction of the social contract where people relinquished their freedom to a sovereign authority which would guarantee their security. Parsons argues that this approach stretches the concept of rationality beyond

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its place in utilitarian theory by permitting actors to see all the possible consequences of any act and to trade the advantages of future security against potential gains from force or fraud in the present. The philosophical problems involved in such foreknowledge need not concern us here but the practical difficulties should be obvious. In effect, Hobbes’s solution leaves off where game theory begins. Even if we could imagine drafting such a contract, how could we guarantee that everyone would adhere to it, given that there are still constant gains to be made from its breach? Yet Hobbes’s question had, and still has, tremendous practical importance. As Simmel pointed out in a discussion of the implications of deception in modern societies, first published in 1908: Our modern life is based to a much larger extent than is usually realized upon the faith in the honesty of the other. Examples are our economy, which becomes more and more a credit economy, or our science, in which most scholars must use innumerable results of other scientists which they cannot examine. We base our gravest decisions on a complex system of conceptions most of which presuppose the confidence that we will not be betrayed… if we were not deterred from (lying) by the utmost severity of the moral law; then the organization of modern life would be simply impossible … (Wolff 1950, p. 313).

A similar argument is implied by Hayek’s (1945, p. 528) discussion of the price system as a method of coordinating social action: We make constant use of formulas, symbols and rules whose meaning we do not understand and through the use of which we avail ourselves of the assistance of knowledge which individually we do not possess… The price system is just one of those formations.

But for prices to fulfill that function, their users must have confidence in their validity as tokens of the information which they encode. If that confidence is undermined, the market cannot operate. Treating individual self-interest as the only guiding principle for action destabilizes and ultimately destroys social organization. As Parsons (1968, p. 101) points out, the utilitarian analytic system of classical economics could only flourish in a society where the basic problem of order appeared to have been solved: …economic relations as conceived by the classical economics can take place on a significant scale only within a framework of order by virtue of which force and fraud are at least held within bounds and where the rights of others are respected to a degree.

By locating the origins of this framework in the realm of nature, the utilitarians could not account satisfactorily for its existence and

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maintenance and for the temporally unique conjunction of circumstances which had created an orderly society approximating to the conditions assumed by classical economic theory. Parsons saw the central problem for his study as the attempt to fill that gap and explain social order without relying on the metaphysical assumptions of the ‘natural identity’ approach of Locke and his successors or the speculative fictions of the contractarian approach. One of the latent consequences of Locke’s appeal to the supposed natural identity of individual interests was the possibility of using nature as a critique for human society. Once freed of the corrupting influence of unnatural social institutions, argued Godwin and the anarchistic or Utopian socialists, people would live in spontaneous harmony. Moreover, if this natural identity existed, was it not more rational to prefer cooperation to competitive individualism as a form of social organization? Competition could not, in itself, check abuse of market power, since the successful could use their gains to coerce or oppress potential challengers. Parsons is more interested, however, in Malthus’s response that anarchism must founder on the irreconcilability of human fecundity and a finite stock of natural resources. Sooner or later it collapses into a bitter struggle for subsistence. The reason why human society has survived for so long is its development of social institutions to restrain individual behaviour. Competition, Malthus asserts, is only beneficent within the proper institutional framework. Parsons traces the implications of this insight through a detailed discussion of the writings of Marshall, Pareto and Durkheim. Of these Marshall is the most relevant for our present purposes, since his formulation of the concept of marginal utility can be said to represent the foundation of modern economics. But this is also the point at which one can begin to identify a bifurcation between economics and sociology. Marshall envisaged two components to his social science: a study of wealth, its creation and distribution, and a study of human character. He repeatedly emphasizes that the market economy can only survive and prosper in an environment which is regulated by strong ethical principles, ‘uprightness and mutual confidence are necessary conditions for the growth of wealth’ (Parsons 1968, p. 151). The Structure of Social Action is mainly concerned to document the convergence of the utilitarian tradition of social thought with the idealist, represented in the work of Weber, on what Parsons called a ‘voluntaristic theory of action’ which modelled humans as choice-makers restrained from the pursuit of pure self-interest by their orientation to a common, or at least widely shared, system of values. This approach, in his view, resolved the implausibility of the utilitarian model. It is interesting to note parallel developments in economic thought. In fact, the economic analysis

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of nonselfish behaviour has a long history (Collard 1978). As Coase (1976) has pointed out, Adam Smith (1976b, p. 86) himself recognized, in The Theory of Moral Sentiments, the facilitative role of an observed moral code: ‘society … cannot subsist among those who are at all times ready to hurt and injure one another’. More recently, both Arrow (1971, 1974) and Schelling (1971) have stressed the importance of norms of socialization as means by which cooperative solutions can be attained. Akerlof (1980) has attempted to incorporate such norms into a utility-maximizing model by explicitly considering the loss of reputation consequent upon abandoning these norms as well as the possibility of direct utility gain from adherence to social custom. However, without a good theory as to what characterizes a social norm or custom, such an approach is in danger of appearing tautologous. What is left open is an analysis of the institutions by which social values are maintained, transmitted and enforced. Professions as Regulators Clearly, Parsons’s model of restrained decision-making requires some means by which collectively-held value systems can be operationalized. Two broad categories of solution may be offered within the voluntaristic theory of action. The first involves the internalization of core values through agencies of moral socialization, especially education and religion. The second entails the policing of behaviour. However, this raises considerable informational problems, the nature of which we have discussed above. The development of particular institutional arrangements may be seen therefore as a hybrid solution, softening the self-interested motivation of the utilitarian actor so as to maintain the social structure necessary for a market economy. The institutional economics of Veblen and Commons, for instance, spans the activities of government, of ‘going concerns’ like firms, trade unions or professional associations, and of less specific sources of values like custom, tradition or the common law. But one of the most influential discussions, in the present context, is Durkheim’s proposal for the development of occupational corporations as a source of moral influence over their members, an idea introduced in Suicide (first published 1897) and elaborated in the second edition of The Division of Labour in Society (first published in 1902). The focus of that book is the state of moral anarchy which Durkheim identified in economic life. This led to incessant conflict punctuated by periodic truces which were constantly threatened by the dissatisfaction of the subordinated parties. Such anarchy was falsely identified with individual liberty but, he argued, liberty was itself the product of regulation:

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The growing importance of the market economy in modern societies means that people spend an increasing proportion of their lives in this anomic sphere, whose effects thus seep out to the general detriment of public morality. The state can police this in a general sense. It is the ultimate arbiter of conflicting interests. But its ability to propagate a positive sense of moral responsibility is limited by its inevitable distance from day-to-day activities. In the economic sphere, it cannot acquire and maintain the specialized knowledge of each trade in a complex division of labour. Yet without such knowledge the conduct of the trade cannot effectively be regulated. Durkheim argues that this space could be filled by the development of occupational corporations uniting all the members of a particular trade or industry-employer, employee or self-employed. It is important to stress that he was not arguing for the revival of the medieval guilds and the system of mercantilism. What he does claim, however, is that the problems of social organization which they solved continue to be present and that a reconsideration of this model and its eventual failure may allow us to devise new and more durable institutions. These will inevitably have certain similarities, because they respond to the same problems, but also significant differences. In particular, Durkheim underlines the need for them to retain their autonomy from the state. Part of the reason for the collapse of the guilds had been their incorporation by the state which had subverted their authority and turned them into agents of coercion, the danger which Smith saw for the church. The corporation would be an independent focus for communal activities, through which members would come to feel a sense of solidarity with one another and a commitment to their craft or vocation, sentiments which might be sustained by various informal or formal group sanctions. Thus even the less successful members of the occupation would be restrained from chicanery by their loyalty to their fellows and to their common ideals. Durkheim’s model is the medieval guild rather than the modern profession, probably because of the differences between French and Anglo-American experiences of occupational formation (Freidson 1983). A very similar approach can, however, be identified in the work of the economists, Carr-Saunders and Wilson, which has influenced many sociological writers. For Carr-Saunders and Wilson, professions are a way of restraining abuses of market power by democratizing occupational routes for social mobility, emphasizing merit rather than birth, and by cultivating

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the moral sensibilities of their members. After a series of case studies of existing professions, they advocate the increased professionalization of business management, partly in order to improve the working conditions of the market by emphasizing natural talent rather than inherited status or wealth and partly to introduce alternative motives to the single-minded pursuit of profit, like pride in the application of technique or the quality of the product: Free fellowship may be a force making for the disruption of society; it is so when it results from the mere loosening of ancient bonds and the consequent anarchic activities of masses which have got adrift… Professional associations are stabilizing elements in society. They engender modes of life, habits of thought and standards of judgement which render them centres of resistance to crude forces which threaten steady and peaceful evolution (Carr-Saunders and Wilson 1933, pp. 495, 497).

These themes are reflected in one of the most important sociological discussions of the policing role of the professions, Parsons’s (1951) other major work, The Social System. In this, he attempted to draw on his earlier critique of utilitarianism to model a system of societal organization which would be sufficiently integrated to be able to perpetuate itself and sufficiently flexible to change in an evolutionary fashion. The overall success or failure of this model is not relevant here, but a particular feature is its emphasis on decentralized means of social regulation – in face-toface interaction, in primary groups and in secondary associations – rather than on the coercive use of the criminal sanction. Decentralized regulation sustains the normative framework which is necessary for the operation of a market economy while containing sufficient imperfections to create space for innovation. The various regulatory devices form a loosely coupled system which generally tends in a particular direction but contains elements of duplication or omission. Occupational associations have not, however, spread and prospered in the way such writers expected which suggests that, in most areas of the market, there are no great social gains to be made from this particular form of regulation. Other mechanisms are sufficient to sustain confidence in the integrity of transactions. The sociological analysis of the professions does, though, suggest that they are more likely to develop in particular areas. The key to these developments may lie in Hughes’s (1971) discussion of the ‘guilty knowledge’ of the professions, first published in 1959. In this Hughes points to the way in which professionals deal relatively with matters that the layman is constrained to deal with absolutely. This is the origin of the informational asymmetry. The priest must be an expert on sin to be able to recognize it, classify it and prescribe penance for it. But sin, for him, is not the uniquely personal experience that it is for the malefactor.

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It is an instance of a type which he has met before and will meet again. Its penitential value lies somewhere along a continuum of possible misdeeds. His studies may well tell him that the very boundaries of the category ‘sin’, let alone the gravity of acts within them, have changed over the course of history. Sub specie aeternitas, the penitent’s wound is but a scratch. But we have already established that the functioning of a market economy demands a certain fixity of social rules and values. Most people most of the time must experience life as stable and predictable, as trustworthy. Yet this is a necessary fiction which cannot be wholly sustained at two points. The first is where the social and the natural intersect. This introduces a random and potentially destabilizing element in the system. Although nature may be brought under partial control, and, to the extent that it is subject to the application of routine formulae, its keepers, like engineers, lose status as a result, it remains a source of indeterminacy or uncertainty which professional work may stabilize. Part of the doctor’s burden is the standardization of the varieties of human biology, matching the body structure to the anatomical atlas, the body process to the physiological textbook or the patient’s complaint to the pharmaceutical formulary, the international disease classification or the eligibility categories of the welfare state. The judgement of the professional stabilizes the unpredictable into a basis sufficiently reliable for human action. The second point of tension is where the social itself becomes contradictory. Although we have written loosely of ‘rules’, we recognize their unavoidable incompleteness. Thus, although there may be ranking principles for the ends of human action, these can never provide an exhaustive set of answers. This is the mystery of the lawyer, the accountant and, perhaps, the priest. For social life to be possible, firm answers are needed to questions which may have no definite answer. The lawyer’s burden is the knowledge that law and justice are not to be equated, that, at its heart, the legal system is an arbitrary but legitimated way of imposing closure on disputes. Yet, if the law were presented as arbitrary, it could not make its contribution to the framework of social discipline around the market of economic life. Professions, in this account, are occupational associations which have contracted with the state, not merely to regulate their own members but also to regulate the behaviour of others. The legislative act of licensing makes professionals indirectly accountable to the state rather than being the simple servants of their clients. They are ‘agents’ who are serving two ‘principals’. Professions are not ordinary service occupations, although, of course, they do share many characteristics and behaviour patterns as a result of similarities in their market position. Nevertheless, when clients purchase a professional service, their discretion, and that of the serviceprovider, is limited by the terms of the professional contract with the state. It is not simply a question of underwriting the confidence necessary to

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sustain particular transactions, as the mainstream public interest approach proposes, but of recognizing the role which the professions play in creating the conditions for a market society to exist at all. Regulating the Regulators We return finally to the question of quis custodiet in order to rebut the argument that our celebration of professional mysteries implies an abdication of social oversight. Let us therefore review a number of points which have been made above. First, for professions to be able to perform their proposed function, they must be seen to have at least an arm’s length relationship with the state which implies that on occasion they may come into direct conflict with it. A profession which becomes the servant of the state loses its moral authority. A state which seeks to become the master of its professions undercuts the possibility of a market based economy. It must either go down the road of centralized planning or collapse into a Hobbesian state of anarchy. Second, professions are nonetheless broadly circumscribed by the state because they owe their existence to a framework of law which provides the protection for their cartel. It makes no sense to study professional/client transactions in vacuo without attending to this context. The professional is not a free actor in the classical economic sense. This is not, of course, to say that professionals may not on occasion behave as if they were free actors. But to analyse them in such terms is to mistakenly import their ideology into a theory of social science in ways which prevent the analyst from exploring the basis of this pathology. Third, it is arguable that the preservation of professional mysteries could be a proper basis for rent but the establishment of any cartel creates a possibility for economic abuse. Thus public policy may properly interest itself in the overall level and distribution of professional remuneration. But this analysis can be taken a little further to propose that the best means of addressing the quis custodiet issue may not necessarily be either the extension of direct state control or the dismantling of professional monopoly but in the deliberate fostering of creative tension between the different professions. The role of law is crucial to this. To the extent that all professions are legally-backed monopolies, they can be made accountable before the legal system. In the area of civil litigation a good part of the lawyers’ business will turn on their ingenuity in discovering abuses among other professions. Yet these cases will also turn on the ability of those other professions to produce public defences for their actions, invoking knowledge which is inaccessible to the lawyer. Thus one aim of state policy might be the encouragement of litigation whether by subsidizing litigants or by encouraging risk-sharing devices like contingency fees. At the same time, it is important to be alert to the possible negative effects of forcing

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other professions to act solely by reference to the legal defensibility of their actions. An excess of successful litigation could upset the balance between the incomes of the various professions and impose undesirable costs on clients. But the answer here may not necessarily be a review of the regulatory system per se so much as the rules under which the contest is fought, to restore a balance between the professionals involved. And, of course, the impact may vary between professions: this is not necessarily the best means of controlling the legal profession itself, for example. We have argued in this paper that neither the ‘economic’ nor the ‘public interest’ theories of regulation give entirely adequate accounts of the licensed profession as a social institution. As Arrow points out, the privilege of restricted entry must have its roots in public pressure, so that a pure form of rent-seeking cartel seems an unrealistic model from which to start. On the other hand, if the source of public pressure is concern over qualitative uncertainty, then it is difficult to see how the licensed profession can adequately solve this problem, given the orthodox public interest emphasis on self-regulated standards enforced by sanction. We have argued that such a sanction-based approach relies too much on the ability of the regulators to identify low-quality standards. Without good evidence on transgressions, the transgressor will often go unpunished. What is needed, in our view, is a model of the licensed profession which explains satisfactorily how it is that such an institution can survive as a cartelized, entry-restricting body of individuals, governed loosely by a self-regulatory framework which is only rarely applied with vigour. The answer, we have suggested, must lie in the process of socialization and group responsibility which, while not directly verifiable, ensures adherence on the part of most professionals to a strict code of conduct. This process is seen as the quid pro quo for the rights and privileges of a legally sanctioned cartel: it is the outcome of an implicit bargain between the state and the group. Clearly, the terms of this implicit contract are important, and may be open to renegotiation. Where the group is perceived to abuse its privileged position, these privileges should be withdrawn. This is ultimately the only workable, ‘real and effectual discipline’.

Chapter 6

Closing the Market: Licensure and English Pharmacy 1794–1868 Pharmacy occupies an uneasy place in the sociology of health care occupations. On the one hand, it is normally considered to be a ‘profession’, whatever that term might mean. On the other, it is a little tarnished by its association with ‘trade’. Professionals are gentlemen, paid for their advice and service, while tradesmen make their living by selling a product. Does the pharmacist have more in common with the physician or with the grocer? As sociologists have frequently observed, however, the study of marginal cases may be particularly useful as a methodological tool for examining classificatory systems. The division of labour is one such system and occupations are the fundamental units. Some of these units are linked in higher-order groupings, of which ‘the professions’ is one. What is special about this grouping? This paper begins with a brief survey of the way sociologists have approached this question. It then uses pharmacy as a case study in examining the relevance of these accounts. Sociologists and the Professions Ever since social scientists became recognizable as a distinct group within the intellectual division of labour, they have been fascinated by the professions. Most of the great British social theorists from Adam Smith (1976) through Herbert Spencer (1914) to T.H. Marshall (1939) discussed their distinctive role in the development of modern capitalism. In the US, they were a central topic for both the Harvard sociology inspired by Talcott Parsons (1939) and the Chicago sociology of Everett Hughes (1971). Emile Durkheim (1992) gave them a key place in his discussions of French society. For the most part, these analyses were broadly appreciative and sympathetic. Professions were seen as a special kind of occupation. Adam Smith exempted them from his general critique of monopolies because of the threat that free competition posed to the quality of provision in areas of vital public and private importance. Parsons, Marshall and Durkheim saw their implicit promise to refrain from abusing their monopoly and their emphasis on service rather than personal gain as models for all economic actors under capitalism. Spencer noted their entanglement with what would

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now be called the governmentality of liberalism (Burchell et al. 1991): professions were part of the decentralized modes of social control that characterized the most successful modern societies. Hughes was somewhat more critical: professions had more in common with other occupations than usually acknowledged. However, even he thought that their special awareness of the fragility of social order and their moral responsibility for this secret underpinned a distinctive position in the market. After World War II, though, the study of professions became trivialized for a while. This is partly due to the changing structure of capitalist societies in the post-war period. Until then, writers seem to have assumed that everyone knew what a profession was: doctors and a few other health specialists like dentists and veterinarians; lawyers; clergymen and their secularized colleagues, university teachers; perhaps the higher ranks of the military. Beginning in the 1920s and accelerating after 1945, however, the demand for professional status took off with the vast expansion of service industry and white-collar employment. The educated labour required by modem societies sought to share in the status and privileges of the old professions. As a result, sociologists became drawn into definitional questions, what has become known as the trait approach. Later critics like Julius Roth (1974) talked about it as keeping a ‘scorecard’: checklists of criteria were drawn up, occupations measured against them and those achieving a certain number of points were declared to be professions. The checklists were regularly criticized for their theoretical incoherence, their special pleading, their lack of discrimination and so on but the real blow to this approach was that people began to recognize that it did not matter very much. The really important judgements about the nature and status of occupations were made by governments, employers and clients, not by sociologists. The objective for a social scientist should be to examine these. As a result, the field took a new turn in the 1960s and 1970s, although the trait approach still survives where a kind of social science has been harnessed to the professionalizing ambitions of an occupation. For example, it is quite common for textbooks addressed to paramedical occupations to begin with a chapter on ‘why this occupation meets the criteria for a profession ...’. Within the mainstream of the sociology of the professions, though, attention returned to the market situation of professionals. A profession was defined as an occupation occupying a particular kind of ecological niche. This was sometimes called a market shelter, an area of work where the occupation had secured a legal regime that gave it a privileged position in the market. Potential competitors were excluded or competitively disadvantaged. The new direction, associated particularly with the writings of Eliot Freidson (1971), Terry Johnson (1972) and Magalli Larson (1977), directed attention back to the fundamental issues about law, economy

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and the state which had concerned classical sociologists. However, there was now a more critical edge: professions were seen as monopolists. The service orientation, which earlier sociologists had regarded as a check on abuse, was dismissed as a rhetorical device that had misled naive and credulous analysts. In reality, professionals exploited their market power just as much as any other cartel did. Professionals achieved their monopolies by organizing more effectively than consumers and by capturing the legislature to supply favourable regulation. This would only be checked where there were powerful opposing interests. Larson, for example, contrasts the position of US physicians, dealing mainly with individual clients, and engineers, dealing with corporate clients, and the greater autonomy obtained by the former. Part of the leverage which the profession might gain was the promise to work for the state in the control of populations, a theme in the early work of Michel Foucault (1977), for example. As a shorthand description, this might be called a demand theory of professionalization: legal and economic privileges are demanded from the state by an organized group. In recent years, however, there has been some reconsideration of this position. Both Freidson (1986) and Johnson (1994) have modified their views and a new theoretical approach has developed around what might be called a supply theory of professionalization. This puts more emphasis on the independent role of the state. The legal intervention which sustains the market privilege of professionals is granted when there is a coincidence with a state purpose. As Paul Fenn and I (Chapter 5) pointed out, the problem with demand approaches has been to explain why so few wouldbe professions actually achieve that status. At any historical moment, there are far more occupations seeking this privilege than ever obtain it. The supply approach acknowledges the important of expertise and the way in which legal protection may be a response to market failure rather than a form of market failure. It also notes the way in which the creation of professions may be part of a particular moment in the development of modem states. Johnson, for instance, has used ideas from Foucault’s late writings (Burchell et al. 1991) while Michael King and I (Chapter 7) have revived ideas from the work of Herbert Spencer to look at the way in which professions can be seen as part of a decentred complex of regulation in liberal capitalist societies. The early history of pharmacy licensing in Britain offers a good case study in these historical processes, which also throws some light on the rather ambiguous status of the British pharmacist. In reviewing this, extensive use will be made of Holloway’s official history of the Royal Pharmaceutical Society, commissioned for its 150th anniversary in 1991 (Holloway 1991). Holloway has made a distinctive contribution to the historical sociology of the medical profession but his book on pharmacy

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makes less explicit use of sociological ideas. This may reflect the constraints of writing an ‘official history’ but his interests ensure that the necessary data for a more sociological account are clearly identifiable in the text. Closing the Market If we could travel back to 1800, the provision of health care would look very different from the present day. In Britain, it was a free market in the most genuine sense. Although a few providers of healing services had some form of accreditation from a university, from the colleges of physicians or surgeons or from the Society of Apothecaries, they had no special privileges or protections. Anybody could, and did, purport to diagnose, prescribe and treat any sort of conditions. There were exceptions such as the military, where the surgeons had established a secure position, but these were rare. By 1914, the market was effectively closed. A succession of statutes had restricted the right to provide certain sorts of healing services for reward and created privileged positions in the supply of otherwise unrestricted services. The origins of British pharmacy are often asserted to lie in the medieval apothecary. In fact, as Holloway points out, the apothecaries were the chief rivals of the eighteenth century druggists who are the true forerunners of the pharmacist. While the apothecaries had established a guild in 1617 and claimed a monopoly as compounders and suppliers of medicines, they had been drawn increasingly into competition with the physicians and surgeons as medical advisers to the middle classes. The druggists had emerged as retailers of medicines to poorer people and to those who rejected the medical theories of the day. Only in a few areas was there a significant volume of dispensing for physicians and surgeons who, unlike apothecaries, did not make up their own medicines. By 1800, the social and market status of the druggists varied widely: some operated little corner shops, while others had large establishments in affluent areas and were respected figures in the community. Many of the latter were Quakers, whose religious beliefs limited the range of trades in which they could work but also gave them a reputation for integrity that was a significant competitive advantage. The founders of the organizations that eventually led to the Pharmaceutical Society were disproportionately from this group, mainly based in London. They clearly had a vision of a ‘gentrified’ occupation that would enjoy a more secure social position as the result of the self-regulation of its members and the exclusion of less reputable people. However, this alone does not seem to have been enough to create any serious degree of solidarity among the druggists. This came more as a defensive response to the various proposals for the reform and consolidation of the medical

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professions that were promoted in the first half of the nineteenth century. Apothecaries, physicians and surgeons all tried to achieve medical reform on terms favourable to themselves. Many of these proposals touched on the supply of medicines. The most significant for the druggists was a Bill introduced in 1841 by an ally of the apothecaries for the comprehensive reform of all the arrangements for medical licensing. It included provisions that would have given recognition to druggists but placed them under the supervision of the apothecaries. An ad hoc committee of London druggists was formed to oppose this Bill. Unlike the groups that had opposed earlier legislative proposals, the committee members were persuaded that the threat would not go away and that they should form a permanent organization, the Pharmaceutical Society of Great Britain. The Society set out firstly to improve the educational and moral standards of its members and secondly to promote legislation favourable to their interests. The Society received state recognition in the form of a Royal Charter in 1843 and succeeded in promoting the passage of a Pharmacy Act in 1852. However, this Act only protected the titles of ‘pharmacist’ and ‘pharmaceutical chemist’: it did not establish the monopoly thought to characterize professions. Thus far, this is a conventional story of professionalization, which could easily be assimilated to a demand model. A group of elite practitioners, who find that their work is threatened by the attempts of their competitors to secure a monopoly and whose social status is compromised by less respectable members of the trade, organize to pursue policies of social and economic closure. They follow conventional tactics of self-improvement and lobbying which eventually persuade the legislature to grant them the powers that they believe necessary to protect their interests. However, Holloway makes it clear that this would be too simple an account. There are at least three other, interdependent, factors at work. It is important not to assign causal priority to any one of them. In no particular order, then, they are: •

The technical changes in scientific knowledge that led to increasing effectiveness and predictability in medical and surgical interventions. In the case of pharmacy, this means the introduction of new drugs based on the alkaloid and phytochemical research of Magendie and Pelletier in Paris from about 1810 onwards and the developments in organic chemistry inspired by Liebig's work from the 1820s onwards. While these were still controversial within British medicine in the 1830s and 1840s, they were increasingly accepted outside. However, these developments also brought new hazards in that they could also lead to the discovery of more effective poisons: the poisoner is one of the recurrent villains of Victorian fiction.

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•

•

The more readily identified risks of scientific medicine created a foundation for a more organized consumer protection movement. Previously, it had not been possible to define the risks and benefits of interventions with a sufficient degree of precision to attribute harm or benefit to them. The reputations of healers rose and fell on the subjective evaluation of their customers: there was no Archimedean point from which an observer could make an independent judgement. Criticisms of healing practice tended to take the form of satirizing pretentious language or classical learning or the bizarre nature of treatments rather than seeing healers as a source of risk to anything other than their customers' purses. Le Malade Imaginaire is very typical of this genre. Now it was much clearer that medical interventions, including drugs, could kill. The coherence of this response should not be overstated: this is not a consumer protection movement in the modern sense but there is a new kind of crystallization of concern. Associated with these developments was a greater willingness to regulate the market in health care. This is not a purely material impulse: as Michel Foucault, for example, has observed, all sorts of areas of social life became more regulated at this period in ways which were not dependent upon new technology. Indeed, to some extent, the technological changes followed and were facilitated by the metaphors and conceptual shifts that marked the social changes. As we read the history, though, there was an increasing state concern with the market for health care and a growing determination to tidy it up, to ensure that healers with particular kinds of backgrounds, education, theories and skills could be easily recognized by customers and selectively appointed to state offices. Given the overlap between diagnosis, prescription and supply in some areas of the market, any restructuring of medical work would have an impact on drug sellers.

We can, then, see a set of changes in technology, in conceptions of risk and in governmentality that alter the conditions in which the founders of the Pharmaceutical Society were pressing for licensure. Their demand was being expressed in conditions that had become more favourable to its supply. This can be seen more clearly if we compare the Pharmacy Act 1852 with the Pharmacy and Poisons Act 1868. The 1852 Act simply restricted the lawful use of the titles ‘pharmacist’ and ‘pharmaceutical chemist’. It did not prevent anyone else trading in drugs, filling prescriptions, etc. Even after 1852, registered pharmacists were only about one-third of all specialist retailers. However, they began to acquire market advantages. In 1862, the Army required its dispensers to be registered pharmacists.

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The same year also saw registered pharmacists given exemption from jury service alongside physicians and surgeons. This was a very characteristic British approach to professional regulation. The Medical Act 1858, for example, did not ban the unlicensed provision of medical services but gave registered practitioners advantages in relation to state offices and other aspects of practice upon which a strong competitive advantage could be built. In 1864, the Pharmaceutical Society tried to ban unregistered work and to exclude its competitors. However, this effort faltered precisely because it was seen as an anticompetitive move. The pharmacists' rivals, organized in the United Society of Chemists and Druggists, introduced a rival Bill to regulate the sale of poisons and, incidentally, to displace the Pharmaceutical Society as the registering authority for those licensed to sell such products. Members of Parliament found the latter approach much more attractive but were unwilling to displace the Pharmaceutical Society. In 1868, the government agreed to support new legislation proposed by the Pharmaceutical Society to restrict the sale of poisons and dangerous drugs to pharmacists registered with the Society. For a variety of reasons the Act was not wholly satisfactory, but what is important here is Holloway’s stress on the importance of the pressure on the government to do something about the sale of poisons. There had been an active campaign by the press, sections of the medical profession and the government's small band of public health officers since the 1840s to regulate the freedom with which substances like arsenic and strychnine could be obtained. One of the activists had been Sir John Simon, who became medical officer of health to the Privy Council (the government’s chief medical adviser) in 1858. In various capacities, he had also been associated with the pressure to reform the medical profession. Simon was one of the first modern bureaucrats, with a vision of public health delivered and administered through a cadre of trained medical officers. In some senses this is a Foucauldian model of a rationally-ordered society. The context created by Simon’s efforts within the small world of politicians and civil servants combined a concern with consumer protection and a desire further to rationalize the delivery of measures affecting the health of the public. The registered pharmaceutical profession would work alongside the registered medical profession in a society restructured according to public health ideologies. The analysis might continue with the Pharmacy Act 1908 and its location within another period of legislative activism around health and social welfare issues but space does not permit. It should, however, be clear from this discussion how analysts of the professions need to be sensitive to the conditions in which bids for monopolies are launched. The process of professionalization and the rise of societies in which this form

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of occupational organization is so important cannot be understood purely through an internalist account. Like all occupations, professions operate in an environment that may from time to time be more or less facilitative of their aspirations. These environments demand our attention equally with the projects and strategies of the occupations themselves.

Chapter 7

Herbert Spencer and the Professions: Occupational Ecology Reconsidered ‘“Who now reads Spencer? It is difficult for us to realize how great a stir he made in the world” ... We must agree with the verdict. Spencer is dead.’ Talcott Parsons’s (1968:3) intellectual obituary for Herbert Spencer, drawing on an equally crushing judgment by Crane Brinton (1933, pp. 226–27), is one of the most celebrated opening lines in any sociological text. We would not be the first to comment on the irony of Parsons’s rejection of Spencer when he was later to construct a social theory on precisely the same functionalist and evolutionary foundations (see Fletcher 1974, pp. 62–63; Turner 1985, pp. 49–50). Nevertheless, the judgment has remained largely definitive for most subsequent social theorists. Perry Anderson (1969, p. 219), for example, after noting that Parsons had shown conclusively why Spencer could not be regarded as a classical sociologist, took as the key problem for one of his most celebrated essays the question of why Britain, alone of major Western societies, never produced a classical sociology. Discussions of Spencer are conspicuously absent from the intellectual surveys of our major contemporary English commentators, such as Anthony Giddens or Bryan Turner. Yet as Philip Abrams (1968) and Roscoe Hinkle (1980) have observed, it is virtually impossible to understand the major currents of twentieth-century Anglophone sociology without appreciating the contribution of Spencer, even if only as the major target against which much of this work was written. Sporadic attempts have been made to promote a Spencer revival. Abrams hinted at the riches to be found, describing The Study of Sociology as ‘perhaps the most successful textbook of general sociology yet produced in Britain (1968, p. 73). There was a brief flurry of interest around the end of the 1960s: The Man versus the State was reissued with an introduction by Donald MacRae (1969); Andreski (1971; Spencer 1969) and Peel (1972) produced selections from Spencer’s writings; and Peel (1971) also wrote a highly regarded intellectual biography of Spencer. In the 1980s, Jonathan Turner (1985) again attempted to stimulate interest. Yet none of these efforts have met with more than limited success. As both Abrams and

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Turner note, much of the problem rests with Spencer’s profound lack of Political Correctness. His stand against social intervention and meliorism was responsible for the slump in his reputation in the 1880s, and thereafter contaminated the reception of his sociology. In the words of Abrams, (1968, p. 152), he is now remembered mainly for what his contemporaries objected to. According to Andreski (in Spencer 1969, p. xxxiv), Spencer’s politics, which ‘favoured the ideals and interests of the free-enterprise, anti-statist bourgeoisie’, were precisely the reason why he should be read. But this attempt to use Spencer against the New Left of the 1960s was 20 years ahead of its time. The New Right of the 1980s does not seem to have established a sufficient hold within sociology to promote his cause, although it may have contributed to a modest revival of interest in his political writings (Mack 1981; Offer 1994) and in his essays on welfare issues (Offer 1983). In addition, Spencer’s complex blend of individualism and organicism makes it difficult for the New Right to be sure he would prove to be an altogether reliable intellectual ancestor (Gray 1985). Nevertheless, the collapse of Marxism as a political and intellectual force has left an opportunity to reappraise the canon of the discipline. The failure of the New Right to establish a rival hegemony in sociology should leave us free to consider past writers on their own merits. In Spencer’s case these are considerable. This is not the place, however, to mount a full defence of Spencer as a neglected theorist. Rather, we propose to concentrate on a case study of his institutional analysis, which has been neglected even beyond the discipline’s general indifference. We refer to Spencer’s writings on professions. Andreski, otherwise an enthusiastic ‘revivalist’, omitted these sections from his abridgement of the Principles of Sociology (Spencer 1969, p. xv) as ‘not particularly illuminating’, and Turner (1985, p. 139) treats the issue as marginal. Indeed, in 1981, when I examined the Bodleian Library copy of the 1896 edition of the Principles, these pages were still uncut! One can argue, however, that a closer attention to Spencer’s writings on this topic would help to solve some problems in the current sociology of the professions, and might serve as a basis for at least a partial rehabilitation of his general reputation among sociologists. Our particular concern here is with the work of Andrew Abbott (1988), which has been a highly influential restatement of the ‘Chicago Tradition’ in the sociology of work and occupations. It hardly seems possible nowadays to read a new graduate thesis in this field without seeing the word jurisdiction on every page. Abbott’s work, however, can be seen to share the limitations as well as the strengths of its predecessors. We want to suggest that Spencer’s account of the emergence, character, and mode of functioning of the modern professions should not be dismissed out of hand as exemplifying an outmoded evolutionary approach of the kind Abbott

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explicitly rejects. Rather, we believe it can be read as anticipating the ecological perspective Abbott adopts – and, indeed, as embodying a way of modelling ecological processes which is more productive, in certain respects, than that proposed by Abbott. Spencer’s Theory of Societal Development Although we cannot discuss Spencer’s general ideas in depth, we must begin with a sketch of his approach to the analysis of societies in order to understand the context in which he develops his analysis of the professions. Spencer sees the professions as related intimately to one particular form of societal organization, namely industrial society, but much of the interest of his work derives from the way in which he traces their evolution from functional alternatives in earlier societies. Spencer holds this general picture in common with most other major theorists of the nineteenth century. He postulates an evolutionary movement from simple to complex societies: a historical movement in Europe and a contemporary transformation in the colonized parts of the world. By looking at the surviving examples of nonindustrial societies, we can see earlier phases of our own history being recapitulated. These simple societies were relatively homogeneous and small-scale, with little division of labour and a high degree of self-sufficiency. In the course of time, they were transformed in both scale and complexity, becoming marked by high degrees of internal and external specialization and an advanced division of labour. This change, however, has the paradoxical effect of increasing both interdependency and the autonomy of individuals. In effect, it is the process described by Durkheim as the transition from mechanical to organic solidarity, or by Maine, Marx, Tönnies, and Weber, each in different terms. In Spencer’s terminology, it is a movement from a state of indefinite homogeneity to one of definite heterogeneity – that is to say, from a condition of society in which people and their activities are very much alike and lack clear structures or organizing principles to one in which people and their activities are more distinct and depend for their coordination on organizing or orchestrating principles. Unlike his contemporaries, with the possible exception of Marx, Spencer had a very clear picture of the dynamic of this process. He saw it arising from ecological competition. Specialization was adaptive for individuals and societies: it allowed them to prosper and gave them a competitive edge because of the way in which it introduced more flexibility, more cooperation, and more space for innovation. As people and societies became more highly differentiated, they had to find ways of cooperating with each other. This differentiation gave the opportunity to develop new ideas and practices, which, in turn, extended the repertoire of

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possible responses to environmental change. Here Spencer is not thinking simply of the material or biological environment, but of selection pressure from other individuals or societies. He has a sense of the arbitrary nature of the allocation of phenomena to species or to environment, which is often missing in modem sociobiology. The individual case being studied in relation to an environment is, at the same time, part of the environment for other cases. There is a constant shift between what a later generation would call ‘field’ and ‘ground’, depending on the immediate analytic interest. Sociology, for Spencer, is the study of the structures which evolve to regulate and coordinate these processes: Comparisons of societies in their ascending grades, have made manifest certain cardinal facts respecting their growths, structures and functions; respecting the systems of structures, sustaining, distributing, regulating, of which they are composed; respecting the relations of these structures to the surrounding conditions and the dominant forms of social activities entailed; and respecting the metamorphoses of types caused by changes in the activities. The inductions arrived at, thus constituting in rude outline an Empirical Sociology, suffice to show that in social phenomena there is a general order of co-existence and sequence; and that therefore social phenomena form the subject matter of a science reducible, in some measure at least, to the deductive form (Spencer 1876, p. 618).

This passage also captures the spirit of Spencer’s functionalism. As Turner (1985, pp. 58–62) notes, Spencer viewed functionalism rather differently from successors such as Durkheim and Parsons. His interest was in the necessary conditions for the operation of a social system, which he characterized as ‘sustaining, distributing, regulating’, and in the ways in which these varied under different structural and environmental conditions. He does not elide the functional and the moral as later writers tend to do. More important, he does not regard the identification of a function as a sufficient explanation of an institution. His functional analysis is not the basis of a typology but a means to understanding how the parts of a particular system interact and generate novelty. Spencer, then, built his theory of societal development around the changing forms taken by sustaining, distributing, and regulating social relations under different conditions of environment, technology, knowledge, and culture. The sustaining system refers to the mode of production; the distributing system, to the means by which products, material or cultural, are exchanged or transported; and the regulating system, to the means by which the former activities are ordered and coordinated. These systems are successively transformed as societies increase in scale, whether by population growth, political alliance, or conquest (Spencer 1876, pp. 10–

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68). In the simplest societies, the institutions through which the functions of sustaining, distributing, and regulating are carried on are themselves relatively simple and undifferentiated. These primitive groups are marked essentially by spontaneous cooperation for the pursuit of private interests (Spencer 1882, pp. 245–47). Under competitive pressures, however, a more deliberate form of organization may emerge. The most important of these pressures is warfare, intersocietal competition that tends to arise as social groups become more settled and start to make more particular claims to territory and resources. Under these conditions, societies are likely to evolve a central coordinating authority that subordinates individual to collective ends. This is the beginning of political organization. Societies that establish this mode of organization acquire a competitive advantage in both defence and offence. They can resist the incursions of less highly organized competitors and can extend the sphere of their own interests by incorporating those groups through alliance or conquest. This is the basis of Spencer’s discrimination of two ideal types of society. The first is what he calls the militant type: a society that has a strong political authority, internal hierarchy, property rights controlled by the state rather than by individuals, strict control of everyday life, the suppression of rival sources of authority, and a culture directed toward the moulding of character to fit the goals of the state (Spencer 1882, pp. 568–602). The militant society is dominated by its regulating system; sustenance and distribution are subordinated to the maintenance of internal control and order. Although the militant society derives competitive advantages from its unity and its strong central authority, these also impose significant costs. The militant society must divert resources into its regulating system in order to maintain the requisite level of control. Those resources are then allocated in accord with a central plan rather than in proportion to individual contributions or initiatives. The society also lacks incentives for innovation and enterprise; it becomes static and has difficulty in adapting to any environmental change that calls for amendments to its control structures. By contrast, the industrial society has a much lower level of social overheads because its structure gives priority to its sustaining and distributing systems. Its regulating principles are built into, rather than imposed upon, the operation of these systems. An industrial society depends on the voluntary cooperation of its members, reflecting the interdependence produced by a high level of individual differentiation and autonomy. This is expressed through representative government and a corporate or public life that is organized to arbitrate between individual claims rather than to enforce a particular view. The reduction in state authority leads to increased efficiency:

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Essays on Professions No longer determined by the principle of inheritance, places and occupations are now determined by the principle of efficiency; and changes of structure follow when men, not bound to prescribed functions, acquire the functions for which they have proved themselves the most fit. Easily modified in its arrangements, the industrial type of society is therefore one which adapts itself with facility to new requirements (Spencer 1882, p. 614).

Spencer is a little ambiguous as to whether he regards the relationship between these two ideal types as evolutionary. Although he tends to depict the industrial society, which he saw as embryonic in his time, as better adapted to competition than the militant society, he recognizes that the latter has distinct advantages if competition intensifies to the point of warfare. In the short term, a tightly controlled command society and economy has advantages because of its ability to unify the entire effort of its members and focus it on a common goal. In the longer term, however, Spencer implies that the greater flexibility and diversity of the industrial society is likely to give it an advantage. The real world may well oscillate between these two models, depending on the precise set of conditions to which different societies are subjected at different times. The Politico-Ecclesiastical Complex Religious institutions play a particularly critical part in societal evolution and are the key to Spencer’s analysis of the professions. Spencer views religion as the basis of a semi-autonomous source of authority in every society. In simple societies with a low level of political organization, the level of religious organization is also low. As a society becomes more complex, it develops a more specialized regulating system which, at least initially, combines religious with secular aspects. The supernatural associations of the priesthood, however, necessarily make them potential rivals to the secular power: both undergo the same tensions of growth of differentiation. Although the priesthood may be an ally of the militant state as a source of integration and moral cohesion, it is always a potential rival because its does not depend on a monopoly of force for its authority. As the scale of a society and its religious institutions increases, the ecclesiastical powers face the same problem of maintaining control over a larger and larger span of territory and personnel. Just as the stresses induced by the effort to widen the range of political control tend to lead to the breakdown of the militant system, so the extension of religious control creates stresses that threaten religious authority. The ‘open’, unbounded social space within which industrialism develops challenges temporal and spiritual coercion alike. The ‘spirit of industrialism’ spreads theories of natural causation that lead people to

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recognize uniformities of relations between phenomena and lays a basis for the development of science. Yet even in industrial societies, despite the subversion of its cognitive claims and its dissociation from secular powers, religion maintains, in principle, an important role as a force for continuity in social arrangements and as a supplementary regulating system, influencing both the moral character of ordinary men and women and the means used to coordinate their actions. Spencer also stresses that the secularization of this authority, the shift from a theistic religion to an ethical creed, does not necessarily undercut the sacredness of its foundations: Those who think that science is dissipating religious beliefs and sentiments, seem unaware that whatever of mystery is taken from the old interpretation is added to the new. Or rather, we may say that transference from the one to the other is accompanied by increase; since, for an explanation which has a seeming feasibility, science substitutes an explanation which, carrying us back only a certain distance, there leaves us in the presence of the avowedly inexplicable (1969, p. 639).

This is a critical passage because Spencer goes on from here to analyse the emergence of the modem professions from religion in the militant society. Professions are not only the bearers of scientific knowledge; they are also, in effect, the secular guardians of the sacred, the priesthood of the modern world, but a priesthood that acknowledges the ultimate unknowability of things, deals in uncertainties, and recognizes the openness of the world to change. The professional system is the regulating structure of the industrial society, whose function is to accommodate society to this reality. The Professions in Spencer’s Sociology Spencer’s writings on the professions can be found mainly in Part VII of The Principles of Sociology (1896, pp. 179–318). His contribution is particularly distinctive for the way it starts, as always in Spencer’s writings, with a consideration of function and evolutionary pattern and then moves into an examination of particular cases; these, in turn, are illustrated by examples from Spencer’s great archive of historical and contemporary observations. In other words, Spencer reverses the common methodology of studies of the professions, namely beginning from a laundry list of occupations and trying to induce features that they have in common. What the professions have in common, according to Spencer, is their function and their origins and evolutionary trajectory, rather than their surface characteristics. Even so, Spencer acknowledges the problems of definition that have bedevilled the field for the last hundred years:

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Spencer first identifies the ‘system of professions’ in terms of its distinctive function. The professions touch everyone’s life. They appear in their present form at an advanced stage of social development, when the basic needs of survival, order, and production have been met. Their unique role is the enhancement or ‘augmentation’ of life. Physicians ward off premature death, creative artists give pleasure to their audiences, historians and men of letters provide guidance and stimulate interest in the facts and fictions they create, lawyers protect the rights of citizens (an important element of differentiation in industrial society), scientists’ discoveries improve the technology of life and add to general illumination, teachers equip their pupils for rewarding occupations and widen their horizons. Spencer, then, puts more emphasis on the creative role of the professions than do most modern analysts: although he acknowledges their roles in industrial societies as market actors, he sees that they have real services to offer, services which are genuinely innovative and which make the world a better place in some way. This view is an important corrective to some of the nihilism of the sociology of the professions in the 1960s and 1970s, when it often seemed that professions were merely rent-seeking monopolies or auxiliary organs of capitalist power. Spencer offers a much wider definition of the professions than that employed in most current writing: he recognizes their role as bearers of expert knowledge, but he includes within the professional system activities whose function is primarily ‘expressive’ rather than instrumental. Thus he avoids the rather fruitless arguments over whether priests, artists, writers, and the like should be regarded as following occupations and possessing expertise, and so qualifying for inclusion among the professions. He also avoids the need to decide which of the roles, institutions, and processes involved in the creation, dissemination, and application of knowledge are within the system, and which form part of its environment. In his mind, function precedes structure; interest should be focused on the whole range of roles and institutions through which both the instrumental and the expressive dimensions of the task of ‘augmenting life’ are fulfilled. Spencer develops his analysis by turning next to the issue of the evolutionary origins of the professions. His argument begins with the question of the emergence of the professional system from the undifferentiated structures of simple societies:

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Stated in a definite form the reply [to this question] is that traces of the professional agencies or some of them, arise in the primitive politico-ecclesiastical agency; and that as fast as this becomes divided into the political and the ecclesiastical, the ecclesiastical more especially carries with it the germs of the professions and eventually develops them (Spencer 1886, p. 181).

So the professions actually emerge from the regulating system, the control structure of the society, particularly from that part associated with the opposition to the command model of the militant society. Spencer argues that the activities of the ecclesiastical agency – healing, the devising of ceremonial employing arts and music, the recording and celebration of accomplishments – prefigure those of the professions. The priest class has the leisure to develop these areas and the motivation to do so because, in the absence of armed strength, their power can be preserved only through their cunning and skill in manipulating symbolic forms. The professions, then, are linked to the augmentation of life but in ways closely associated with the regulating system: ‘the [professional] agencies ... will develop in connection chiefly with those who permanently minister to the apotheosized rulers-the priests’ (Spencer 1896, p. 183). Their accomplishments are an alternative expression of the regulating system. Spencer does not pursue the implications of this observation as consistently as he might. Most of the case studies of particular professions that he offers are devoted to charting the specific course of their various emergences from religious sources; they provide opportunities to further assert the general thesis of movement from homogeneity to differentiation and interdependence. Nevertheless, Spencer returns to this point in his conclusion as he analyses the breakup of the militant type of society: ... a centralized and coercive control, political and ecclesiastical, becomes less needful, and plays a continually decreasing part in social evolution ... As the foregoing chapters have shown, all the professions originate by differentiation from the [regulative] agency which, beginning as political, becomes, with the apotheosis of the dead ruler, politicoecclesiastical, and thereafter develops the professions chiefly from its ecclesiastical element. ... (1896, pp. 310–11).

Thus the professions collectively constitute the regulating system of industrial society. The monolithic control of militant society disintegrates into the more flexible and more differentiated control of industrial society. Natural processes have spontaneously generated a loosely coupled mode of societal organization whereby controls are decentred (ordering interchanges between private individuals in pursuit of private ends rather than directing those interchanges toward collective purposes), hierarchies are flattened out, and boundaries (between whole societies and their environments as well as between their various constituent elements or groupings) are

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made permeable. In effect, as the focus of Spencer’s analysis shifts from militancy to industrialism, the organic metaphors that inform and shape it also change. He leaves behind the language of cell biology and takes up what is, in all but name, the language of ecology. In this respect he anticipates the work of the Chicago sociologists. Spencer and Occupational Ecology Today it is often forgotten just how deeply the tradition of social thought associated with the University of Chicago drew on biological metaphors. Both Dewey and Mead identified themselves as heirs of Darwin, although neither drew the conclusions conventionally associated with social Darwinism (Shore 1987, pp. 82–84). They were attracted by Darwin’s introduction of the ideas of plasticity and system: nature had not been fixed at the point of creation, but was constantly changing through a myriad of interactions between its elements. This position was worked out in sociology by Park, McKenzie, and Wirth in their development of an ecological approach to social organization (Shore 1987, pp. 95–120). Everett Hughes’s 1928 doctoral dissertation on the Chicago Real Estate Board stood at the crossroads between the ecological study of the city pioneered by his teachers and the ecological study of work and occupations that he developed. The study of competition for territory or land use became a prototype for studies, by Hughes and his students, of the way in which the competition for control of desirable activities in human society was structured. Abbott’s work stands in this tradition. Unlike evolutionists such as Wilensky (1964) – who explain difference and hierarchy among professional occupations by assuming that they are all moving, but from different starting times and at different speeds, down a single path toward full professional status – Abbott can see no way-marked, developmental path to professionalism. He sees occupations, or, in the case of the ‘professional system’, particular kinds of expert occupations, struggling among themselves to carve out a niche in the field of work, drawing boundaries around the territories they claim for themselves, extending them whenever they can, drawing back when they are forced to do so, sometimes lording it over their neighbours, at other times finding their own patch of land under threat of colonization. Spencer’s ecology, however, is not identical to Abbott’s, who is concerned with the processes by which boundaries are drawn and redrawn between the elements in an ecological system. Spencer is interested primarily in the channels of interchange both between system elements and across the boundary that distinguishes the system from its environment. Both Spencer and Abbott are concerned with the regulation of

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the processes they analyse, but they draw on different legal analogies to characterize the regulatory systems that fulfil this function. For Abbott what is at stake is jurisdiction, the rights of an occupation to a piece of territory defined by the division of labour. For Spencer, what is of concern is contract, the terms that govern interchanges among occupational groups and between them and their various publics. Abbott sees border guards doing most of the regulatory work; according to Spencer, the customs officials are kept busy. Perhaps one can sum up the difference by saying that Abbott’s ecology is the ecology of the militant system, revolving around a struggle for territory and the maintenance of the integrity of boundaries, whereas Spencer’s is the ecology of the industrial system, focusing on the traffic between increasingly differentiated elements and across increasingly permeable boundaries. One crucial advantage of Spencer’s conceptualization is that it opens the way to a more convincing analysis of the relations between the state and the professions. Abbott appears uncertain as to where the state as an actor stands in relation to the ‘system of the professions’: is it in the system, intervening in the interactions among professional groups, or is it part of the environment to which the system accommodates itself? Does the state actively define boundaries and confer powers, or does it merely confirm claims to jurisdiction? Abbott is obviously anxious to avoid the problems he associates with Larson (1977) and the monopoly school, whose central narrative concerns the professions’ capture of the state to produce regulation in their own interest. He seems more concerned, however, with challenging Larson’s narrative form than with considering the role of the state and the problems of capture theory (See Chapters 5 and 6). Similarly, in his chapter ‘The Social Environment of Professional Development’, Abbott (1988, pp. 143–76) presents a familiar list of factors influencing the struggle for jurisdiction – technology, capitalism, bureaucracy, mass communications, and class structure – which includes a section reviewing the difference in the state as an audience for jurisdictional struggles in France and in the United States (pp. 157–67). No theoretical framework ties these environmental factors together: this is simply a list of things that might have some influence and sometimes seem to do so. They are features in the environment of the system of professions, but the system does not seem to interact very coherently with them or to ‘internalize’ their effects. Spencer, by contrast, places the relations between the state and the professions at the centre of his analysis of the regulatory system of industrial societies. In developmental terms he envisages the progressive transfer of responsibility for the regulation of these interchanges away from the state to the agencies themselves. This is not so much a matter of deregulation as of differentiation and devolvement:

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The value of Spencer’s analysis of the regulatory mechanisms that control interchanges within the industrial system is partly obscured by the overlying political ideology. Characteristically he proceeds from his analysis of the evolutionary emergence of the professions out of the politico-ecclesiastical complex to deliver a paean for laissez-faire and regulation: For in agriculture, manufactures, commerce, banking, journalism, immense injuries have been done by laws-injuries afterwards healed by social forces which have therefore set up afresh the normal courses of growth (1896, p. 316).

By this point Spencer is clearly overlooking the importance of law in the constitution of most modern professions. His political agenda has carried him off in a direction inconsistent with his own statements about the role of law as a means of accomplishing and protecting differentiation in industrial societies. As he acknowledges at other points, law can be a positive force in social and economic development, not merely a tool of government obstruction: ... the differentiation ... between those laws which derive their obligation from the will of the governing agency, and those laws which derive their obligation from the consensus of individual interests – between those laws which, having as their direct end the maintenance of authority, only indirectly thereby conduce to social welfare, and those which, directly and irrespective of authority conduce to social welfare ... the justification for a law is that it enforces one or other of the conditions to harmonious social co-operation (1882, pp. 527–28, 534).

These conditions include restitution for damaged interests, liberty of conscience, equality of treatment, and the enforceability of promises. In

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an industrial society, law is a means of defining and stabilizing private social relationships rather than of imposing commands on people. It rests on a basis of consent. This discussion also opens up for Spencer the question of the sources of legitimation in an industrial society. As he notes, the legitimacy of a political order arises ‘partly from the public opinion of the living, and more largely from the public opinion of the dead’ (1882, p. 323). By this he means that any society rests partly on the values and experiences of the past, as these are incorporated in various institutions that carry forward and articulate the traditions of the society (and, as the Lamarckian in Spencer would have it, in the genetic inheritance of the population), and partly on the immediate concerns of current members in the environment in which they find themselves. The one is a force for stability, the other a force for adaptation. It is clear from the sections dealing with professions that much of their activity is concerned with the representation of the past. As they assume some of the functions of the political head in the militant type of society, they become the agents through which ‘the feelings of the dead control the actions of the living’ (Spencer 1882, p. 323). Taken together with Spencer’s comments on the sacredness of professional knowledge, its mystery in the classic sense, these elements can be combined in a way that gives a greater coherence to his sociological project than his political concerns allowed. Why Spencer? There is life still in the organic analogy, as demonstrated amply by the ecological studies conducted in the Chicago tradition. It is capable of yielding up yet more. As Peel (1971, p. 185) remarks: ‘Organic analogies are especially fertile in contrary implications ....’. Spencer, perhaps more fully than any other writer before or since, has shown how the ambiguities in the analogy can be exploited. His sociology cannot be reduced to its evolutionary core, nor should we allow distaste for some of his more extravagant political views to blind us to the other possibilities it contains. We have argued that his account of the modern professions rests on an interpretation of ecological processes that complements the model employed by Chicago writers such as Abbott. Moreover, in the field of the professions, as elsewhere, events are moving in a direction that is bound to encourage a re-examination of Spencer’s conceptualization of the structure and functioning of industrial societies. New relationships are being formed between the state, the professions, and the market system, which make the established ‘market control’ and ‘state capture’ approach to the analysis of the professional project appear outdated. Abbott’s jurisdictional studies are the product of an ingenious attempt to elaborate

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this ‘control/capture’ approach with the help of an ecological model of the workings of the professional system. We suggest that Spencer’s work contains an alternative characterization of the functions of the ‘system of professions’, its emergence and regulatory processes, which is linked to an alternative ecology and which might help to illuminate precisely those developments which cast doubt on the adequacy of the received view.

Chapter 8

Professions and Social Order in a Global Society These do not seem to be propitious times for professions. The deregulation of labour markets is said to be a crucial condition for success in the global marketplace and national professions are widely viewed as obstacles to free trade in services. In the UK, a series of deregulatory measures have eroded the market shelters of health professions, lawyers and architects over the last 15 years. It is not clear that a change of government will significantly alter this movement. However, if national professions are under pressure, it is arguable that the logic of global markets will stimulate the rise of global professions. The Sociological Analysis of Professions For the best part of a generation, sociologists have analysed the creation of professions as a process of regulatory capture: professions were wellorganized occupations that could close markets and create shelters, in Freidson’s (1982) phrase. Perhaps the most influential statement has been Larson’s (1977, p. xvi.) discussion of professionalism as a collective mobility project: I see professionalization as the process by which producers of special services sought to constitute and control a market for their expertise. Because marketable expertise is a crucial element in the structure of modern inequality, professionalization appears also as a collective assertion of special social status and as a collective process of upward social mobility. (Original italics)

However, it is arguable that the power of Larson’s rhetoric has led later writers to neglect two important qualifications. The first is her acknowledgement that the market is not passive: ... the structure of the market in which a profession transacts its services does not depend on the profession’s action and intentions – or at least not until the profession gains considerable social power. The structure of a particular professional market is determined by the broader social structure. (pp. 17–18)

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She illustrates this by explaining the limited power of professional institutions in engineering, relative to medicine, in terms of the different positions of a profession serving powerful corporate clients and one serving individuals. She also accepts the role of the state: ‘ ... to view professional modernization as a project of market control, underlines the central role of the state in the development of this project...’ (p. 18). Having made this concession, however, she offers little analysis of the state, tending to see it as a mere vehicle for the interests of capital. Larson’s position is typical of a line of work which has focused on ‘occupational imperialism’ (Larkin 1983; cf. Parry and Parry 1976; Parkin 1979). However, although it continues to be fashionable, as in the recent work of Witz (1992) and Krause (1996), there has been increasing disquiet about both the theoretical and the empirical basis of this argument. Johnson, for example, whose neo-Marxist analysis prefigured Larson’s work, has moved steadily away from an occupation-oriented position to one which places increasing emphasis on the interdependence of professions and the state (Johnson 1972, 1977, 1982, 1995). Dingwall and Fenn (see Chapter 5) pointed to the general weakness of occupation-oriented analyses in explaining why the state chose to allow the creation of market shelters: at any historical point far more occupations were seeking this protection than were ever afforded it. Professionalization might be a response to market failure rather than a form of market failure, as the conventional view proposed. This shift from demand theories of professionalization to supply theories (see chapter 6), in other words from stressing the occupation’s organized pursuit of its interest to the environmental conditions under which it is made, also seems more consistent with the empirical evidence. That chapter re-analysed Holloway’s (1991) study of the formation of the Royal Pharmaceutical Society in Great Britain. It argued that the decisive moves to licensure owed less to the organization of pharmacists than to state responses to moral panic about the increasingly potent organic compounds that were becoming available and to a state project to tidy up the market for health care provision in support of its own developing stake in public health. Halliday’s (1987) study of the Chicago Bar pointed to the incoherence of the idea of a professional project in a large and divided group and to the need to take seriously more structural analyses of the market and the state in creating the space within which professions operated. Although Abbott (1988) underplays the influence of the state, his analysis of the division of labour as a field of turf battles and his emphasis on the need for a systemic understanding of professions in relation to their environments and markets also directs our attention away from the kind of single case study that has often led to overgeneralization. More recently, Light’s (1995) discussion of professions through theories of countervailing

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powers, borrowed from political science, has started to respond to the observation that what professions have won or been given, can be lost or removed. His argument would perhaps be more familiar cast in economic terms: that the exploitation of a long-run market disequilibrium will ultimately lead to the emergence of opposing forces or the reorganization of production or supply to eliminate this rent. His particular target is the US medical profession, where the perception by major industrial corporations that high health insurance costs are imposing an international competitive disadvantage has finally brought interests of comparable weight into the political process. Perhaps, then, the time has come for a re-reading of the historical case studies on which the demand theory has been based and for a new attention to the relations between occupations, and between occupations, markets and the state, which sees the emergence of modern professions as a more complex story of the conjunction of interests and ideologies that we call modernization. In doing so, it may be necessary to reappraise some earlier contributions. This paper focuses particularly on the writings of Adam Smith and Herbert Spencer who were observing these processes at first hand. Adam Smith and the Moral Base of Professional Work In Book I of Wealth of Nations, Adam Smith draws a dear distinction between skilled labour or mechanical trades, common labour and ‘liberal professions’ (Smith, 1976a, I, pp. 112–150). The latter group, which includes law, medicine1, the clergy and a less clearly defined group of teachers, scholars, intellectuals and artists, enjoy above-average rewards which are justified by the special nature of their work: We trust our health to the physician; our fortune and sometimes our life and reputation to the lawyer and attorney. Such confidence could not safely be reposed in people of a very mean or low condition. Their reward must be such, therefore, as may give them that rank in the society which so important a trust requires. The long time and the great expense laid out in their education, when combined with this circumstance, necessarily enhance still further the price of their labour. (Smith, 1976a, I, p. 118)

All of these occupations are in the business of trust. Why could this not be ‘reposed in people of a very mean or low condition?’ The answer might be rendered as an argument that if we pay people more, they will be more honest. However, Smith suggests a more subtle approach in his other major work, The Theory if Moral Sentiments (Smith, 1976b). This book prefigures many of the ideas that would now be associated with symbolic interactionism in arguing that society is

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constructed from social interaction based on a process which Smith calls ‘sympathy’ and which might now be called ‘role-taking’. It is by putting ourselves in the role of the other viewing our actions, or by imagining how they would look to an ‘impartial spectator’, Smith’s version of Mead’s ‘generalized other’, that we are able to interact. Unlike many modern interactionists; however, Smith is also concerned to explore the criteria by which action might be judged and the motives that might lead us to interact. We are more disposed, Smith suggests, to interact with joy than with sorrow, and riches are normally a source of joy both to their owner and to their observer. Our deference towards them rests on the pleasure that we derive from it rather than any personal expectation of benefit. This deference is sustained, however, only so long as the rich display the moral qualities with which we assume them to be endowed. A person who is rich, virtuous and wise is more admired than one who is poor, virtuous and wise. Smith concedes that we also allow the rich more scope for folly and vanity than we do the poor. However, when the rich fall, their distress and humiliation is such as to constitute a terrible warning to us all. Our trust in the professional, then, is the product of our readiness to identify with and defer to people of rank and wealth, underpinned by the penalties of dishonour that would arise from its breach. The maintenance of honour is not the narrow, post hoc and reactive sanction of a legal system: it is something which proactively informs and permeates every action lest it be compromised. Poor people may empirically be just as honourable, or just as interested in avoiding dishonour, but we do not perceive them in the same way. Smith also justifies the professions’ high earnings by reference to the ‘tedious and expensive’ nature of their education and to the improbability of success: ‘In a profession where twenty fail for one that succeeds, that one ought to gain all that should have been gained by the unsuccessful twenty’ (Smith, 1976a, I, pp. 118–19). However, he questions whether this is actually the case. People are not deterred from entering the lottery, because they believe that they have a real chance of winning. The prize is not solely fortune but also, harking back to the theme of Moral Sentiments, honour and reputation: ‘The public admiration ... makes a considerable part of that reward in the profession of physic; a stiIl greater part perhaps in that of law; in poetry and philosophy it makes almost the whole’ (Smith, 1976a, I, p. 119). The moral dimension of professions as a class of occupations is further emphasized in Smith’s later discussion of competition policy when he wonders whether it is ‘indecent’ to compare the pay of a curate or chaplain to that of a ‘journeyman in any common trade’, although the actual figures are similar. This discussion has some other striking features. It forms part of a chapter which looks at distortions in the labour market. The

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first section examines the effects of guilds and corporations in restricting competition and contains many of Smith’s most celebrated criticisms of these bodies as conspiracies against the public or contrivances to extract excess profits. The real controls on quality are the disciplines of the market, supplemented where necessary by hallmarks on the product, rather than, say, the length of apprenticeship. Most trades could be easily learned in a few weeks. However, his discussion of the liberal professions begins as a contrast between the knowledge and experience required for their practice and that of other trades. He remarks on the way that they face in greater degree the challenge faced by farmers of working with constantly variable materials and instruments which ‘require to be managed with much judgement and discretion’ (Smith, 1976a, I, p. 142). The knowledge of farmers, artists and the liberal professions cannot be standardized in the same way as that of a mechanical trade. Interestingly, Smith never questions the value of a professional education: it is long, tedious and expensive but not irrelevant or inappropriate as most apprenticeships are said to be. For Smith the professions illustrate the effects of market distortions that create excessive competition. Law and medicine have an approximation of supply and demand which gives successful practitioners reasonable rewards. Clergy and scholars, however, face a market overcrowded by the misguided philanthropy that has created a raft of bursaries, scholarships, exhibitions, etc. which lower the price of entry and produce an excessive supply of qualified people whose earnings are then driven remorselessly downwards. The result of overproduction in other areas would be the ‘entire degradation of the now respectable professions of law and physic’ (Smith, 1976a, I, p. 147). Smith does not make a specific argument for professional corporations as the method of managing supply: he seems to be more inclined to leave this to the market solution of ensuring that entrants meet the full cost of their education. However, he dearly identifies a special group of occupations. They have a distinctive moral character and a high level of public reputation. Their practice requires a special kind of skill and judgement and is necessarily based on a lengthy training. All of these combine, in theory, to restrict supply and to justify high incomes, although market distortions may undercut this. We must be careful not to make Smith sound like an attribute theorist before the event. He may have described certain characteristics shared by a group of occupations but these pivot around two things which, in his view, are real discriminators between professions and the guilds of mechanical trades. All corporations claimed to promote the trustworthiness of their members and the esoteric knowledge of their members. Smith rejected these assertions in all cases other than those of the professions. In other words, he thought that their market niche was founded upon an objective

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difference. Trust mattered with professional services and they did have relevant esoteric knowledge which was needed to deal with the variability and uncertainty of their work. The management of the related problems of trust and uncertainty is a crucial functional issue for market societies. One of the particular contributions of the Scottish Enlightenment to social thought was its proposed alternative to the idea that social order rested on a fictive compact, contract or convention. As noted above, Smith and his contemporaries invented much of what we would now call symbolic interactionism (Muller, 1993, pp. 101–112). Order in society did not emerge from an agreement to create an authority or an explicit body of rules which everyone would obey. It emerged in a more spontaneous and natural fashion. Our inherent desire for relationships with others and for their approval led us to treat their reactions as the mirror to observe our own conduct and, from observing what actions have what effects, to learn what was fit and proper behaviour. However, it was not merely enough to produce this: we also aspired to a sense that we merited approval for our sincerity, that we had behaved with propriety because it was the right thing to do rather than because we hoped to gain some advantage. In the same way, we needed to be able to trust the reflection, that the other’s response was also sincere. The process of reflection can be mediated through symbols. When you give me a piece of paper in return for a good or service, it is the trust between us that makes this into a unit of currency. The exchange rests upon your confidence in my warranty for the good or service and mine that I can take your paper to someone else who will also trust its value. The transaction encodes a long train of trust relationships (Hayek, 1945). However, as Smith notes, there is a difference between warranting a claim to quality in a material product – hallmarking gold or silver items and stamping linen and woollen cloth are the examples he gives – and making the same claim to be able to heal the sick, manage a law suit, teach philosophy or preserve the immortal soul. How do I know that I can trust your promise? The action you are going to perform lies in the future, is attended with much uncertainty and I cannot easily judge what part you have played in the outcome. You say you will heal me but we shall all die some time. Has my time come? You say you will win my case but the other lawyer has promised their client the same. You say I will go to heaven but I shall find out in the next world rather than this one. An important part of this trust reposes in the conduct of our interpersonal relationship, that the professional comports himself as a professional could reasonably be expected to (Smith, 1976b, pp. 201–204, 209). However, it does not solve the ultimate problem of sincerity. This person is behaving like a lawyer or a physician: how do I know they really are one? In the small-scale society of Lowland Scotland in the 18th century, this may not be a huge difficulty.

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In the contemporary world, it is much more serious. The larger in scale and the more complex societies become, the more difficult it is to check that the other does indeed have the skills that they claim. Herbert Spencer and the Analysis of the Modern World The first half of the 19th century and the social movements that led to the licensure of the major professions by the l880s are often described as the period of market closure, when the foundations of modern monopolies were established. However, it may be better examined as a period of institution-building, when the limitations of an open market became apparent and societies tried to find a solution to the problem of trust. How could the providers of these services be defined in a way that would assure their quality? Herbert Spencer viewed the development of human societies as a movement from what he described as indefinite homogeneity to definite heterogeneity. This characterizes the emergence of modern professional corporations quite well. Looking at the market for healing at the end of the 18th century in both England and the USA, we can see a vast range of providers from herbalists, bonesetters and handywomen through grocer / druggists to apothecaries, surgeons and physicians. Although there was a great variety of healing systems and practices on offer, these did not map neatly on to any particular kind of provider and many seem to have been entirely eclectic. By the end of the century, in both countries, this market had been more or less neatly tidied up with roles assigned by law to certain groups and particular theories given legitimation as the officially recognized knowledge of medicine. Other groups and theories had been excluded and delegitimated. The picture in law was very similar, although the clerical profession and the intellectual profession were rather less clearly organized. Other professions were becoming identifiable in the form of accountants and engineers and a guild or corporatist model had become established as the basic institutional form of the profession. Spencer sees the emergence of professions as intimately linked to the institutional development of modern states. In early phases of development, societies tend to adopt what he calls the militant form with a tightly controlled command economy and central planning. However, this is a costly form of society to maintain because of the resources which are consumed in maintaining order and control. It lacks incentives for innovation and enterprise because rewards and goals are allocated by central planners rather than in proportion to individual contributions or initiatives. In times of peace, militant societies tend to be displaced by industrial forms which are marked by voluntary co-operation and forms of control designed to promote and support spontaneous order rather than to

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impose it. Spencer saw religion as playing an important part in the process. Its supernatural connections gave it a measure of autonomy from a militant state and its concerns for motivation and inner belief tended to make it an ally of industrial states. In the process, however, its sacred character is transferred to other, secular bodies. Some of these are the professions: Professions are not only the bearers of scientific knowledge; they are also, in effect, the secular guardians of the sacred, the priesthood of the modern world, but a priesthood which acknowledges the ultimate unknowability of things, deals in uncertainties, and recognizes the openness of the world to change. The professional system is the regulating system of the modern society, whose function is to accommodate society to this reality. (See Chapter 7, p. 91)

At the heart of Spencer’s scheme is a more positive view of professions as people with real skills and a beneficial contribution to society. They emerge at a stage when the basic needs of survival, order and production have been met and adopt the unique role of focusing on enhancing the quality of life (Spencer, 1896, pp. 179–184), In the process, they also make possible a more loosely coupled society where control is decentralized, hierarchies are flattened and boundaries made permeable. As Johnson (1995) has recently noted, from a different theoretical direction, in modern societies, professions are not opposed to states, nor are they part of them: rather professions and states perform sometimes complementary and sometimes competitive roles in a system of regulation, control or ordering which is greater than either. With Spencer’s concern for the sacred character of professional work, we also return to the theme of uncertainty. This is a notion which is also central to the work of Hughes (1971) when he writes about the ‘guilty knowledge’ of professionals. One way in which we might see the emergence of professions in the 19th century is as a reflection of the process of modernization. Old certainties had disappeared but the need for certainty remained. The organization of lives depends upon the creation of certainty. On some occasions we need for all practical purposes ways of deciding the meaning of texts or resolving disputes without violence. Of course texts can be indefinitely reconstructed and disputes closed in many ways but one of the things which law supplies is a practical and legitimated certainty. If we are investing our capital in a major engineering project like a dam, a railway or a bridge, then we need some assurance that it will perform its intended function. Of course no engineer can guarantee that a suspension bridge will stand up in the face of a once in a 100 years climatic event unless it is built at a cost that would be wholly uneconomic. However, his or her professional judgement is the practical certainty that makes our investment possible. It is the foundation of our trust that the world is a less uncertain place than it might seem, were we constantly

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to reflect upon it. The 19th century was also the period of unification of societies. As even the smallest villages became drawn into the national society and economy, they came to need a consistent basis for dealing with each other. It was this logic as much as any occupational imperialism that closed markets. A national framework of public health and social assistance provision, sustained by national taxation, requires a reasonably consistent means of interpreting and applying it. The village healer lost out precisely because she or he was only the village healer whose skills and legitimacy were acknowledged no further than that community. A largescale society demands comparable institutions to sustain and regulate it. These are not all to be found in the state but the modern nation-state could not have developed without their co-evolution. These observations also help to make sense of two otherwise puzzling phenomena. One is the variation between professions. Every commentator since Smith has noticed the differential distributions of material and symbolic rewards between different professions. However, the reasons for this have remained largely unexplored, beyond Smith’s comments on the level of competition. Why, though, should levels of competition vary? Why do some professions have more effective monopolies and the power to extract rents as well as status? There may be an answer to be found by considering the relationship between professions and the state in the management of order. The least rewarded and least regulated professions are those which are seen as most marginal to the maintenance of social integration over a national territory. In many societies, the dispersal of the preservation of the sacred with the break-up of the politico-ecclesiastical complex left the clergy with a largely residual role in which the state has often shown a relatively limited interest. In some, however, the clerical interest retained a hold over other professions that gave it a central position of power and influence within the nation. An example might be Ireland, where the health professions remained subordinated to the Catholic hierarchy until relatively recent years. We might also note the varying status of the educational profession according to whether the educational system is seen merely as a supplier of technical labour or as the creator of morally formed citizens, in the way that some mainland European states have viewed it. The other point is the way in which the ecclesiastical background provided the models of occupational organization adopted by professions. One of the neglected topics of historical sociology is the influence of the churches on later secular organizational forms. Many of the techniques of discipline associated by Foucault with the 19th century, for example, have recognizable precursors in the monastic rules of earlier periods. In the same way, if we ask where the model of a self-governing corporation comes from, the answer must surely be certain religious orders and their

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subsidiary foundations in the medieval universities which survived the culling of the guilds. The gap left in Smith’s account for the choice of an organizational form for an occupational corporation might be filled by Spencer’s understanding of the sacred sources of professional work. This line of analysis may offer a more secure basis for thinking about professions in the contemporary world. Of course, there are longer-term processes at work. If professions have a particular relationship with the sacred, then they cannot expect to be immune from the continuing transformation of that sphere. If we are living through a dis-enchantment of the world, then occupations associated with enchantment are likely to decline. But there may be limits to this process. Theorists of post-modernity point to the torrent of information that is available to us. A surfer’s roll on the World Wide Web will offer us expertise on anything. For some, indeed, cyberspace is the new realm of the sacred. And yet many of the great social theorists of our century have pointed to the impossibility of knowing everything. The practical solution to this problem is one of the core preoccupations of Schutz’s work, for example (Schutz and Luckmann, 1974). Hayek gave great attention to the problems of uncertainty and limited information in economic life (Hayek, 1945; Gamble, 1996). The concern may be best defined by Simmel (in Wolff 1950, p. 313), a key precursor to both: To be sure the innumerable errors and superstitions in the life of primitive man are harmful enough to him, but far less so than are corresponding ones in advanced epochs, because the practice of his life is guided in the main by those few facts and circumstances of which his narrow angle of vision permits him to gain directly a correct view. In a richer and larger cultural life, however, existence rests on a thousand premises which the single individual cannot trace and verify to their roots at all, but must take on faith. Our modern life is based to a much larger extent than is usually realised upon the faith in the honesty of the other. (Original italics)

In principle, we might be able to check anything: in practice life is too short. The expansion of information does not make us any more skilled at evaluating it. As we all recognize, the difficult thing is not collecting data but knowing what they mean. It might be argued that judgement can also be computerized, that some sources might be hallmarked. But, as Smith saw, that kind of approach becomes more difficult to operate with less tangible products or services. It will be very hard to eliminate intermediaries, whose ability to interpret information and apply it to our case will rest on familiar legitimations. The professional is our means of reducing uncertainty about important things that we cannot easily or economically verify for ourselves

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Professions and Global Order If this is one aspect of the market for professional services, another might be the emergence of state-like formations above the level of the nation. Here again we return to the insights of Smith and Spencer. There is a sense in which globalization recapitulates an 18th and 19th century experience. One of the great transformations was the creation of effective national markets. Trade was not defined by the speed of a wagon or the carrying capacity of a pack animal. Canals, turnpikes and railways opened up and unified nations. Further advances in the division of labour became possible as areas specialized in goods for which they had a comparative advantage. The accelerated and democratized mobility of peoples unified national cultures and created national languages. Starr (1982, pp. 69–71) has noted the impact of the automobile and the telephone on medical practice. He suggests that they led to productivity gains of the order of 300%, reducing cost and increasing accessibility. It became possible for everyone to live within reach of a professional and to be able to travel over longer distances to sustain specialism in practice. At the same time, these material changes facilitated cultural standardization. A rural community in the 1870s might have had no choice but to use a traditional midwife for a home delivery: by the 1920s that community would be within the catchment of an officially licensed practitioner and have sufficient means of transport to move a woman in labour to a hospital. The choice of birthplace and birth attendant became a real choice. A common theme in recent Westerns has been the bringing of order to the frontier. In the absence of judges, lawyers and law-enforcement, people had to settle their own disputes in their own ways. By the 1890s, the spread of the railroads and the creation of national markets made this increasingly difficult to sustain. A chain of contracts stretching from the Southwest through the Mid-West to the East Coast could not dependably rest on the gun to define property rights in land or cattle. National markets required national law, national accountancy and so on. When the great capital projects of the period were being undertaken, an important part of the security for investors was the certified skills of the constructors. The first railways may have been built by self-taught engineers but, by the end of the century, elaborate systems of apprenticeship and formal examination had developed. If we look at the international marketplace today, we see much of the unregulated and anarchic capitalism that our predecessors saw. Ultimately, that order proved to be unsustainable. The logic of large-scale enterprise required a degree of management of its organizational environment that tamed the system. When you have to mobilize capital globally to build the Channel Tunnel or the bridge from Sweden to Denmark, then you need engineers whose skill will be acknowledged by every international

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banker and you need a legal and accounting regime that everybody trusts. The global order may find that it needs trust-promoting groups much as nation-states did. This seems likely to pull the professions into a global organization of some kind. Those groups will not necessarily be organized in the same way as professions in the era of nation-states. Their descent from national professions may be more symbolic than real, just as with the lineage from the medieval professions to the modern. Global professions may not sit alongside a single state-like entity but form part of a network of international bodies involved in regulating, co-ordinating and managing economic activity and political risk. National professions may co-exist with them in areas which are less touched by the global order – health and social welfare may be a particular example. If these arguments about the necessity of the professional niche in the organization of market societies are correct, then obituaries for the professions seem distinctly premature.

Chapter 9

‘After the Fall ...’: Capitulating to the Routine in Professional Work At first I thought that Liberty and Heav’n To heav’nly Souls had been all one; but now I see that most through sloth had rather serve, Minst’ring Spirits, train’d up in Feast and Song; Such hast thou arm’d, the Minstrelsy of Heav’n, Servility with freedom to contend, As both their deeds compar’d this day shall prove. John Milton, Paradise Lost Bk. VI, Vs. 165–701

All institutions have creation myths, stories about how they began and how they came to be what they are today. Those stories are so much part of the landscape of our culture that we often have difficulty in recognizing them as stories, designed to fulfil an entirely different purpose than that of the sceptical historian. Interestingly, many of these myths share Milton’s focus on the idea of a fall from grace, that there once was a golden age, of which the present is but a pale reflection. As a result, both storytellers and audiences risk finding themselves chronically dissatisfied with their present condition relative to that of the past. Mediation seems to be in the process of developing its own creation narrative. This article will look at some of the reasons why institutions seem to have these stories, why mediation is acquiring one, and what some of the consequences might be. It begins, however, by introducing some ways of thinking about work, occupations, and organizations that provide a wider context for the issues confronting mediation. Work, Occupations, and Organizations Just over half a century ago, Everett Hughes, one of the most creative US sociologists of his generation, was invited to talk to the American Nurses’ Association about the study of nurses’ work. In a brief address, he encapsulated a way of thinking about work, the people who do it, and the settings in which it is done, which permeates his writings:

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In the same way, people have long tried to help others resolve disputes peaceably but in the last two decades or so have begun to turn this into a profession. Although a number of different job titles are in use, let us call this the profession of mediation. Hughes’s comments on the predicament of U.S. nurses around 1950 resonate clearly with anyone familiar with the community of mediation practitioners in recent years. Continuing the previous quotation: There are certain symptoms to be seen wherever this happens. The people in the occupation get somewhat self-conscious about many things concerning their work; jealous of their name and badge…; dreadfully afraid that some of their number will not observe company manners and so will hurt the reputation of all; not quite sure what their jobs are or ought to be and consequently not certain what their training should be (Hughes 1971, p. 311).

For sociologists, then, many of the debates that have preoccupied mediators in recent years – about the relationship between theory and practice, about licensing and regulation, and about training – while important in themselves, are also interesting as data on a community that is trying to respond to rapid changes and to reposition itself in the market for its labour. Just as the nurses around 1950 were beginning the long march away from the image of the bedside comforter to become the skilled technicians and coordinators that we find in modern health care, so mediators have started to shuck off the amateurish notion that anyone with the right personality can settle disputes. In the same way as the nurses, mediators seem to be finding this a harder sell than they might have hoped. In the UK, at least, people can still be found to argue against demanding some evidence of intellectual capacity among recruits to nursing on the basis that an ability to care is all that really matters.2 Given a choice between a nice but dim nurse and one who actually understands the potential interactions between the medications she is administering, our preferences would be clear.3 In the same way, most readers’ mothers will have done conflict resolution, especially if there were siblings in the family (Davis 2001). This does not necessarily make them into the sort of people who can resolve the wide variety of disputes that mediators are asked to deal with in complex modern societies. Hughes makes a number of other observations that will be useful as we come to consider the relationship between work and organizations. He notes that a job is always a position in an organization, or as contemporary

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scholars would be more likely to put it, in a system of jobs (Abbott 1988, p. 112). The job ‘mediator’ is substantially defined by the incumbents’ interactions with people doing other jobs called ‘lawyer,’ ‘judge,’ ‘referee,’ or ‘manager,’ as well, of course, as by the bundle of tasks that we call ‘mediation’ (Lynch 1997) Hughes points to the question of what holds each of these bundles together and makes them unique. Elsewhere, he (Hughes 1971, p. 287) talks about this as an occupation’s license, what it does for reward that is different from other occupations: an occupation consists in part in the implied or explicit license that some people claim and are given to carry out certain activities rather different from those of other people and to do so in exchange for money, goods, or services.

The term ‘licence’ is important in Hughes’s work, but his usage is often misunderstood. For Hughes, this is a metaphor. Although it encompasses the idea of a ‘licence to practice,’ such as one might find in professional work, he does not restrict it to professions. All occupations have licences, symbolic contracts between workers and the rest of their society that acknowledge the propriety of their jobs and specify the terms of exchange between the production of goods and services for others and the return of material or non-material rewards. Some occupations, however, also have licenses in the narrower legal sense. In general, these are the occupations that we tend to call professions.4 They have established a special place in the market for their services, which has led to a formal grant of recognition, protection of their title, restriction of competition, and so on. Scholars have often analysed this in terms of the ability of specialized workers to unite and mobilize to extract legal privileges, often amounting to a monopoly, from passive legislatures at the expense of less organized and less organizable consumers. This has been characterized elsewhere (see Chapter 6) as a ‘demand theory’ of professionalization. Hughes (1971, p. 287), however, points us to the importance of seeing a licence as the product of interaction between a profession and its environment. At any one time, for example, many more occupations are looking for legal protections than legislatures are willing to grant.5 We also need to think about the ‘supply side’ of licencing. How do occupations persuade legislators to look kindly on their pleas? The answer appears to have something to do with whether there is a compelling interest at stake. The nineteenth century decision to licence UK pharmacists, for instance, after half a century of lobbying, seems to have turned on the development of powerful new poisons and a moral panic about servants using these against their masters and mistresses, among whom, of course, were many legislators. By restricting the supply of these substances to a group of shopkeepers who had earnestly sought respectability, legislators could dine more safely in their homes (see chapter 6)! More seriously,

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perhaps, the development of UK medical licencing at the same time was clearly linked to the development of state involvement in public health and in the supply of health care to the poor. Once the state created public offices for these services, it needed to be able to identify fit and proper people to fill them. The warring suppliers of medical services, who had been promoting rival legislation for sixty or seventy years, were forced to adopt a structure designed by the state to certify the people who were being hired by the proliferating body of central and local government agencies. This shift of focus toward the environment links the study of occupations to recent work in the study of organizations. In a sense, an occupation is merely a special kind of organization. Both fields have a similar history since World War II, with an initial focus on formal definition giving way to approaches that look much more closely at what people are doing and how they do it. Just as a profession is no longer studied as an occupation marked by a particular bundle of traits, an organization is no longer studied as a chart on the wall of the managing director’s office. In the same way as we have argued that we need to understand occupations through an interaction with their environment, which supplies them with certain kinds of resources and recognition, so too have organizations increasingly been viewed through the same lens. The scholars involved have developed some important tools, which may help us to understand what happens to emerging occupations like that of mediation. The study of organizations used to be dominated by attempts to find the most efficient structures of command and control for the achievement of the organization’s goals. This programme, which has its origins in Frederick W. Taylor’s (1911) vision of scientific management, was developed in an era when the future seemed to lie with the giant bureaucracies of the modern state and the Fordist corporation. Although the belief that there can be a rational science of management is not yet dead – and there are powerful interests vested in keeping it alive – the paradigm has been in increasing crisis since the 1960s. As early as the 1930s, the Hawthorne experiments showed that output from production groups was not consistently associated with the way they were organized.6 After World War II, there was a rapid accumulation of studies that pointed to the importance of the informal relationships among workers, even in apparently highly disciplined organizations, to the incoherence of the idea that goals were shared or could even be specified in any rigorous fashion and to the difficulty in changing organizations or transporting models from one plant to another, let alone one country to another (Dingwall and Strong 1985). By the 1960s, some analysts were even questioning whether the idea of organization was very much use at all. However, a new line of work began to develop that focused on the idea that organizations were best understood as groups sharing a common culture and bound together by recurring relationships. Writing

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in 1977, Meyer and Rowan (1977) presented formal structures as smoke and mirrors, essential for the performance of the trick of coordinating a disparate collection of workers around the production of some good or service, but not the heart of the trick itself. They were assembled from ‘building blocks’ of legitimacy, which lie around in modern societies and can be assembled Lego-like in various ways. ‘Creation myths’ are one of those building blocks. Subsequently, however, critics suggested that the randomness of this process had been overdone. The programme of work inspired by DiMaggio and Powell (1983) is particularly relevant. This examines the pressures that lead organizations in the same line of business to adopt similar forms regardless of the consequences for efficiency or effectiveness. It is only in the early stages of a new technology or a new market, they suggest, that we see very much diversity in the forms of delivery. Competition winnows out the participants but, in the process, encourages those who remain to model themselves on the most successful of their peers, regardless of whether the forms or strategies are right for them. By adopting the features of successful organizations, they make themselves legitimate even though the right strategy for an individual organization is not necessarily the right strategy for an entire industry. The pressures towards what DiMaggio and Powell call ‘isomorphism’ are coercive, mimetic, and normative: Coercive isomorphism is represented by pressure from the state and other organizations, and from wider cultural expectations. This would include the applications of environmental quality and health and safety regulations, compliance with ISO standards imposed by customers as a condition of contract, and equal opportunities policies. The common environment of law sets limits to the possible ways of organizing. Mimetic isomorphism is a response to uncertainty: when in doubt, do what everyone else is doing. Once upon a time nobody got fired for buying IBM computers—so IBM computers appeared everywhere, regardless of whether they were the most efficient or economic equipment for the organization’s needs! Normative isomorphism arises from the professionalization of managers and specialized workers. The spread of higher education and credentialing has led to increasing homogeneity among those who form the elite cadres of organizations. These common experiences, together with the networks created by subsequent training, speciality associations, participation in public service bodies, and the like, encourage organizational leaders to think and act in similar ways. Di Maggio and Powell acknowledge the relevance of their thesis to the study of professions but do not pursue this in detail. However, such an extension should not be difficult and will help us to see some of the roots of the predicament that the mediation profession faces.

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Becoming a Profession If we follow the logic of DiMaggio and Powell’s argument, the crisis facing the mediation profession is one of success; it has become sufficiently conspicuous for the pressures towards isomorphism to be felt. Hughes (1971) posed the question of what it took to get a licence, to be recognized as doing something distinctive that merited some form of distinctive treatment. DiMaggio and Powell suggest that the answer may be that the licence is granted because the practitioners succeed in making themselves look like other successful operators in similar markets.7 The irony is that mediators perceive this result as a disappointment. The freewheeling, creative, entrepreneurial individual, operating pretty much as he or she pleased, has given way to the accredited practitioner offering a standard package of interventions to all clients: Liberty and Heaven have been superseded by Ministering Spirits; Freedom has lost the contest with Servility. The mediators’ self-representation resembles that of Satan and his allies in Milton’s poem: fresh, swashbuckling, and gung-ho innovators, entrepreneurs challenging a long-established, static organization – the civil justice system – marked by bureaucratic ordering, strict hierarchy, and a degree of nepotism. This ordered world is the antithesis of the dreams of romantic rebels, visionary artists, and critical realists. Generations of readers and critics have committed what Fish (1967, p. 44) calls the ‘affective fallacy’ of preferring Satan. William Blake (1982, p. 35), for example, asserted: ‘[T]he reason Milton wrote in fetters when he wrote of Angels and God, and at liberty when of Devils and Hell, is because he was a true Poet, and of the Devil’s party without knowing it.’ Satan’s iconic stature amongst critics has tended to override the extent to which order and organization define the practical outcomes of the republican democracy of which Milton and his contemporaries dreamed and for which they fought. Heaven’s squadrons of angels are organized to move on command or stand in flocks. They display a consistent sense of service. They can ‘produce’ or sing as required. The demonic hordes churn around in chaotic disarray. There is much movement, much apparent purposefulness, but the only result is sin: clearly a negative outcome. There is a saying, allegedly an ancient Chinese proverb, that advises us to be careful what we wish for in case our wishes should be granted.8 For entirely understandable reasons, many mediators have long aspired to greater public recognition for their work, to a measure of public investment in their services, and to some encouragement for potential clients to consult them. Earlier writers might have interpreted this as part of a conventional conspiracy against the laity, the charge that George Bernard Shaw (1911) levelled at the medical profession. It is probably time to grow out of this

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cynicism and acknowledge that most mediators sincerely believe in the value of what they are doing, and would like to see it more freely available and taken up by those who are currently unaware of its benefits or unable to afford their services. Moreover, there is nothing particularly wrong with wanting to be reasonably paid for the work that one does. However, public recognition comes at a price. It involves striking a bargain with the key actors in the environment and designing one’s work and organizations, including professional bodies, in ways that will be considered legitimate. In particular, this involves accepting or adopting elements of organization, both structural and cultural, already in use by those groups whose status and privileges one is hoping to copy. If we return to Hughes’s (1971) list of things about which professionalizing occupations get self-conscious, we can reformulate them in a slightly more contemporary way as concerns about protection of title, about ethics and quality of practice, about job boundaries, and about the relative contribution of experiential and formal knowledge. However, people are not sensitive about these on their own account. It is because they know that they have to have a good answer to questions from the people or organizations around them and from those whom they hope to derive support and resources. If you want to restrict the use of your title, then you must have an explicit way of determining who is fit to join and remain a member of your club. However, that process also has to be accepted by people outside as legitimate. You will have a much easier time persuading them if you have membership tests that look like the tests used by other, better-established clubs and if your decision-making processes, whether about admission or about challenges to good standing, match those used by your models. Establishment alone is not enough, of course, particularly for new entrants. Think, for example, of the 2003 controversy over whether Augusta National should be allowed to host a major U.S. golf tournament because it excludes women from membership. Here is a well-established private club doing something that is entirely legal for a private club. However, the members find the legitimacy of their organization challenged by a growing public sentiment that such exclusions are unacceptable. It is noticeable, for example, that the UK attempt to form a private licensing body for mediators has adopted both a traditional title – the College of Family Mediators, which invokes powerful elite symbols in the UK,9 and a radical equal opportunities statement, which is designed to appeal to an alternative constituency. The organization needs to signify both tradition and modernity simultaneously. The history of the College is itself interesting in this context. Until 1997, there were three membership organizations representing different groups of family mediators.10 These organizations had been discussing

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the formation of an umbrella body for several years. However, the matter became more urgent when the government began to implement the Family Law Act of 1996. This process included an initiative on publicly funded divorce mediation to be managed through what was then the Legal Aid Board (LAB), a quasi-autonomous government agency responsible for all legal aid in civil cases.11 The LAB immediately faced the problem of determining who was a proper recipient of public funds. Their first response was to devise a set of certifying tests of their own, which were widely criticized by the practitioner community, but which gave the LAB a basis for claiming that it had quality-assured the mediators in the scheme. This was important for the LAB’s relationship with its sponsoring government department and for its legitimacy in terms of the current fashions in UK public sector management. Part of that thinking is that public agencies should not extend their reach, which militated against the LAB accepting a long-term responsibility for regulating mediation rather than setting and controlling the framework within which self-regulation would be delivered.12 In effect, the College and the Legal Aid Board became locked in mutual dependency. The LAB needed a certifying body to declare that its funds were being spent only on competent and quality-assured family mediators. The College needed the LAB to support its claim to be that certifying body. Over a fairly short period of time, the College remodelled itself to meet the LAB’s requirements, while the LAB acknowledged that its funding would be confined to College-certified mediators. This process shows all three forms of isomorphism: coercive, in the pressure from the LAB to fit a state-approved model of professional organization; mimetic, in the copying of features from established professions and the adoption of the competence-based model of assessment that was fashionable at the time; and normative, in the extent to which the College drew on the basic training in psycho-social work common to many of its leaders to develop its own licensing criteria, which then shaped the training programs that it recognized. Over a period of approximately thirty years, family mediation in the UK has gone from being the avocation of a handful of enthusiasts, searching for a new way to help families at a time of trouble, to being an organized occupation, with increasingly restricted entry and standardization of practice.13 In the beginning, more or less anybody could be a practitioner and do pretty much as they pleased. Today, any practitioner wishing to receive public funds has to be certified and committed to practising in accord with the broad consensus of their peers, as agreed with the supplier of those funds. This is not a licence in the strict sense and there is no restriction of title or practice, but the certified mediator has been handed an advantage in the marketplace, in exchange for the restrictions

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associated with that certification. This is not to say that there have not been considerable tensions in imposing that closure and that the family mediators have not consistently tried to assert more autonomy than the LAB has been willing to allow (Davis 2001, p. 378). Part of the coercive isomorphism was the demand for an evaluation of the pilot programme by an independent research team (Davis et al. 2000; Davis et al, 2001a; Bevan et al. 2001; Davis et al. 2001b; Dingwall and Greatbatch 2001) but the team’s access to data was constantly frustrated by the mediators’ refusal to part with information for reasons of client privacy. The notion of a private professional/client relationship conflicted with a competing model of a publicly funded and publicly accountable service that needed to demonstrate its cost-effectiveness. Liberty and Heaven versus Ministering Spirits; Freedom versus Servility. Reconstructing the Past The model of the private professional whose license to practice is apparently unconfined by governments, courts, or even clients is a pervasive one (Kaufmann and McAdoo 2003). Most professions invoke it in support of their resistance to the perceived encroachments of recent years. Aspirant professions still take it as their cultural model: real professionals are concerned only with doing their best for individual clients, even when their clients do not know what is best for them. In this sense, it becomes part of the aspirants’ mimesis—to be real professionals, they need the same kind of autonomy. As we all know, this is a claim that has attracted responses ranging from scepticism to derision among politicians, activists, and commentators. It is also a claim whose evidential base is quite thin. The affluent and autonomous private practitioner has almost certainly never been the majority experience of professional work and was probably only found on a large scale for a relatively short period from the 1930s to the 1950s. Our images of medicine and law, which tend to be the archetypes here, are strongly coloured by the self-serving accounts of elite practitioners, who formed the leadership and interacted with other civic elites. Historical work is now drawing a very different picture of the often marginal economic existence of rank and file practitioners and their impatience with the etiquette imposed on them by the elite, pursuing their own agenda of gentrification (Stevens 1966; Starr 1982). In Britain, at least, from the late nineteenth century until the 1930s many doctors began their careers as employees of friendly societies, a form of working class mutual insurer (Hodgkinson 1967; Green 1985). The accounts of low pay and the humiliation of deferring to social inferiors left deep scars on the profession’s self-esteem. It became an important element in the acceptability of a National Health Service that treated doctors as

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independent contractors answerable only to their peers. The continuing objections of a London-based elite were overridden because doctors and hospitals in the rest of the country were essentially bankrupt by 1948, and the change promised them new investments and financial security (Eckstein 1958; Webster 1988). In the same way, for every millionaire corporate or tort lawyer in the U.S. today, there is a salaried public defender or an inner-city storefront lawyer dealing with the petty business of an ethnic clientele. The vulnerability of both the latter groups to organizational or client pressures is well-documented, but their story often goes untold (Carlin 1962; Feeley 1979). Why does this happen? One argument might be that the myth of a Time Before the Fall from Grace has become one of those building blocks of legitimacy upon which professions draw. It is a powerful resource in contests with the strong forces in contemporary societies that are pressing for tighter regulation, more detailed quality assurance, more aggressive policing of practice standards, and so on. In the end, it may well be a losing contest. One of the historic themes of sociology is the inevitable triumph of the mundane. The great German sociologist, Max Weber (1964), wrote almost a century ago about the routinization of charisma. This came out of his extensive studies of the great religions of the world. He noted how most of them had been founded by a powerful individual, who had assembled a small group of devoted followers around his distinctive and innovative vision. The successful religions, however, were those that had proceeded to create institutions for the perpetuation of that vision. In the process, though, the vision was diluted by the everyday politics of the institution. The Catholic Church, for example, lost sight of Christ’s message in its internal struggles for power and influence, which, in turn, led to the Reformation that produced competing versions of the message itself. Although some of those competitors might have sufficient charisma to attract followers and create rival churches, those churches ultimately fell victim to the same processes.14 Weber’s contemporary, Robert Michels (1949), develops a related argument in regard to political parties and their ‘iron law of oligarchy.’ ‘Democratic political organization’ is, in this account, an oxymoron; whatever the ideology or moving spirit, all political associations are required to adopt oligarchical forms if they are to survive and compete effectively for power. Weber summarized this as a general tendency towards the ‘dis-enchantment of the modern world,’ where men and women would become imprisoned by the ‘iron cage’ of the rationalist social order. Ultimately, the human spirit would succumb to the spread of calculative rationality, which he saw permeating institutions as diverse as law, music, and art. Our Feasts and Songs would be scripted for us, with no space for our own voices or our own discords.

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This stands in contrast to Milton’s understanding of the necessity of order and organization. Only the post-Romantic readings of Milton view Satan’s wild excesses as a desirable rebellion of the individual against the oligarchic ‘tyranny’ of heaven. Milton, himself, would almost certainly have seen these readings as evidence of sin and of the unwillingness of their authors to accept the responsibilities of community. Nevertheless, the Paradise myth of an age of free professional work may be an important countervailing force to the pathologies explored by Weber, if it is told to inspire members, novices, and other actors in the profession’s environment about the heroic alternative, a world where people get high quality and affordable services because of the devotion, creativity, and altruism of the individual professional. The migration of these myths from one occupation to another seems to be a dimension of normative isomorphism, part of what a certain class of educated labour shares as its understanding of the sort of history that a profession should be able to tell. In the process, however, the result may be to make the current generations profoundly dissatisfied. If we once lived on speaking terms with angels, how low have we now been brought? This mythified past may both challenge the process of rationalization and obstruct any creative response to it. What Hope for Mediation? As a British scholar once remarked, sociology has a deserved reputation for being a thoroughly glum discipline (Strong 1997). Max Weber’s vision is unexceptional in its depiction of modernity as a fallen world. In fact, it is arguable that this gloominess is, in itself, something of a creation myth for sociology—that the world needs a new faith for these dark times that is capable of invoking either a Golden Age of pre-modernity or the Bright Light that is yet to come. A good deal of revered sociological writing is mired in hopelessly romantic visions of an Eden before capitalism or of a post-capitalist Utopia (Strong and Dingwall 1989). It is important to remember that the past was not wonderful, and that one thing we can say with total confidence about the future is that we can say nothing with total confidence about the future. Mediation is undeniably experiencing a range of new challenges and isomorphic pressures towards the clearer specification of its license. These are leading to a heightened concern for the basis of education, training, and quality assurance. Practice is becoming more homogenized. Mediators are asked to work in ways that make them more accountable, both to those who pay for their services and to those who use them. No doubt this feels like an iron cage. At the same time, it is important to recognize that the old days were not necessarily that good. During Dingwall’s first visit to observe U.S. mediation directly—a visit to the southwest in 1984—he

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watched a nationally-recognized group of practitioners charge a group of aspirant practitioners substantial fees for a week-long training only to tell them on Friday afternoon that the regional market was hopelessly overcrowded and that the prospects of them earning back the costs of the course were pretty small. There are still many comments to the effect that the people who make the best living from mediation are the trainers because the demand for mediation lags so far behind the supply of practitioners. However, there does now seem to be a situation where most citizens could access mediation if they wanted to, where most of those mediators have some recognizable measure of training that is based on some kind of evidence and where their practice has some measure of accountability for its professional and ethical standards. Some people even make a decent living from the work – not just the high-end arbitrators dealing with big corporate disputes. There can be little doubt that the world of mediation is in better shape than it was thirty years ago or that its clients have a less hit or miss experience. However, professional mythmaking paints this glass as half empty rather than half full. By insisting that the past was better in all ways than the present, it results in a more or less endemic state of frustration and unhappiness for mediators. Two particular complaints by mediators require a more critical appraisal. The first is the complaint about the demands associated with extending regulation and public funding. The profession needs to be more honest with itself about the inevitability of these. If the profession wants legislatures, public agencies, and the like to supply it with recognition and resources, those agencies will want something in return (Davis 2001, p. 378). This will include evidence on practice standards, proper treatment of clients, fiscal integrity, and so on. The claim, ‘I am a professional, therefore I can be trusted,’ no longer carries much weight. The second is the complaint about the lack of space for creativity. In the past, the result has been not only the opportunity to deliver high-quality and innovative practice but also the opportunity to deliver downright bad practice that is exploitative and oppressive of parties. If what is happening now is consistent mediocrity, then it is probably still true that as many clients are better off as are worse off. What has changed is the circumstances under which innovation is possible. Nothing stops this in a recognized profession. Indeed it remains an important driver of market advantage. However, the market generally requires some legitimate verification of the claimed advantages – simple assertion is rarely treated as convincing evidence. Innovation remains important: it simply requires proper specification and evaluation. A greater danger would be pressures towards mediation by rule or by script. This is not entirely implausible but faces important constraints in the contingency of the mediation encounter, which ensures that a key

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skill for mediators is always likely to be an ability to improvise, even if this is hard to teach or to measure. Paradise and the Loss of Innocence If a creation myth has any practical value, it may be as a steadying counterpoint to the challenges of change and development. A critique of ‘heavenly’ pasts may, however, provide a better context for the present. The idea of a golden age in Milton’s writing is clearly problematic: just like any boss, God often appears in the text to be out of date and somewhat out of touch. The institutional questions of order, form, and freedom are central to this analysis: was the Fall really a Fall, or was it an appropriate reaction against an oppressive, autocratic, and nepotistic ruler? How seriously should we take Satan’s statement, that his legions should celebrate their Fallenness and its accompanying agony, because it is better than being fawned upon and forced to obey a dictator: Shall we then live thus vile, the race of Heav’n Thus trampl’d, thus expell’d to suffer here Chains and these Torments? better these than worse By my advice; since fate inevitable Subdues us, and Omnipotent Decree, The Victor’s will. Paradise Lost Bk. II, Vs. 194–99

Milton’s Puritan readers would have judged his argument very differently from the modern, romantic response evoked by his portrayal of heaven. In the Heavenly bureaucracy, symphony is everything and individuality is denied: Like Quivers hung, and with Preamble sweet Of charming symphony they introduce Thir sacred Song, and waken raptures high; No voice exempt, no voice but well could join Melodious part, such concord is in Heav’n. Paradise Lost Bk. III, vs. 367–71

The angelic bureaucrats know their parts so well, that when God asks them a question about the possibility of human salvation, following the (inevitable) future disobedience, there is no reply: Dwells in all Heaven charity so dear? He ask’d, but all the Heav’nly Choir stood mute,

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In our day, we find heaven unsympathetic because we have difficulty understanding the virtues of obedience. In Milton’s text, obedience to God’s glory means that heaven and earth are not open to interpretation, that text is plain and clear, that creation can ring with heavenly spheres moving in tandem, and that the pages of the sacred work can sing to heavenly choirs. Satan’s revisionism is his call to disobedience. Themes such as disobedience, sinfulness, and human fallibility may seem far removed from the institutional environment of mediation practice. However, the relationship between a creation myth and the realities of contemporary life for professionals stems from the same struggle to avoid the loss of autonomy involved in being held formally accountable to someone ‘above.’ Arguably, however, the unattractiveness of Milton’s heavenly bureaucracy is exactly the point. Paradise Lost is less an exploration of divinity than an exploration of the sources of order in creation. To make creation work well, God needs to be significantly more than an averagely likeable boss. All organizations need the same balance between the working environment of their employees and the provision of efficient, effective, equitable, and humane services to their users or clients (Strong and Dingwall 1989; Dingwall 1992). These interests do not necessarily coincide. Romantic fictions of personal fulfilment, development, and growth may compete with the economic or isomorphic viability of an organization. As a paid-up Puritan, deeply invested in the superior qualities of his version of ‘heaven,’ this is a particular irony in Milton’s text. One of the central difficulties of Puritanism as an ideology was its unattractiveness to the general public; this consequence was almost inescapable given the Puritan view that almost all human desires were grounded in sin. The Puritans turned this unpopularity into a performance indicator; it became a measure of their success in identifying and confronting the sinful desires of the multitude. Milton reflects this. Satan’s populist rhetoric may be attractive to readers but that does not mean that it is wise or that the readers are right to endorse it. As a revolutionary, Milton understood the dilemma particularly well. Rebellion had to be based on more than a will to anarchy, disobedience, and selfish self-realization. A just revolt was a charismatic renewal of an order that had grown corrupt. Potentially, Satan’s most effective argument against God turns on the nepotism of promoting his Son over the heads of a host of loyal servants. However, Satan never couches this in the language of equal opportunities so much as of personal pique. His challenge is based on self-interest rather than an attempt to hold God

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accountable to some set of constitutional values, much as the Puritans had done to the English monarchy. The Puritan vision of the confrontation between Satan and God, between individual interest and collective order, converges with the confrontation between professions and bureaucracies in contemporary societies. The latter is just as vulnerable to misunderstanding. Bureaucracy is viewed as pathological in the light of the romantic creation myths of the professions. It epitomizes the Weberian vision of the ‘iron cage’ of capitalism, occupied only by those who have lost their souls.16 As Talcott Parsons pointed out, however, this is essentially a false opposition: the same society that gave rise to bureaucracy also gave rise to the professions. Both institutional forms share the same Janus-faced character. Publicly they assert that they offer impartial, objective, and freely-available ways of delivering collective goods or services; privately, they promise users, customers, or clients, goods or services that are personal, individualized, and oriented to satisfying particular rather than general needs or interests (Murray, Dingwall and Eekelaar 1983). Paradoxically, each now tends to be seen as the answer to the other’s failure to resolve the contradictions. Parsons argued for the professionalization of business management, where contemporary commentators argue for the bureaucratization of the professions (Power 1997). For Parsons, the professionalization of management would reinforce the service ethic that he saw in professions but not in corporate bureaucracies (Parsons 1939). One might argue that the argument for the bureaucratization of professions arises from a perceived failure of the service ethic in the face of producer self-interest. The real problem, however, may be an inadequate understanding of the service ethic itself, a problem to which Parsons unwittingly contributed and to which our reflections on Milton may offer some path to resolution. In his translation of The Protestant Ethic, Parsons inserted imagery from his own Puritan background; the ‘iron cage’ echoes a passage in John Bunyan’s Pilgrim’s Progress, which emphasizes the idea of doom and despair. Peter Baehr (2001) has recently argued that the original, stahlhartes Gehaüse, would be better translated as a ‘shell as hard as steel.’ This evokes a quite different imagery, linked to Nietzsche’s Last Man, ‘a hedonist motivated by the quest for materialistic consumption and confident of his superiority’ (Baehr 2001, p. 160). Milton’s Heaven offers an alternative understanding, of ‘service as perfect freedom,’ to adapt the words of the Book of Common Prayer.19 Can people be drawn out of their steel-like shells by an ethic of community, an opportunity to serve others in an organized and coherent way? For Weber, bureaucracy was always a means not an end. It might succumb to a pathological obsession with its own internal processes, but its creation and ultimate justification was the delivery of a service characterized by

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‘straightforward duty without regard to personal considerations. Everyone is subject to formal equality of treatment; that is everyone in the same empirical situation’ (Weber 1964, p. 340). To be sure, this can be a somewhat bloodless and impersonal service encounter (Strong 1979, pp. 204–19). However, it may well be preferable to the alternatives. Productive modes of service are more likely to occur in a context of productive co-operation and useful agreement, where individuals are prepared to sacrifice their own desires and needs into the larger demands of the whole. Participation in an effectively running bureaucracy can be one such environment. Service means generous integration into the community of individuals with specialist skills rather than coercive isomorphism. Milton’s Hell is a vision of individualism and life without community. Satan’s achievement is to detach Adam and Eve from the community of Eden; his defeat is their mission to rebuild that community anew: Lament not Eve, but patiently resign What justly thou hast lost; nor set thy heart, Thus over fond, on that which is not thine; Thy going is not lonely, with thee goes Thy Husband, him to follow thou art bound; Where he abides, think there thy native soil. Paradise Lost Bk. XI, vs. 287–92

The contemporary challenge for mediators is to learn how to live in an imperfect world, to avoid mistaking surface institutional forms for the substance of their professional ethic, and to understand that successful practice carries obligations to communities as well as to individuals. If their creation myth does not support this, then it may be time to draft a new one.

Chapter 10

In Memory of Eliot Freidson: Is ‘professional dominance’ an obsolete concept? When I was asked to contribute to a special issue of the journal in which this chapter first appeared, I was in the process of negotiating a suitable memorial essay for Eliot in Sociology of Health & Illness. While discussing possible themes and authors with various colleagues, however, I was struck by a comment from a prominent contemporary medical sociologist, who questioned the appropriateness of commemorating Eliot at all. The only thing for which he was really known, my interlocutor observed, was ‘professional dominance’ and that was now merely a historical curiosity. The rise of managed care, whatever form it took in different countries, had overtaken Freidson’s critique of professional autonomy. As Bosk (2006) points out, this is a partial judgement: one of Freidson’s great strengths as a scholar was his readiness to reappraise his own work. He knew that the institutional system criticized in Profession of Medicine (Freidson 1970a) and Professional Dominance (Freidson 1970b) had, in significant respects, passed into history, to be replaced by a managerial system, whose pathologies he came to assess as far more pernicious in Professional Powers (Freidson 1986) and Third Logic (Freidson 2001). The medical profession of the 1960s might have been paternalist and unaccountable but it was preferable to the soulless and impersonal care doled out by corporatized medicine. Nevertheless, Freidson continued to hold to the proposition that expert knowledge remained a source of power and authority capable of tempering the calculative rationality of managed care. The alliance of doctors and patients that he yearned for in the conclusion to Profession of Medicine might still protect us all from the Gradgrinds’ grudging concern. The Professional Dominance Thesis Bosk observes that the great achievement of Profession of Medicine is its assimilation of medicine to the new sociology of deviance that developed in the 1960s. Although Parsons (1951) had been the first to argue that

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illness should be analysed as unmotivated deviance, in comparison to crime or sin as motivated deviance, his insight had been stripped of its radical edge by the conservative empiricism of 1950s social science. Freidson restored this edge by incorporating ideas from labelling theory and insisting on their relevance to physical illness as much as to the psychiatric conditions discussed by 1960s writers like Scheff (1967). A particular feature of labelling approaches was their insistence on giving equal attention to agents and definers. Criminals were constructed by their interactions with the defining institutions of the justice system and their personnel. In the same way, disease was defined in encounters between people experiencing some disturbance of, or damage to, the structure and functioning of their bodies, and those institutions and personnel socially licensed to label them. Professional Dominance was Freidson’s sketch of a general statement about those defining organizations and their staff. It opens by noting the tendency of medical sociologists to be preoccupied with the individual experience of sickness, and its social distribution, and to neglect the institutional structure of health care. This remains an important criticism of medical sociology: it is notable how many organizational studies of health care delivery are now carried out by the sociology of the professions or, indeed, by management researchers from business schools. After a brief diversion in the 1970s, under the influence of Freidson, among others, medical sociology has returned to the topic of social class and health, now under the euphemism of ‘health variations’, and to individuals and their experienced worlds, through the postmodern sociology of the body. As Freidson notes, however, Parsons’s understanding of the sick role, as conditionally legitimated deviance, obliges us to investigate the conditions of legitimation, the activities of the legitimating agents and the cultural and material environments in which they operate. Freidson (1975) had already shown, in Doctoring Together, that professional behaviour in practice settings could not be understood in the narrow terms of 1950s socialization studies, whether Mertonian (Merton et al. 1957) or interactionist (Becker et al. 1961). Medical school was not a place where students learned how to practice medicine: that learning occurred in situ, in the course of everyday work under the, visible or invisible gaze, of colleagues, peers and subordinates, as well, of course, as patients. Physicians would not become better practitioners or more humane beings through educational reform, but only by changes in the contexts of their employment. As Freidson (1970b, p. 19) put it, the role of the professional is a dependent variable, contingent on the institutional environment within which it is exercised. Writing in the late 1960s, he stressed the ‘corner-shop’ nature of the medical role, at least as it operated in the USA. Physicians were typically one-man – the gendered term is not accidental – businesses rather than

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corporate employees. However, their primary worksites, were hospitals with a complex division of labour involving a wide range of technical, skilled, semi-skilled and unskilled occupations. The practice setting could not be analysed solely in terms of an account of the physicians’ relationships with each other. Those other occupations contributed to defining the parameters of professional practice. Some of them had professional aspirations of their own. These were, however, incompatible with a structure dominated by the profession of medicine. Freidson’s comments on nursing are typical: …by pushing them towards a professional orientation, [nursing] schools do not prepare [students] for subsequent subordination in the hospital, and so their lessons are understandably compromised in the face of reality. Perhaps the net effect of professionally oriented schools is to make the nurse more sensitive to her status, at once intensifying the normal inclination to pass on to lesser occupations one’s ‘dirty work’ and to require tactful treatment by superiors (Freidson 1970b, p. 21).

The professionalism of nurses, and other subordinate groups of skilled technical workers, was better understood as a device for motivating and controlling work that was inherently difficult to subject to immediate supervisory oversight. The requirements of 24/7 care, for example, create a problem of ensuring that nurses continue to provide a service at an adequate standard, even when supervisors are not present. This has been compounded by the abandonment of the open Nightingale-style wards and the introduction of physical barriers that make most nursing work with patients invisible. Encouraging nurses to think of themselves as professionals introduces an element of self-policing into their practice, with their conscience or ethics as a check on the temptations to cut corners at the expense of patient care. The aspirations and sensitivities of nurses exemplified the challenges that the hospital environment might present for physicians. These were explored in a body of work that had originally transferred the ‘human relations’ approach from industrial sociology into the study of the hospital, to conclude that the production of outputs – recovered patients – could best be facilitated by clear job descriptions, well-defined lines of communication and straightforward lines of authority. This simplistic optimism had, however, now given way to an understanding of hospitals as sites of conflict, in the performance of tasks, in the specification of goals and in the mobilization of resources, whether internal or external. In particular, Freidson notes the tension between expert and administrative authority. Again, he acknowledges a debt to Parsons, to the latter’s critique, in the volume’s introduction, of Weber’s (1964) analysis of rational-legal bureaucracy. Could an organizational form be simultaneously rational and legal, Parsons asked, when the rationality principle prioritized deference

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to expertise and the legal principle, deference to hierarchical authority? Hospitals tried to resolve this tension by separating administrative and professional decisions, with the former made by a managerial staff operating as a classic Weberian monocratic bureaucracy and the latter by physicians operating in a more collegial fashion, where status was determined by expertise rather than by office. Although Weber regarded collegial organization as a somewhat degenerate form, Freidson argued that it survived in environments like hospitals and universities, in an uneasy co-existence with powerful administrations. The result was a difficult working environment for many of the subordinate groups in the division of labour, because they were exposed to the conflict between medical and managerial orders without the buffering that had developed around the physicians and their acknowledged areas of expertise. The solution to this was, in some measure, the active promotion of a shared sense of hospital community, what we might now call an organizational culture, where subordinate staff and, to a degree, managers, came to share the professional values of patient care as a central feature of their own institutional identity. Medicine, then, occupied a position of cultural as well as structural privilege in its worksites. Freidson explores a number of dimensions of this privilege and its consequences, without ever quite explaining the sources from which it is derived. He notes the physicians’ weak accountability, whether to the state or to each other or, indeed, to patients. The social control of the medical profession is relatively ineffectual. In contrast to Weber’s analysis of authority, based on office, or Hughes’s (1984) analysis of science, where authority is based on transparency, the physician’s authority is based mainly on persuasion and deference. If the patient chooses not to take the physician’s advice, the physician can rarely compel compliance, and then only by invoking legal resources subject to external review. The professional is consulted and advises: s/he does not compel patients to present themselves and to follow instructions. The social status of the physician may contribute to this process, as one who is seen to be educated, affluent and materially successful relative to most patients, one who has succeeded in terms of the society and, therefore, merits deference. The consequences of this can be seen in the ecological niche that is occupied by physicians within the health care system. The organized autonomy and independence of the profession gives rise to the professionally dominated division of labour. Licensure creates monopolies on the performance of certain tasks, the right to prescribe many drugs and to make most kinds of incisions in the body, for example. It also establishes a monopoly in the legitimation of expertise, of what counts as valid and relevant knowledge to sustain the practice of healing. Only those who share the licence can authoritatively criticise an individual professional’s

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decisions about what knowledge is to be considered to be canonical, and the ways in which it may be used in specific cases. Finally, admission to the licence also has a normative dimension, which may be embodied in a code of ethics but which is certainly not defined by that. The licence is an admission ticket to an occupational community, of shared values as much as of shared expertise. The organization of this autonomy leads to the physicians’ dominance in the division of labour: ‘the authority to direct and evaluate the work of others without in turn being subject to formal direction and evaluation by them (Freidson 1970b, p. 136)’. The dominant profession judges others without itself being judged. The result, according to Freidson, is an environment where both patients and co-workers feel increasingly alienated. The asymmetry of knowledge and the uncertainties of diagnosis and prognosis make it difficult for physicians to share their expert knowledge with patients. Co-workers may share elements of the knowledge but lack the understanding of the whole that would allow them to make sense of their place and to respond appropriately to patients’ undifferentiated understanding of the nuances of who legitimately knows what, and is authorized to speak about it. The imperfections of the profession are not imperfections of individual humans, to be corrected by education or training, but of the structures in which their work is embedded. Freidson concludes both Professional Dominance and Profession of Medicine with proposals for reforms of the US health care system that would keep it true to the professed, humane, values of the physicians through significant reductions in their professional autonomy and structural dominance. …professional dominance and autonomy could be tempered by administrative accountability , by accountability to the individual patient himself, and by the deliberate encouragement of workers who can compete with the medical practitioner (Freidson 1970b, p. 234).

However, Profession of Medicine continues on a more pessimistic note that questions the professional enterprise itself. There is a real danger of a new tyranny which sincerely expresses itself in the language of humanitarianism and which imposes its values on others for their own good. Insofar as my analysis has been successful in delineating the question of what is expertise and what concealed class morality, and what is actual performance rather than unrealisable ethical intent, I hope it can clarify the problem of determining how far professions may be given the authority to determine their own work (Freidson 1970a, pp. 381–2).

While Freidson does not share the nihilistic view of the medical profession, that characterized much of the commentary that appeared in the late 1960s

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and 1970s, epitomized by the celebratory treatment of Illich’s (1975) Medical Nemesis, he was nevertheless a considerable sceptic about the profession’s use of its authority and the interests that this served. Professional Dominance: The Last Thirty Years Professional dominance was, then, originally primarily a proposition about the division of labour in health care, not about the status and prestige of physicians in the wider society, although these two elements are not wholly unrelated. In the years since the publication of Professional Dominance and Profession of Medicine, the situation of the medical profession has changed considerably. Indeed, Freidson (2001, pp. 182–5) himself acknowledged, in Third Logic, that he had been writing towards the end of what many would think of as a Golden Age of American medicine. Like other commentators, he identified the changing organizational and market context of the physician’s work and the degree to which this had impinged on the profession’s dominance of the division of labour. We can summarize this in relation to the headings, he set out at the end of Professional Dominance. Administrative accountability At the beginning of the 1970s, the American medical profession was still dominated by solo practice or by loosely coupled groups of practitioners, who might share premises and back-office facilities, and refer patients preferentially to each other, but who were subjected to little managerial oversight. The same would have been broadly true in the UK: the introduction of the National Health Service in 1948 had merely nationalized existing organizational arrangements rather than brought the physicians into a civil service bureaucracy. Hospitals were administered rather than managed, with doctors retaining the dominance that they had enjoyed since the late 19th century. By the end of the 20th century, when Third Logic was being written, the medical profession in both countries had become largely subjected to managerial control. The two countries had travelled down rather different routes to get there, with the US using the private regulatory efforts of insurers and the reimbursement requirements for Medicare to impose managed care on a reluctant profession while the UK began with conventional bureaucratic approaches and then moved to introduce state-managed markets as a means of subordinating clinical to financial expertise. In Weberian terms, both countries prioritized legal over rational principles of organization, and elevated the power of managers, as bearers of the former expertise, over that of clinicians, as bearers of the latter. Although more traditional forms of health care organization survived in

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other developed countries, notably in Mainland Europe, the freebooting days of unconstrained practice and fiscal irresponsibility were drawing to a close almost everywhere. The new managers sought to introduce Fordism to health care, ironically in an era when it was going out of fashion in industrial settings. The managerialist project required practice by algorithm, with a minimal and standardized set of diagnostic tests leading to an unequivocal diagnosis and a specification of treatment. Each step along way could be broken down and costed, much as FW Taylor (1911) had advocated at the beginning of the century, with the costs being manipulated to create appropriate incentives for the workers involved in the process. However, this was not a uniquely managerialist project. The creation of a Fordist programme could only take place through the co-option of a significant element of the medical profession, in the movement for evidence-based medicine (EBM). The EBM programme has encountered significant difficulties from two directions. The first was the material base of human biology. Standardized medicine requires standardized humans, and we are not a species that reproduces by cloning into uniform uterine and post-uterine environments. The result is that EBM only works well at the population level. When applied to individual cases, there is an inevitable gap between the evidence-based and fiscally sanctioned treatment and the unique physiology and anatomy of the unique patient. Human beings are not Model T Fords and become rather resentful when offered a standard package, regardless of whether or not it fits their circumstances. Indeed, the major car manufacturers have long-recognized this, in adapting their lines to allow for customization. A better example, though, may be Dell Computers, which has flourished on the basis of its flexibility in assembling uniquely-tailored products, according to each individual customer’s requirements. Effective health care in the 21st century is likely to look more like a Dell computer than an old-style Ford. The construction of health care, however, is still likely to require an expert and trusted intermediary, since the process of specification is somewhat more complex than the online or telephone transaction with a computer manufacturer’s call centre. The second difficulty, then, has been patient resistance. Where patients have a choice, there is ample evidence of their readiness to desert managerialist medicine for unlicensed healers. Where they do not, both the US and the UK have seen energetic popular campaigns against Fordist health care. While these have not added up to significant national movements, they have served notice on the managerialist project that its legitimacy cannot be taken for granted: it may have persuaded governments but it has not won the hearts of voters. The forms of resistance have been somewhat different in the two countries, with the US depending

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more on litigation strategies, like those that have overturned many of the exclusionary rules of managed care packages, and the UK seeing electoral campaigns, including the Labour government’s loss of a secure Parliamentary seat to an independent candidate campaigning against the closure of a much-loved local hospital. Nevertheless, both are indicative of the uncertain legitimacy of the project. Given the choice, patients trust doctors much more than they trust managers. Patients are far more likely to believe that their physician is on their side, while managers are seen as agents of cost-cutting states or profit-maximizing corporations. While the former belief may well be mistaken, it is held with sufficient strength to be consistent with WI Thomas’s famous maxim about the consequences of belief for action. Accountability to the patient When the professional dominance thesis was being developed, medical practice was still marked by a belief in the virtues of paternalism. The asymmetry in information, knowledge and understanding between doctors and patients was felt to justify an approach to decision-making that assumed patients were unwilling or unable to cope with difficult decisions or seriously bad news. It was still quite common in the early 1970s, for example, for patients diagnosed with terminal cancer to die in ignorance of their diagnosis. Many feminist writers of that time were strongly critical of the exclusion of women from any meaningful role in making decisions about reproductive care. Conceptually, at least, much has changed, although this has not necessarily led to quite the results that were expected. Some patients with terminal diagnoses, for example, seem to prefer not to hear the news that newly-enlightened physicians seek to press upon them, and the result of more obstetric choice for women seems to have been an upsurge in Caesarean sections rather than an extension of ‘natural’ childbirth. Nevertheless, it would now be hard to find a doctor in the Anglophone world who did not at least pay lip-service to the notion that patients had some basic right to share information about diagnosis, prognosis and choice of therapy and to join the process of decisionmaking. Whether this always translates into practice is another matter, but the official stance of the profession in these countries has changed greatly. A more contentious dimension of patient accountability has been the rise of negligence litigation in the Anglophone world. This has often been represented as a threat to professional dominance, but its real significance is less clear-cut. It has been firmly established by law and society researchers that the US does not have either a litigation crisis or a compensation culture. What it does have is a well-organized manufacturing lobby that

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has been very successful in creating the perception of a problem, as means of restricting its liabilities. Although there has not been as much empirical work in the UK, a similar picture is emerging there. All health care systems inevitably generate a certain error rate, but the US and the UK have social security systems that are inadequate for dealing with the consequences. If the US has a high rate of negligence litigation, this is in part because the legal system functions as a privatized means of social security in a country that has deliberately chosen not to make the kind of public provision that is common on the European mainland. As a private system, it has all the defects associated with privatized welfare – high transaction costs, unpredictable and irrational coverage and perverse incentives for both practitioners and victims. The rising, but still trivial, cost of litigation in the UK reflects the consistent and continuing decline of public social security provision under neo-liberal governments since the late 1970s. Negligence litigation does not actually contribute much to the erosion of professional authority because decisions still rest heavily on the contributions of expert witnesses drawn from the profession itself. Although the judiciary has been taking a larger role in vetting experts, an array of other members of the same profession declaring that the practice of one of their peers is unacceptable hardly seems a convincing demonstration of a loss of collective authority, although it may embarrass the physician on the receiving end. Where there may be more to the argument is in relation to the increasing encroachment of law in advance of treatment decisions – abortion, assisted conception, transplants, end of life issues and so on. This may well be more indicative of a diminution in professional dominance. However, we must again be careful how we interpret this phenomenon. In many ways it is more suggestive of a wider shift in modes of governmentality that happens to impinge on physicians in this particular way. The decline of the social democratic state, even in the limited form that it developed in the US, has been accompanied by a shift from the authority of enlightened expertise to a more open contest of views, mediated by law. It is not, however, clear that this necessarily makes a great difference to the outcome or to the status of the groups involved. The rise of competitors In his 1970s writing, Freidson placed some hope in the partial dilution of medical monopoly by the deliberate encouragement of other occupational groups to enter the field and compete in at least some areas of health care, offering alternative and more accountable forms of practice. This has certainly been evident over the last thirty years, as nurse practitioners, midwives and pharmacists have acquired wider licences to diagnose

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and treat a range of minor or straightforward conditions and, in some cases, to modify or question physician interventions that seem to be inappropriate, ineffective or damaging. While a nurse practitioner may not formally diagnose diabetes, for example, s/he may be licensed to vary an insulin routine that is not producing stable results. What Freidson did not anticipate at that time, was the explosion in complementary and alternative medicine, coupled with demands for official recognition and exclusionary regulation of quite a traditional kind. As he notes in Third Logic though (Freidson 2001, pp. 185–6), this has been less a desertion of physicians than an increase in the consumption of healing and associated products from both ‘official’ and ‘unofficial’ sources. Physicians, however, tend to remain important gatekeepers to the most effective, critical and desired technologies. This is quite marked in relation to new pharmaceutical products. One of the long-standing observations of medical sociologists is the relative conservatism of the medical profession in the face of innovations, including new drugs. It is forty years since Coleman and colleagues (1966) showed how innovation diffused in medicine through the advocacy of a handful of early adopters who became cheerleaders for the ideas or products among their peers, although often with limited impact. The pharmaceutical industry has struggled to find ways through this cultural barrier. While bribery, whether direct or indirect, was fashionable for a while, the reputational costs became counter-productive for both parties and marketing by pharmaceutical companies to physicians has become quite heavily regulated in most developed countries. What we are now seeing is a new strategy of consumer mobilization, where marketing is directed to consumers, who are then encouraged to demand products from physicians. Where direct to consumer advertising is banned in the UK and Europe, unlike the US, we have simply witnessed the emergence of a strategy of corrupting patient organizations to support pharmaceutical sales by pressing physicians and national regulators to ensure access to new products of marginal benefit or for newly-defined problems. The Neo-Liberal State While Third Logic is somewhat sceptical of the claims made by many observers of the changing world of health care, that specific empirical changes of the kind outlined above have cumulatively abolished the dominance that physicians had established at the end of the 1970s, it does concede an important environmental change that has had a more dramatic impact. In effect, Third Logic fills the gap left by the sketchy treatment of the state in both Professional Dominance and Profession of Medicine. By doing so, the meaning of professional dominance shifts, away from the occupancy of a particular niche at the apex of the division

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of labour in hospital to a much broader exploration of the status and authority of professions in contemporary societies. The Golden Age of medicine coincided with the high-water mark of the welfare state, riding on a tide that was about to turn. Both books were published almost as the economic shock of the 1970s oil crisis disrupted the post-World War II accommodation between capital and labour and propelled neo-liberal politicians and ideologists into positions of power and influence. Third Logic marks an important break with Freidson’s early identification with what I have elsewhere called ‘demand’ theories of professionalization, exemplified by the work of Larson (1977) to which he had contributed a glowing cover endorsement: ‘This is the most important book on the professions to be published in years … an authoritative analysis ... an essential scholarly resource’. Demand theories present professionalization as a process of capture, through which well-organized occupational groups persuade states to establish legally-protected market shelters. More recent ‘supply’ theories have concentrated on the factors that lead states to select occupational groups for protective treatment and to see professionalization as at least as much a state project as an occupational one. Although Freidson had previously given considerable attention to the formation of market shelters, Third Logic introduces the state as a major independent actor. In sum, [the state] is the key force required for the creation, maintenance, and enforcement of ideal typical professionalism. Whether or not it does so depends upon its own organization and agenda, which varies in time and space. (Freidson 2001, pp. 128–9)

He endorses (p. 133) Johnson’s (1995) argument that professions are part of the apparatus that constitute the state, part of a mode of governmentality. The question, then, is what part is played by the state, and what part by professions, in the governmentality of a particular era. In the Golden Age of state welfare, professions formed part of a paternalist complex of governance that assured citizens that their basic human security would be met as a matter of enlightened obligation. Expert public servants would consult fellow experts in the professions and so arrange matters that citizens would be provided for, according to these expert perceptions of their needs and deserts. To the extent that professional services were rationed, this was based on non-market principles, of queuing or of social exclusion. States and professions worked in a partnership of benevolent concern. The crisis of this system of governance has been a crisis for the professions. The causes of that crisis need not be discussed here. We can, however, see its consequences, in the loss of faith in either the capacity or the benevolence of expertise and in the new forms of discipline applied to populations. On the one hand, we can see the erosion of confidence among

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the former governing classes in their ability to manage, let alone plan, social and economic relations through the application of well-intentioned expertise. Neo-liberalism has brought with it an argument that only markets and the price system can transmit information and react rapidly enough to deal with contemporary challenges from emerging economies. State action merely encourages citizens to expect a degree of security that cannot be delivered in the modern world. Citizens, however, have an annoying habit of making demands of governments and must therefore be disciplined to become the kind of consumer required by the neo-liberal model. While professions lose their status as partners in governance, as markets displace expertise in the co-ordination and delivery of welfare, they become increasingly subject to the control of governments. Autonomy and selfregulation are displaced by direction and executive control. In both the US and the UK, for example, autonomous professional licensing boards have given way to state-controlled bodies for the maintenance of discipline and quality. Freidson (2001, p. 129) cautions against simplistic readings of this as a process of deprofessionalization or proletarianization, not least because many of these processes effectively co-opt some segments of the profession to police their peers rather than introducing unmediated lay control. However, it is undeniable that there has been a significant shift in profession/state relations and that this alone would justify a greater emphasis than in the past on the supply of professional regulation. What the state grants, the state can take away, should its own project change – and it seems that professionals can do rather little about it, as the demand school of explanation would imply. Does this, then, mean the end of professional dominance? Freidson is sceptical about this because of the degree to which expertise forms a structural basis for monopoly and uncertainty a basis for ethical practice. In Third Logic, he criticises those analysts who have seen professions purely as rent-seeking monopolies. The social closure represented by a licensing regime may also reflect the asymmetry of expertise between professionals and clients. Although this closure may map onto other inequalities – of gender, class or race – that make it morally unacceptable, there is nothing inherently objectionable about a closed occupation with open recruitment. Closure provides for a coherent and consistent service in an environment where clients are ill-equipped to judge, a point also conceded by Adam Smith (1976) in a passage that Freidson does not quote – he argues against Smith’s critique of guild monopolies without recognizing that Smith also concedes that professions should be exempted from this critique. Professional monopoly introduces internal competition among professionals for symbolic rewards in addition to the economic rewards that go with their practice. Again without explicit acknowledgement, Freidson endorses Smith’s argument that professionals need to be reasonably well-

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paid in order to minimize the temptations to abuse the asymmetries in knowledge between themselves and their clients. Where managed care providers operate tariff systems that fix prices for items of service, for example, there is a recurrent incentive to over-diagnose and treat, just as there may be incentives to under-diagnose and treat in capitation systems. However, professionals are also motivated by the regard of fellowmembers of their occupational community, by an ethic of humane service that complements the material conditions of their economic environment. It is this ethic that allows them to transcend the Fordist agenda of the managerialists and to treat patients as individuals, whose conditions necessarily require the conscientious and discretionary application of judgement based on the facts of the particular case, regardless of the evidence-based template that may be dictated, and to act as the patient’s ally and advocate in the face of this routinization. Here, Freidson has moved a long way from the scepticism that he expressed in Doctoring Together. Peer esteem may be less potent than the myth-makers of the Golden Age argued, but its contribution to the maintenance of quality in practice is not trivial, and certainly not to be lightly dismissed. Professional ethics represent transcendent values that justify professionals’ independence, by virtue of which they ‘claim the right to judge the demands of employers or patrons and the laws of the state, and to criticize or refuse to obey them (Freidson 2001, p. 221). Freidson, then, rejects much of the body of critical work, to which Professional Dominance and Profession of Medicine had contributed, as exaggerating the problems of the professional mode of governmentality and thereby undermining its ability to resist market and bureaucratic forces. Where he concluded Profession of Medicine with concerns about a new tyranny of professionalism, Third Logic concludes with a call to sustain the independence of professions as a source of resistance to the greater tyrannies of markets and capital. Expertise and Control I am not, however, sure that I find this argument conclusive. Although I think Freidson is correct to argue that the decline of professional dominance has been exaggerated, and that the inevitable informational asymmetry between physician and patient ensures that expertise remains a source of autonomy, other changes in state/society relations may have more significance than he allowed. If we return to Profession of Medicine and its Parsonian inheritance, we can see that the professional monopoly rests both on the physicians’ expertise and on their role as control agents. Despite the ambivalent relationship between much contemporary medical sociology and its Parsonian roots, it is clear that the assumptions of the sick role are deeply

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embedded. Sickness is something to be socially managed: dependency claims are to be rationed to match the ‘carrying capacity’ of the society and physicians are primary agents in this process. However, the Parsonian model rests on two assumptions. One is of the scarcity of societal resources, which reflects both Parsons’s intellectual debts to economics, a discipline that takes scarcity as a fundamental axiom, and the real material conditions of Parsons’s lifetime. The other is that there is a societal responsibility to meet dependency claims: if the sick can expect others to aid them, then those others may reasonably expect to test the claims for support. The first of these assumptions has been increasingly obscured by the escalating wealth and prosperity of the developed world, although it remains a critical problem elsewhere. Whatever the health economists may try to tell us, it is clear that many citizens and governments have difficulty with the notion that many dependency claims arising from sickness should be rationed. As a result, the sick role may no longer be quite the deviant role that both Parsons and Freidson analysed. Health care is increasingly portrayed as a luxury good, something to be consumed alongside SUVs and designer jeans rather than accepted as the price of social re-integration. The physician’s work is no longer confined to healing the sick but includes important elements of promoting the perfectibility of the well. This does not necessarily mean that the sick role, or the patient role, ceases to be a deviant one: in a world that expects perfection, the blemished are inevitably deviant. But the control agents may be not necessarily be physicians: the management of the female body may be as well judged by celebrity magazines as by licensed professionals. If physicians are merely suppliers of a consumer good, then the case for licensing is one of consumer protection rather than of a socially accountable control agent. The policy objective is to ensure that consumers are getting what they are paying for, rather than that the providers of support can be assured that it is only being given to appropriate cases. This is a much weaker case and certainly does not lead to an argument for monopoly in the same way. The issue of societal responsibility for dependency is linked to the motivational questions raised by Parsons. The sick role is about the management of unmotivated deviance, failures to function in everyday life. If it is now about imperfection, failure to achieve the highest physical standards in everyday life, can it so easily be conceptualized as unmotivated? If it is not unmotivated, how far do others have a responsibility to sustain those who fail? Take obesity, for example. If this is a lifestyle choice, who is responsible for the consequences? The motivated deviant may be expected to take a much greater part in the search for moral re-integration, not least as part of a public cleansing of their soul, a demonstration of the earnestness of their commitment to reform.

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Many of these questions raise much larger issues than can be discussed here, and would need a reworking of the whole opening section of Profession of Medicine to address their full implications. However, they should serve to problematize the basic argument, that the nature of the sick role requires an identifiable and societally accountable body of control agents to regulate access. This may well lie at the heart of the confusions about the present condition of professional dominance. To the extent that such a role survives – and Parsons’s arguments about the inevitability of rationing access to it have probably not been destroyed but merely temporarily eclipsed by the current prosperity of sections of the planet – then a licensed group of control agents are also likely to survive. If those agents are to be treated as legitimate decision-makers, then some distance from state or private managerialism is probably essential. However, the space for this may be much narrower than in the Golden Years. Third Logic is not, then, an exercise in nostalgia. It tries to come to terms with a world that has changed in ways that were not acknowledged in the original intellectual project of Professional Dominance. Part of Freidson’s achievement as a scholar was his recognition, even late in life when many of his peers were simply touring the world with anecdotes about the famous years of the Chicago School, that history had revealed aspects of the conditions of professions that had been taken for granted in his original contributions. In particular, it engages with the issue of state/ profession relations and the socio-historical conditions for professional autonomy and dominance in a way that could not have been identified in the conditions of the 1960s and which corrects the one-sided emphasis on occupational capture of states in the writing of the 1970s and 1980s. However, it may better seen as a transitional stage in the development of a new professional project for the sociology of the professions, one which would take us back to further reflections on Freidson’s own sources and the evolving nature of deviance and control in contemporary societies. Eliot himself would have been the last to urge a slavish adherence to his own thinking of thirty years ago – but his legacy is a set of questions that remain as compelling today as when they were first asked.

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Endnotes Chapter 1 1.

2. 3.

‘ ... the most important single figure neglected in The Structure of Social Action and to an important degree in my subsequent writings is probably Simmel. It may be of interest that I actually drafted a chapter on Simmel for The Structure of Social Action but partly for reasons of space finally decided not to include it. Simmel was more a micro- than a macro-sociologist; moreover he was not, in my opinion, a theorist on the same level as the others. He was much more a highly talented essayist in the tradition of Tocqueville than a theorist like Durkheim ...’ (Parsons 1968, p.xiv, n.l0.) Henderson (1935) had himself produced one of the first essays on the doctor/patient relationship. Given Parsons’s involvement with psychotherapist/patient interaction during his study of medical practice, it is tempting to wonder whether this represents a case of a researcher ‘going native’. (2007: In fact this study did not involve psychotherapist/ patient interaction – see Gerhardt 2002, p. 167n.153.)

Chapter 2 1.

Health visitors are a British type of public health nurse with advanced training beyond basic nurse education. Their work has no direct clinical component, being exclusively educative and advisory, delivering preventive health and social welfare advice to particular categories of the population. Their main client group is mothers and young children, although they may also be involved with services for ante-natal women, old people and sufferers from various chronic diseases. (2007 At the time of the study, health visitors provided a near-universal service of home visiting to women with young babies but this has since been much curtailed, partly because women are tending to return to employment more quickly but mainly because of the declining political support for universalist provision in public health and welfare services.)

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2. 3.

4.

5. 6.

All the data extracts have been edited for anonymity. Students are identified by first names and faculty by title and last name. 2007 The poem is comparing health visitors and midwives, who are obliged to use bicycles because of their low salaries and/or miserly employers with schoolteachers and social workers. ‘Panda cars’ were the first generation of routine patrol vehicles used by police in the UK at the end of the 1960s. Various marques were used but the nickname derives from their distinctive black and white markings. The use of cars for routine patrol work in urban areas, as opposed to rapid response, has remained a subject of discussion among police analysts. 2007 The 1974 reorganization of the National Health Service sought to unite the previously separate arms of the system that had been set up in 1948. Before this date, public health services had been delivered by local government, while hospital and primary care services were locally administered through parallel structures under boards of central government nominees. Although the 1974 reorganization did not fully integrate primary care, it did transfer public health services from local government to a new structure intended to merge their management with that of the hospital sector. 2007 The subject of atrocity stories is explored in more depth in Chapter 3. 2007 At the time of the fieldwork, nearly all basic nurse education was carried out in hospital-affiliated schools of nursing, while virtually all health visitor education was carried out within institutions of higher or further education. There was a contrast in organizational cultures that would not necessarily be found today, although the argument about the challenge to construct a narrative of transition would still be relevant – it is simply that this might now be achieved in a rather different fashion.

Chapter 3 1. 2.

The discussion in the two preceding paragraphs is generally informed by Mary Douglas’ work, especially Purity and Danger (1970). It may also be the case that stories are told which reflect illegitimate attempts to enforce legitimately grounded controls. While social security agencies may be regarded as having a legitimate mandate to check expenditure of public funds, their interventions in the daily lives of citizens to carry out this task may become defined as illegitimate control of private lives.

Endnotes

3.

4.

5.

6.

7. 8.

9. 10.

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See Sacks (Unpublished lecture notes 1970: April 2) ‘And plainly enough you’ve experienced being in scenes the virtue of which was that as you were in them you could see what it was you could later tell people had transpired. And there are presumably lots of things which, at least at some points in people’s lives, are done just for that; i.e. it seems fair to suppose that there’s a time when kids do ‘Kissing and telling’ that they’re doing the kissing in order to have something to tell, and not that they happen to do kissing and happen to do telling, or that they want to do kissing and happen to do telling, etc. But that a way to get them to like the kissing is via the fact that they like the telling’( See Sacks 1995, ii, p. 218). Much of this lecture concerns the way the world may be monitored for its storyable properties and Sacks argues that the ability to produce appropriate stories may be an important element in sustaining one’s claim to being a competent observer of that world. 2007 This situation has now changed substantially as a result of subsequent NHS reorganizations. However, this does not affect the general argument that is being made here. 2007 The research predated the decision to supply contraception free of charge under the NHS, whether through specialist clinics or general practitioners. 2007 This competition is less marked than it used to be since health visitors have largely seen this element of their work handed over to other groups of community-based nurses and have become more focused on work with children. 2007 Nursing at this time had few degree programmes. See note 6 to Chapter 2. 2007 Until the early 1970s British social work was divided into separate specialisms with separate training programmes. It was then reorganized with social workers being called upon to take general caseloads although many of the older staff had not had a general training. At that time, probation work was defined as a branch of social work, although it was only merged into municipal social services departments in Scotland. In England it remained a separate agency and has since been merged with the prisons service and taken on a much more correctional character. This modifies the original interpretation that I gave to the students’ stories in my PhD thesis (Dingwall, 1974a: 313). 2007 British hospitals traditionally provided a great deal of residential accommodation for single nurses as part of their assumed responsibility for the morals and welfare of young or unattached women. This model was replicated in many areas for nurses working in the community, although they would necessarily

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have been rather older. It was becoming obsolete by the time that this research was carried out but the research site referred to was in a particularly remote area with a strong influence of religious conservatism. Chapter 4 1.

2.

3.

4.

5.

6.

In fact, the introduction of paid assistants to the voluntary workers was less novel than is sometimes suggested. From about 1864 Manchester had had a similarly organized scheme for district nursing of the sick poor which might have provided a model (Bullough & Bullough 1979, p.134). A Mrs Greenwood was also involved in setting up the Huddersfield scheme in 1905/6 (Parton 1981) and a Florence J. Greenwood is the author of an article on ‘The evolution of the health visitor’ in the Journal of the Royal Sanitary Institute for 1915. If this is the same woman, then a study of her career might throw some interesting light on the process of the occupation’s development. The other voluntary schemes described in the evidence to the Interdepartmental Committee seem, in fact, to lie much closer to this model than to the Salford version. B. S. Rowntree described a visiting scheme attached to the infant milk depot in York, using the paid secretary to the local health society who had been a sister in a London hospital and a health lecturer for the London County Council. His own secretary, a former sanitary inspector, also did visiting. Rowntree favoured the use of nurses with some additional instruction to carry out this work at a salary of £l50 per year. (Report II: Qs 5158-68, 5252-63.) Dr Hawkes, a local GP, described the work of Queen’s Jubilee Nurses in Finsbury and stressed that they were being used to give sanitary instruction as much as home nursing care for the poor. (Report II: Qs 12984-9, 13207-13.) In an article on ‘Municipal social work’ from Women Workers (1902), Miss Nolan-Slaney from Birmingham asserts that, ‘The Birmingham City Council was among the first (if not the first) to recognise the value of the services of experienced women, garbed as accredited officials’. It may also be relevant to note that the complaints recorded by Smith (1979, p. 117) and Lewis (1980, pp. 106–7) from mothers about patronizing health visitors, date from this period. The early history of the Women Sanitary Inspectors’ Association is described briefly by Weller (1967).

Endnotes

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The argument is made in Dingwall (1974, pp. 77–80). Its basic idea is adopted from Bohannan (1952). See also Dingwall and Strong (1985).

Chapter 8 1.

The discussion is clearly intended to include apothecaries as well as physicians, despite the former’s closer connection with trade. Smith notes that ‘apothecaries’ profit’ is used as a metaphor for excess or extravagance. In reality, however, it represented the value added to the actual drugs sold by the skill and trustworthiness of the vendor (Smith, 1976a, I, p. 125).

Chapter 9 1.

2.

3.

4.

5.

The Miltonic theme to this chapter was suggested by Christopher Honeyman in commissioning the paper for the conference where it was originally presented. See, for example, Nigella Lawson, ‘Is it the end, nurses?’, The Times, 26 December 1996, p. 17 and Richard Horton, ‘Health: a complicated game of doctors and nurses’, The Observer, 30 March 1997. A general discussion can be found in Allen (1997). In the words of the political architect of the British National Health Service, Aneurin Bevan, opening the debate on the Second Reading of the National Health Service Bill: ‘I would rather be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy in a small one.’ Hansard HC, 30 April 1946, col. 44. ‘In general’ because this is a complex and unresolved issue in scholarship. In the UK for example, registered plumbers have a monopoly on connecting appliances to the natural gas supply network without being considered a profession. Similarly, university teaching is often described as a profession but there is no legal protection of its services or job titles. In the UK, for instance, estate agents (realtors) have been trying to achieve a legally backed monopoly on house sales for several decades. Although there is abundant evidence of various kinds of malpractice, legislators have been quite happy to apply the doctrine of caveat emptor and to leave the area unregulated. UK Funeral directors are another group who have pursued the same goal with no success whatsoever.

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The Hawthorne studies subjected workers in a plant making electrical equipment to a series of experiments varying their environmental conditions—workflow, lighting levels, etc.—and found that their output tended to increase more or less regardless of what was going on around them. The researchers concluded that the experiment had created a degree of social solidarity within the workgroup whose influence was independent of changes in the physical or organizational environment (Roethlisberger and Dickson 1939). For a long time it has been fashionable to deride ‘scorecard’ approaches to professionalization, the idea that an occupation gained promotion to professional status by taking on features from a set of criteria – codes of ethics, formal credentials, etc. (See Roth 1974). However, if one sees these criteria as indicators of attempts at isomorphism, particularly mimetic, then it may suggest an alternative way of thinking about the work of these authors. Despite extensive inquiry, it has not been possible to establish that this is indeed an ancient Chinese proverb, as opposed to a piece of Western folk wisdom attributed to the Chinese and, hence, about as authentic as a fortune cookie: The fortune cookie, like chop suey, is a U.S. invention that is often thought to be from another country. Discovering their exact origins, however, proves to be as elusive as finding one’s way through San Francisco’s Chinatown, where a handful of small, family-run fortune cookie factories remain scattered along narrow alleyways and smoky side streets. While the self-proclaimed “Fortune Cookie Capital of the World” seems the likeliest birthplace, some maintain that fortune cookies actually come from Los Angeles, where Canton-native David Jung, a baker and restaurateur, began making cookies with thin slips of paper inside sometime around 1920. Jung founded the Hong Kong Noodle Company, which was producing more than 3,000 cookies an hour in the 1920s. Still another theory holds that the delicate cookies were the brainchild of Makoto Hagiwara, a Japanese designer who first debuted them at the 1915 Panama-Pacific Exhibition.

9.

Alexandra Abramian, ‘Who Invented the Fortune Cookie’, Hemispheres (1999), available at http://modelminority.com/ article69.html (last visited July 29, 2003). Medical specialists are members of ‘Royal Colleges,’ solicitors receive their vocational training at the ‘College of Law,’ and, of course, the college is a key organizational unit at the historic universities of Oxford and Cambridge.

Endnotes

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11. 12.

13. 14.

15.

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National Family Mediation, Family Mediation Scotland, and the Family Mediators Association. The first two mainly represented non-profit organizations employing lay mediators, while the third mainly represented lawyers with a family mediation practice and counselors working with them. A fourth organization, LawWise, a private company linked to the British Association of Lawyer Mediators, representing lawyers with a generic mediation practice, became an ‘approved body’ when the College was established. This has since been restructured and renamed the Legal Services Commission. In effect, present policies call for the maintenance of professional self-regulation, provided professions regulate themselves according to the prescriptions set down by the UK Government. See, e.g., Department of Health, Modernising Regulation in the Health Professions: Consultation Document (2001), available at http://www.doh.gov.uk/modernisingregulation (last visited July 30, 2003). Hedeen and Coy (2000) present a similar analysis of community mediation and court systems in the U.S. As a former chair of a church finance committee, I have noted the tensions between the mission to proclaim the Gospel as understood by this denomination and the need to pay the local share of the minister’s salary, fix the roof, make sure the kitchen passes sanitary inspections, and the like. In some senses, the last thing the finance committee wants is an activist minister who may alienate regular donors and run up costs. At the same time, ministers who preach only to the converted risk having the church fold up beneath them as all of the converted pass on to the next world and are not replaced by fresh recruits. ‘That great historical process in the development of religions, the elimination of magic from the world [Die Entzauberung der Welt] . . . came here to its logical conclusion … [The modern economic order] is now bound to the technical and economic conditions of machine production which today determine the lives of all the individuals who are born into this mechanism, not only those directly concerned with economic acquisition, with irresistible force. Perhaps it will so determine them until the last ton of fossilized coal is burnt. In Baxter’s view the care for external goods should only lie on the shoulders of the ‘saint like a light cloak, which can be thrown aside at any moment’. But fate decreed that the cloak should become an iron cage.’ (Weber 1965, p. 181). ‘No one knows who will live in this cage in the future, or whether at the end of this tremendous development entirely new prophets

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will arise, or there will be a great rebirth of old ideas and ideals or, if neither, mechanized petrification, embellished with a sort of convulsive self-importance. For of the last stage of this cultural development, it might well truly be said, “Specialists without spirit, sensualists without heart; this nullity imagines that it has attained a level of civilization never before achieved”.’ (Weber 1965, p. 182). ‘The fact that the professions have reached a uniquely high level of development in the same society which is also characterized by a business economy suggests that the contrast between business and the professions which has been mainly started [sic] in terms of the problem of self-interest, is not the whole story.’ (Parsons 1939, p. 458). See e.g., Learning from Bristol: The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984-1995 (Chairman, Professor Ian Kennedy) (CM 5207), The Stationery Office, London. Book of Common Prayer: Morning Prayer, Second Collect for Peace (‘O God, who art the author of peace and lover of concord, in knowledge of whom standeth our eternal life, whose service is perfect freedom….’).

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Donajgrodski, A.P. (ed.) 1977, Social Control in Nineteenth Century Britain, Croom Helm, London. Donnison, J. 1977, Midwives and Medical Men, Heinemann, London. Douglas, M. 1970, Purity and Danger, Penguin, Harmondsworth. Durkheim, E. 1964, The Division of Labour in Society, Free Press, New York. Durkheim, E. 1992, Professional Ethics and Civic Morals, Routledge, London. Eckstein, H. 1958, The English Health Service: Its Origins, Structure and Achievements, Harvard University Press, Cambridge, MA. Evans, R.G. 1974, ‘Supplier-induced demand: some empirical evidence and implications’, in The Economics of Health and Medical Care, (ed.) M. Perlman, Macmillan, London. Feeley, M. 1979, The Process Is the Punishment: Handling Cases in a Lower Criminal Court, Russell Sage, New York. Fish, S. 1967, Surprised by Sin: The Reader in Paradise Lost, Macmillan, London. Fletcher, R. 1974, ‘Evolutionary and Developmental Sociology’, in Approaches to Sociology: An Introduction to Major Trends in British Sociology, (ed.) J. Rex, Routledge and Kegan Paul, London. Flexner, A. 1915, ‘Is social work a profession?’ in Proceedings of the National Conference of Charities and Correction, Hildmann Printing Co., Chicago. Forgotson, E.H. and Cook, J.L. 1967, ‘Innovations and experiments in uses of health manpower – the effect of licensure laws’, Law and Contemporary Problems, vol. 31, no. 4, pp. 731–50. Foucault, M. 1977, ‘Intellectuals and power’, in Language, CounterMemory, Practice: Selected Essays and Interviews by Michel Foucault, (ed.) D. Bouchard, Basil Blackwell, Oxford. Freidson, E. 1970a, Profession of Medicine: A Study of the Sociology of Applied Knowledge, Dodd, Mead & Co., New York. Freidson, E. 1970b, Professional Dominance: The Social Structure of Medical Care, Atherton Press, New York. Freidson, E. 1975, Doctoring Together: A Study of Professional Social Control, Elsevier, New York. Freidson, E. 1978, ‘The official construction of occupation: an essay on the practical epistemology of work’, paper presented at the 9th World Congress of Sociology, Uppsala, Sweden. Freidson, E. 1982, ‘Occupational Autonomy and Labor Market Shelters’, in Varieties of Work, (eds) P.L. Stewart and M.G. Cantor, Sage, Beverly Hills, CA. Freidson, E. 1983, ‘The theory of professions: state of the art’, in The Sociology of the Professions, (eds) R. Dingwall and P.S.C. Lewis, Macmillan, London.

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Milton, J. 1968, ‘Paradise Lost’ in The Norton Anthology of English Literature, (eds) M.H. Abrams et al. Norton, New York. Moerman, M. 1974, ‘Accomplishing ethnicity’, in Ethnomethodology (ed.) R. Turner, Penguin, Harmondsworth. Moore, M.W. 1974, ‘Demonstrating the rationality of an occupation’, Sociology, vol. 8, no. 1, pp. 111–23. Moore, T.G. 1961, ‘The purpose of licensing’, Journal of Law and Economics, vol. 4, no. 4, pp. 95–117. Muller, J.Z. 1993, Adam Smith in his Time and Ours: Designing the Decent Society, Free Press, New York. Murray, T., Dingwall, R. and Eekelaar, J. 1983, ‘Professionals in bureaucracies: solicitors in private practice and local government’, in The Sociology of the Professions: Lawyers, Doctors and Others, (eds) R. Dingwall and P.S.C. Lewis, Macmillan, London. Offer, J. 1983, ‘Spencer’s sociology of welfare’, Sociological Review, vol.31, no.4, pp. 719–52. Offer, J. (ed.) 1994, Herbert Spencer: Political Writings, Cambridge University Press, Cambridge. Olesen, V.L. and Whittaker, E.W. 1968, The Silent Dialogue, Jossey-Bass, San Francisco. Pape, R. 1974, ‘Touristry: a type of occupational mobility’, Social Problems, vol. 2, no. 4, pp. 336–44. Parkin, F. 1979, Marxism and Class Theory: A Bourgeois Critique, Tavistock, London. Parry, N. and Parry, J. 1976, The Rise of the Medical Profession, Croom Helm, London. Parsons, T. 1939, ‘The professions and social structure’, Social Forces, vol. 17, no. 4, pp. 457–67. Parsons, T. 1951, The Social System, Free Press, Glencoe, IL. Parsons, T. 1968, The Structure of Social Action, Free Press, New York. Parton, C. 1981, ‘Liberal individualism and infant mortality; the infant welfare movement in Huddersfield 1900–18’, MA thesis, Huddersfield Polytechnic. Peel, J.D.Y. 1971, Herbert Spencer: The Evolution of a Sociologist, Heinemann, London. Peel, J.D.Y. 1972, Herbert Spencer on Evolution: Selected Writings, University of Chicago Press, Chicago. Peltzman, S. 1976, ‘Towards a more general theory of regulation’, Journal of Law and Economics, vol. 19, no. 2, 211–37. Posner, R. 1974, ‘Theories of economic regulation’, Bell Journal of Economics, vol. 5, no. 2, pp. 335–51. Power, M. 1997, The Audit Society: Rituals of Verification, Oxford University Press, Oxford.

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Spencer, H. 1969. The Principles of Sociology, abridged by S. Andreski. Macmillan, London. Starr, P. 1983, The Social Transformation of American Medicine, Basic Books, New York. Stein, L.I. 1968, ‘The doctor-nurse game’, American Journal of Nursing, vol. 68, no. 1, pp. 101–105. Stevens, R. 1966, Medical Practice in Modern England, Yale University Press, New Haven, CT. Stigler, G. 1971, ‘The theory of economic regulation’, Bell Journal of Economics, vol. 2, no. 1, pp. 3–21. Stimson, G.V. and Webb, B. 1975, Going to See the Doctor, Routledge & Kegan Paul, London. Straus, R. 1957, ‘The nature and status of medical sociology’, American Sociological Review, vol. 22, no. 2, pp. 200–209. Strauss, A.L., Schatzman, L., Bucher, R., Ehrlich, D. and Sabshin, M. 1964, Psychiatric Ideologies and Institutions, Free Press, New York. Strong, P. M 1979, The Ceremonial Order of the Clinic, Routledge, London (New edition Ashgate, Aldershot, 2001). Strong, P. M. 1997, ‘One branch of moral science: an early modern approach to public policy, in Context and Method in Qualitative Research, (eds) G. Miller and R. Dingwall, Sage, London. Strong, P. M. and Dingwall, R. 1989, ‘Romantics and Stoics’ in The Politics of Field Research: Sociology Beyond Enlightenment, (eds) J.F. Gubrium and D. Silverman, Sage, London. Taylor, F.W. 1911, The Principles of Scientific Management, Harper, New York. Thurow, L. 1975, Generating Inequality, Macmillan, London. Tullock, G. 1982, The Economics of Redistribution, Kluwer-Nijhoff, Boston. Turner, J.H. 1985, Herbert Spencer: A Renewed Appreciation, Sage, Beverly Hills, CA. UK College of Family Mediators 1977, Standards, UK College of Family Mediators, Bristol. Weber, M. 1964, The Theory of Social and Economic Organisation, Free Press, New York. Weber, M. 1965, The Protestant Ethic and the Spirit of Capitalism, Unwin, London. Webster, C. 1988, The Health Services Since the War: Volume I, Problems of Health Care: The National Health Service Before 1957, HMSO, London. Weller, M.F. 1967, ‘Seventy years on: inaugural lecture at the annual conference of the Health Visitors’, Association held in Folkestone in October 1966’, International Journal of Nursing Studies, vol. 4, no. 3, pp. 233–43.

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Author Index Abbott, A. 86, 95, 100, 113 Abel, R.L. 7 Abrams, P. 85-86 Adams, F.R. 58 Akerlof, G.A. 65, 71 Allen, D. 147 Anderson, P. 85 Andreski, S. 85 Arrow, K.J. 68, 71 Baehr, P. 125 Becker, H. S. xiii, 6-7, 11-12, 14, 29, 128 Benham, A. 66 Benham, L. 66 Bevan, G. 119 Birdwhistell, R.L. 19 Bittner, E. 58 Blair, R.D. 66 Blake, W. 116 Bloomfield, R. 31 Bohannan, L. 147 Bosk, C. 127 Bottomore, T. 63 Brinton, C. 85 Buchanan, J.M. 64 Bucher, R. 46 Bullough, B. 146 Bullough, V.L. 146 Burchell, G. 78-79 Campbell, C.M. 8 Campbell, D. 7 Carlin, J. 120 Carpenter, M. 52 Carr-Saunders, A.M. 73 Christ, E.A. 39 Clark, J. 22, 31 Coase, R.H. 71

Coleman, J. 136 Collard, D. 71 Cook, J.L. 62 Coy, P.G. 149 Davies, C. 45 Davis, A. G. 20 Davis, G. 112, 119, 122 Denzin, N.K. 14 Dickson, W.J. 148 DiMaggio, P. 115 Dingwall, R. 7, 15, 20, 25, 31-32, 41, 53, 58, 114, 119, 121, 124-125, 145, 147 Donajgrodski, A.P. 48 Donnison, J. 57-58 Douglas, M. 144 Durkheim, E. 72, 77 Eckstein, H. 120 Eekelaar, J. 125 Evans, R.G. 66 Feeley, M. 120 Fish, S. 116 Fletcher, R. 85 Flexner, A.11-12 Follis, P. 31 Forgotson, E.H. 62 Foucault, M. 79 Freidson, E. 9, 12, 47, 58, 63, 66, 72, 78-79, 99, 127-129, 131-132, 136-139 Friedman, M. 62-63, 66 Gamble, A. 108 Gerhardt, U. 143 Gilbert, B.B. 53 Gill, D. 12

164

Essays on Professions

Goffman, E. 18, 39 Gold, R. 29 Gray, T.S. 86 Greatbatch, D. 119 Green, D.G. 119 Greenwood, E. 6 Habenstein, R.W. 39 Hakim, C. 45 Halliday, T. 100 Hayek, F.A. 69, 104, 108 Hedeen, T. 149 Henderson, L.J. 143 Hinkle, R.C. 85 Hodgkinson, R.G. 119 Hodgson, E.L. 62 Holloway, S.W.F. 79, 100 Horobin, G.W. 12 Hughes, E.C. 1, 45-46, 58, 73, 77, 106, 112-113, 116-117, 130 Illich, I. 13, 132 Johnson, T.J. 7, 9, 78-79, 100, 106, 137 Kaserman, D.L. 66 Kaufmann, S. 119 Kessel, R.A. 62 Klein, B. 67 Krause, E.A. 100 Kuznets, S. 62 Langton, B.M. 49 Larkin, G.V. 100 Larson, M.S. 7, 9, 63-64, 78, 95, 99, 137 Lees, D. 62-63 Leffler, K.B. 67 Leland, H.E. 65 Lewis, J. 146 Light, D. 100 Longmate, N. 49 Luckmann, T. 108 Lynch, M. 113 Mack, E. 86 MacRae, D. 85

Marshall, T.H. 77 Mauksch, H. 30 McAdoo, B. 119 McEwan, M. 48-49 McIntosh, J. 31-32 McQueen, I.A.G. 18, 48-49 Mechanic, D. 41 Merton, R.K. 7, 128 Meyer, J.W. 115 Michels, R. 120 Mill, J.S. 64 Milton, J. 111, 123, 126 Moerman, M. 15, 27 Moore, M.W. 28-29, 62 Muller, J.Z. 104 Murray, T. 125 Offer, J. 86 Oleson, V.L. x, 59 Pape, R. 39 Parkin, F. 100 Parry, J. 100 Parry, N. 100 Parsons, T. 1, 3, 13, 68-70, 73, 77, 85, 125, 127, 143, 150 Parton, C. 53, 57, 146 Peel, J.D.Y. 85, 97 Peltzman, S. 64 Posner, R. 64 Powell, W.W. 115 Power, M. 125 Rock, P. 3 Roethlisberger, F.J.148 Roth, J.A. 12, 29, 78, 148 Rowan, B. 115 Rubel, M. 63 Sacks, H. 145 Scheff, T.J. 128 Schelling, T. 65, 67, 71 Schutz, A. 19, 24, 37, 108 Shaw, G.B. 116 Shore, M. 94 Simon, S.D. 56 Smith, A. 61-62, 71, 77, 101-104, 138, 147

Author Index Smith, F B. 52, 54, 146 Spencer, H. 77, 85-86, 88-93, 96-97, 106 Starr, P. 109, 119 Stein, L.I. 22, 32 Stevens, R. 119 Stigler, G. 63 Stimson, G.V. 23, 29 Strauss, R. 8 Strauss, A.L. 7, 29, 46 Strong, P.M. 20, 58, 114, 121, 124, 126, 147 Taylor, F.W. 114, 133 Thurow, L. 64 Tullock, G. 64

165

Turner, J.H. 85-86, 88 Webb, B. 23, 29 Weber, M. 1, 120, 126, 129, 149-150 Webster, C. 120 Weller, M.F. 146 Whitfield, K. 62 Whittaker, E.W. x, 59 Wieder, D.L. 14 Wilensky, H.L. 94 Wiles, P. 8 Wilson, P.A. 73 Wittgenstein, L. 14, 27 Witz, A. 100 Wolff, K. 69, 108 Zimmerman, D.H. 14, 43

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Subject Index Atrocity stories 23, 27, 29-30, 32-3, 35-43, 144 Attribute approach see Trait approach Autonomy 12-13, 32, 38, 41, 119, 127, 131, 138 Boundary work xi, 21, 23-24, 28-9, 31, 34-7, 39-42 Bureaucracy 2-3, 6, 114, 116, 123, 125-6, 129 130, 132, 139 Control agents 139-41 Creation myths 59, 111, 120-4, 126 Demand theory xiii, 79, 81, 100-1, 113, 137 Doctors 5, 7, 16, 20-24, 27, 29-34, 37, 40-1, 53, 57, 61-2, 74, 78-81, 83, 92, 101-2, 104-5, 109, 116, 119-20, 127-32, 134-6, 140, 143, 147 Dominance 127, 131-9 Dirty work 45, 57 Division of labour xii, 4, 7, 9-10, 46, 52, 72-3, 77, 87, 100, 129-32 Ecology 4-5, 7, 45-6, 87-8, 94-5, 97-8, 130 Economists ix, 1-3, 5 Engineers 64, 79, 100, 105, 109 Ethnomethodology xi, Evidence-based medicine 133 Folk concept 14 Globalization xiv, 99, 109-10

Health visitors xi, 11, 13, 15-25, 27-8, 30-41, 43, 46-52, 54, 56, 58-9, 143-6 Industrial society xiv, 87, 89-91, 93-7, 105 Informational asymmetry 65-7, 71, 131, 138 139 Knowledge commonsense 11-13, 26-7, 37, 40 expert 3, 9-12, 23-4, 47, 69, 72, 75, 81, 91-2, 97, 103-6, 117, 127, 130-1, 134, 139 guilty 4-5, 73-4, 106 sociology of x, 2-3 Law 7-9, 74-6, 78, 96-7, 103, 115, 119, 135 Lawyers ix-x, 5, 7, 61-2, 65, 74, 76, 78, 92, 101-2, 104-5, 109, 120 Legal profession see Lawyers Legitimacy xiv-xv, 2, 97, 115, 117-8, 128, 133-4, 141 Licence xiii, xv, 4-6, 12, 58, 62-4, 67, 74, 76, 79, 81-3, 100, 113-4, 116, 118-9, 121, 130-1, 138, 140-1 Mandate 4-6 Market 6-7, 47, 49, 54-5, 58-9, 61, 63, 65, 72, 74-5, 78-80, 92, 99 100-1, 103, 109, 138 failure xiii, 64-5, 79, 100 shelter 78, 99, 137 Mediators xiv-xv, 111 112, 115-119, 121-4, 126, 149 Medical profession see Doctors

168

Essays on Professions

Medicine 2-3, 7-9, 46, 64, 100, 103, 119, 130, 132, 137 Micro-structuralism xi, Monopoly xiii, xv, 61-3, 66-7, 75, 77, 79, 81, 92, 95, 103, 105, 107, 113, 130, 135, 138, 140 Militant society xiv, 89-91, 93-5, 97, 105 Nurses x-xii, 16, 20, 22, 24-25, 27-8, 30, 32, 34, 36-9, 56-9, 112, 129, 135-6, 144-7 Occupations xii, 10, 20, 26, 28-30, 457, 55, 59-60, 102, 114, 118 capture 58 fission 57-8 fusion 57 taxonomy xii, 21, 28, 45, 77 Official histories see Creation myths Paternalism xv, Pharmacists xiii, 77, 79-83, 113, 135 Pharmacy see Pharmacists Phenomenology xi,

Physicians see Doctors Sacred 91, 106-8 Sanitary inspectors 53-4, 56-7, 146 Sick role 128, 140-1 Socialization 7, 71, 76, 128 Social policing 48-9, 71-2 Social work 12, 24, 58-9, 112, 145 Social worker 16, 20, 24, 27-8, 34-7, 40, 144 State xiv, 12, 63-4, 67, 72, 75, 78-9, 81-3, 95, 100-1, 106-7, 110, 114, 122, 136, 138-9 Supply theory xiii, 79, 100, 113, 137 Symbolic interaction xi, 14, 101-2, 104 Teachers x, 16, 20, 40, 57, 92, 112, 144 Trait approach vii, 6, 11-14, 78, 103, 114, 148 Trust 68-71, 101, 103-4, 106, 108, 110. 133 Uncertainty xv, 62, 65, 68, 74, 76, 104, 106, 108, 115, 138