Category Archives: Places and Communities

Biopower and the NHS

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Here in the UK, we are increasingly seeing biopower at work in the national health system (NHS). A target driven culture allows patients to be treated like numbers or labelled as disease entities. It is common place to hear of people referred to as ‘Diabetics’ or ‘Asthmatics’ rather than understood as a person, with a name, in a particular life context and set of relationships who has diabetes or asthma. In my area of work, that of general practice, a huge part of our income every year comes through meeting ‘QOF’ (the quality and outcomes framework) targets. The idea behind such targets is to ‘drive up standards’ and ‘improve patient care’. In real terms, however, people can end up having various changes and increases to their medications, so that their blood pressure meets a government target, for example. The ill effects of this, particularly on old people has been recently well documented. Clinicians work hard to get everybody’s blood pressure below a certain value, but due to a lack of research and understanding behind the targets set, especially for people over the age of 75, lowering the blood pressure too much has been causing an increase in falls, fractures and long hospital stays! This is one of many examples where ‘payment by results’ is actually subtracting from patient centred care.

In the recent top down re-organisation of the NHS, which has cost more than £2billion, despite a government promise that such a reorganisation would not happen, more services are being driven out of a traditional hospital setting into the community with no extra resources or time provided to do this work. The new clinical commissioning groups (CCGs) are the new local governing bodies, which have replaced PCTs (primary care trusts). The idea behind this is that GPs, clinicians who know their patients and areas well, should be those who commission services rather than non-clinically trained managers, as they potentially have a better knowledge of the needs of patients. However, it transpires that if the government don’t like decisions being made, they can simply dismiss a board and replace it with another one which will comply with their wishes or cause them less of a political headache.

The implication of the EU-US trade agreement has opened the NHS in a way, like never before, to the forces of the free-market. This is based on a philosophy that competition drives up standards of care, and that private providers should be able to bid for services. At first this sounds like a credible and plausible idea. If another provider can offer the same service for less money, surely this is a good thing? Actually it is problematic on two levels. Firstly because the philosophy is deeply flawed. Competition does not drive up standards. It increases stress and breaks apart well integrated services. It destabilises services which currently work well in a symbiotic manner. For example, if Spec Savers offer a cheaper hearing aid service than the local hospital, then they can win a bid to provide this service. But it destabilises the hospital audiology department, which then has a knock on effect to the ENT department. The private company benefits, but in the long term the local population does not. Secondly, when companies limited by shares become the providers of care, care begins to play second fiddle to the need to make money. And here is a major stumbling block. The marginalised poor and the chronically sick do not make good financial sense, and share holders who live in another part of the world care little for their needs, but care a lot about making more money for themselves. So, we will find that those who need care the most will be unable to access it, as greed becomes the driving force. This is sadly proven in the US health system, where this philosophy is rife and 50 million people cannot afford healthcare and 40,000 people died last year as they could not afford the operations they needed. It is only media hype that causes some to believe the US to have the best health system. Most consider it to be inequitable and highly wasteful of resources.

The Ring of Power

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I’m currently reading Tolkien’s ‘The Lord of the Rings to my eldest son. We have just finished that part in ‘The Two Towers’ in which Gandalf has returned to Aragorn, Legolas and Gimli at the turning of the tide. He makes this awesome statement about Sauron the dark lord:

‘That we should wish to cast him down and have NOONE in his place is not a thought that occurs to his mind. That we should try to destroy the ring (of power) itself has not entered into his darkest dream.’

There are still the stirrings of revolution in many nations. But revolution that is based on violence and only replaces one form of dominant power with another sort of hierarchical dominance is no revolution at all.

Kenarchy is about the emptying out of power. It comes from an understanding that the politics of Jesus were about emptying out power and utterly transforming it. Leadership is not only to be kenotic (that is poured out for others), it is to be kenarchic (that is emptied out) so that we begin to understand that the lowest place is the highest place. We begin to understand that level playing fields are the order of the day. We are not looking for new political parties, but a new politics, that is a new way of relating to one another. We are not looking for new economic regulations, but a new economics. We are not searching for peace maintained through violence but a genuine love of one another, including the love of our ‘enemies’ that transforms how we live together as humanity.

William T Cavanaugh gives a radical reinterpretation of the christian eucharist in the light of this. We live in a divided world in which the ‘powers’ crush and break the multitude. When Jesus breaks bread and gives it away, he is not looking to form an exclusive club. He is, rather inviting us to partake of this kind of givenness, to embrace brokenness in the face of violence and to find that this way of life-poured-out-love finds hope in resurrection. As we eat the bread, we receive life, we become life and we give life as we share with others. The bread is given and is available to all who will receive it. Our barriers are broken down, our borders and our flags lose their relevance. We become part of this trans-local body that only exists to bring life, love and peace. There is no politics (way of doing life) that is more radical than this.

The nation state project holds power at the centre. It uses the components of money, law and control through violence to do this. I believe that as we build relationally in our localities we can find new ways of being. This is happening on a vast scale already and many stories are emerging of alternative ways of being that provide a different narrative to the dominant (economic and political) one of our day.

The Myth of the Nation State

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Here begins a mini series, which will take a few blogs to get to where I want to go, but please bear with me, as I give some background to where my thoughts are currently!

I had until fairly recently misunderstood what is meant by a myth. I thought it to be a story which lacks truth. This can be the case but is only one of its meanings. It can also describe “a traditional/legendary story which may or may not have a factual basis and is used to explain some part of life.” Or it can refer to “an unproved or false collective belief that is used to justify a social norm.”

If we are going to reimagine the future, we must become more aware of some of the myths we believe to be true and question their basis for having shaped our thinking. I have recently been reading a book entitled ‘Theopolitical Imagination’ by a chap called William T Cavanaugh. It is deeply challenging. Cavanaugh argues that all politics is a practice of our imagination. The state itself, he argues doesn’t actually exist. It exists only in our imaginations. What actually exists are things like buildings, tax forms, border patrols and aeroplanes. “What mobilises these into a project called ‘nation-state’ is a disciplined imagination of a community occupying a particular space with a common conception of time, a common history and a common destiny of salvation from peril’. Our belief in this myth is so strong that a young man (or woman) from a rural village can become convinced that he/she must travel to another part of the world to kill people he/she knows nothing about. (Think on that for a minute or two). We have become reliant on the state for our provision and protection.

The nation state, as we know it, is relatively young, having only found its place in history within the last four hundred years. Cavanaugh argues that the myth was born out of the context of the ‘religious wars’ in Europe (in the sixteenth and seventieth centuries) to ‘save us’ from the ill effects of religion and enable us to live peacefully. The hope being that the borders and flags to which we would give our allegiance would save us from the divisions that plague us. Yet this has not been the case. The borders and flags in fact deepened our sense of the ‘other’ and created barriers where previously there had been less. Cavanaugh would argue that it was the ‘spirit of empire’ that used religion as an excuse for the wars, that was the real culprit. Mitchell would argue, however, that it was a complicit agreement between Church and Imperial powers that lead to the vast blood shed in the 30 years war that in turn gave way to the enlightenment and the creation of the nation state. What’s the point? The point is that the nation state is not our saviour. It is built on exactly the same foundations of empire and employs the same currencies – money, law and violence.

If you don’t believe me, then witness the economic threat of Westminster towards Scotland, or see how much clout the banks and huge corporations play in their lobbying power of government and ability to run the show. Or think about those who are held in the state of exception in our eleven detention centres around the UK alone (plenty of examples in other countries) where law is put aside to maintain the status quo, revealing the true foundation of ‘the law’. Or have you noticed how we now talk of those who die in war as being ‘martyrs’? I am not saying that we shouldn’t remember the lives of those who were given so appallingly in war, but let us also clearly see the undergirding message that strengthens the myth of the nation state. “War brings peace”. ‘dulce et decorum est pro patria mori’…. it is sweet and right to die for one’s country…….

The nation-state project is both waning and failing. But the myth which perpetuates it is incredibly strong and acts as a huge barrier to our imagination of anything different. Peace will not come through a remodelled version of empire. True nationhood will not be recovered whilst configured as states. But there is a hope rising of something different, of new ways of being. Sometimes we have to tear down some mindsets in order to think in new ways……