Are Recent Judgements by the Care Quality Commission Symbolically Violent?

Earlier in the year I co-authored a paper in BMC Medical Ethics. It was part of a cross-journal special issue on the Many Meanings of Quality in Healthcare and argued that the evaluation of ‘care’ held significant potential for symbolic violence. The main thrust of my paper was that the auditing of specific health and social care institutions necessarily involved a certain level of bureaucratic standardization. As such, the work of bodies like the Care Quality Commission (CQC) involve the imposition of a formal evaluative framework, one that reduces the thick context(s) of practice and care to a thin, semi-quantified, account structured by the requirements and imperatives of bureaucratic evaluations and a culture of audit. In short, bodies like the CQC are organized so that, albeit implicitly, they care less about the quality of care than they do the bureaucratic evaluation of the quality of care. Put another way, we might say that our ability to audit the quality of care lacks a certain degree of nuance and, therefore, quality.

If we examine this picture in the social theoretical terms of Pierre Bourdieu, we can construe the audits carried out by bodies like the CQC as symbolically violent. Because the practice of care has a relational and interpersonal dimension - it is experienced intersubjectively and this experience is an essential aspect of the reality of care - there is an aspect of care’s quality that cannot be subject to standardized forms of evaluation. This does not, of course, mean that it is beyond our grasp. However, getting to grips with care in its fullest sense requires a more qualitative approach that bodies like the CQC can provide. Unfortunately, the production of qualitative evaluations is not only expensive but fundamentally at odds with the aims and objectives of an audit. The purpose of an audit is to create evaluations that can be directly compared so that their respective merits objectively adjudicated.

The very nature of qualitative accounts means that they are too variable - too contextual – to be entirely suitable for or appropriate to this purpose. Thus, in an effort to evaluate various contexts in a comparable manner, audits necessarily neglect some aspects of care’s quality. Furthermore, there is no acknowledgement that this is the case, it is not taken into account. This sows the seeds for symbolic violence to flourish. As published our account suggests the evaluative practices of the CQC are such that they symbolically violate the object(s) being evaluated; the actual practices of care. In this instance symbolic violence is a feature of evaluating care through the imposition of a ‘top-down’ bureaucratic framework. 

However, recent reports suggest that there is another approach to understanding the symbolic violence of the CQC’s evaluations. The most prominent example is the determination that Cambridge University Hospitals Foundation Trust – which runs the world famous Addenbrooke’s hospital - is not only failing, but is doing so to such a degree that it has been put into special measures. Given previous reports this represents a radical decline in the quality of care being delivered by this institutional and the healthcare professionals that work within it.

The audits conducted by the CQC offer no substantive comment or wider analysis on the results they produce. Simply put, the CQC is engaged in the evaluation of healthcare, they do not engage in any wider reasoning as to why those evaluations might have come about. There is no mechanism through which the CQC can consider if the wider political, governance and funding arrangements are responsible for the apparent decline in care quality, as their audit suggests. As it is an independent and ‘arms-length’ body the fact that the NHS has suffered a real term cut in its funding and is under increasing pressure to not only do more with less, but to do more, and better, with less is not something the CQC can address or even make reference to.

The standardized evaluation of care and its quality remains the same regardless of the wider political circumstances. This means that the CQC’s activities hold further potential for symbolic violence. However, rather than simply being in relation to the imposition of an evaluative structure – the topic of the article we published – it lies in the imposition of this structure in a manner that is apolitical, which is to say insensitive to the broader socio-political context. On the one hand, this is the very purpose of bodies like the CQC organized in accordance with the dictates of New Public Management (NPM) – they are meant to be able to pursue their objectives whilst avoiding a certain degree of ‘politicking’ and ‘game playing.’ However, being created as independent and politically neutral does not make such bodies entirely apolitical or value-free. In pursuing its work the CQC enacts certain values – including a certain form or kind of objectivity – and, furthermore, is constituted to do as much precisely because these values are valued politically and political valuable.

Where politicians could previously make claims about the success or failure of public services bodies like the CQC attempts to determine or, better, establish the fact of the matter. However, where politicians bear responsibility for the successes and failures of public services, the CQC has no responsibilities beyond conducting audits. Even in cases when it makes recommendations they are relatively standardized and accordance with the dictates and norms of NPM. Thus, when the CQC finds that a hospital is failing they have little option but to articulate managerial solutions and, in effect, blame current management. However, it is not clear that the managers are to blame. When half of all services to the elderly and disabled are now considered to be failing we have to look at the bigger picture. But the CQC is not able to do so.

A recent entry on its blog the CQC has defended itself against suggestions that it is part of a conspiracy to undermine the NHS. It argues that we should not shoot the messenger. On one reading they are correct. The CQC is ‘just’ a messenger and there is no ‘conspiracy’ – at least, not one that the CQC is party to. Nevertheless, the message it has to offer must be considered partial and maintaining that its assessments are objectively true is, in effect, an act of symbolic violence. At the present time, continuing to suggest that hospitals and trusts are failing in the absence of any acknowledgements of their constraints and challenges they face is symbolically violence. Certainly, such violence is not promulgated by the CQC alone; it is a function of its NPM constitution and our particular political circumstances, circumstances that could well be called ‘the age of austerity.’ Nevertheless, we might ask ourselves, for how long can the CQC ignore the difficulties currently being faced by the institutions it purports to audit and still maintain that its evaluations are (politically) objective?