Abstract
How do professionals respond to the commodification of health care? Using an interactionist perspective, we answer this question by referring to the findings of five qualitative studies of hospital surgeons, mental health-care professionals, emergency and ambulance personnel, and youth workers in the Netherlands. We find that differential levels of professional autonomy, dominance and discretion spawn different combinations of the logics of the market, bureaucracy and professionalism. We discern five new ways of enacting professionalism: (1) entrepreneurialism: embracing commodification as integral part of professionalism; (2) activism: rallying against encroachment on the profession; (3) bureaucratization: seeking reassurance in procedures; (4) pretending: faking compliance to protect autonomy; and (5) performing: upholding the profession through conscious and skillful management of appearance in the eyes of patients and the public. Hidden strategies of opposition, however, support commodification since most professionals outwardly play by the rules and mix the logic of care with those of the market and bureaucracy, rendering alternative courses of action and solidarity more difficult. Uncertainty is increasing for all professionals, leading to feelings of insecurity and reflexivity but also to creativity. Professionalism is increasingly ‘disembedded’, called into question, and de-routinized.
Highlights
It is a commonplace that professionalism in Western welfare states is changing under the organizational demands of managerialism, new public management and the marketization of services
To fill in the right forms is much more important now.’ (Study I, participant XV, ambulant care worker) While many scholars have focused on the limitation of professional autonomy by bureaucratic procedures (e.g. Exworthy and Halford, 1999; Freidson, 2001; Vogd, 2006), the youth workers in our study did not seem very bothered by this
A youth group leader states: ‘All protocols are useful, it is more work and it takes away some creativity and autonomy, but I still think that safety is more important.’ (Study I, participant X, Group Leader) An ambulant care worker emphasized the importance of protocols above professional autonomy: Protocols are very useful and it is important to follow them properly, because you are safe and you can show how we do it within the organization
Summary
It is a commonplace that professionalism in Western welfare states is changing under the organizational demands of managerialism, new public management and the marketization of services (for an introduction see Muzio and Kirkpatrick, 2011). We found professional ideas and practices to be subject to subtle but significant changes In their strategies of dealing with the commodification of care, we discern five ways of professionalism, which we coined entrepreneurial, activist, bureaucratic, pretending and performing. Even where there is no market for health-care products, another facet of commodification – ‘demand steering’ – has made significant inroads in the Netherlands, with patients recast as consumers entitled to services and choice (Tonkens, 2011). In the Netherlands, insurance companies gradually gained more freedom to (not) sign contracts with organizations and individual professionals and to set the terms when doing so Compared to their Dutch counterparts, German medical professionals were more successful in softening competition and preserving their autonomy (Kuhlmann, 2011). Inspired by the symbolic interactionist tradition in sociology (Mead and Morris, 1934; Blumer, 1969), we analyze social phenomena in terms of their basic building blocks – interactions between people and how social patterns arise out of these interactions (for two early examples addressing professionals, see Becker, 1961 and Goffman, 1959)
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