Austerity creates numerous problems for professionalism within healthcare. While it can affect extrinsic rewards (e.g. pay and status), more importantly, austerity can significantly diminish the intrinsic value of professional work because of the deterioration of conditions in which professionals are operating. This shapes our expectations of what it is reasonable to demand of professionals. There is no point expecting professionals to adhere to ethical principles and attain particular standards if their circumstances make these impossible to attain [29]. Reflecting about austerity ought to make us sensitive to the impact that challenging conditions have on professionals’ capabilities and conduct. There is plenty of scope for disagreement about the linkages between structural conditions and the agency of professionals, but it makes no sense to ignore them.
The fundamental point here is that the very existence of professionalism depends upon complex sets of social conditions being put in place and maintained. Professionalism is both an expression of individual capability and of social organisation—both are required. (This is a theme developed in literature within both sociology and applied philosophy, which we have analysed elsewhere [30]). Professional roles are always constructed by and discharged within particular social conditions and relationships. This is not to say that individuals outside of professional roles cannot exercise expertise to bring about good ends, and do so with integrity, but outside of professional roles these things are not examples of professional ethics in the standard sense. Professional ethics is one way in which individual responsibility can be harnessed and developed but it is distinctive because it is embodied in specific socially defined, sanctioned and organised roles, settings and forms of authority. Part of the demand of a profession is that a practitioner can and will take individual responsibility (for example, be worthy of trust and capable of exercising leadership) even when operating alone, separated from their peers and/or working in over-stretched conditions; but, even in those circumstances, they still gain their bearings and legitimacy from their professional role. This is to flag up the fundamentally social character of professionalism: professional ethics cannot be enacted in the abstract, they must be situated in practice. We can insist on asking searching questions about the integrity of individual professionals but questions about the integrity of the social conditions of professionalism must be equally insistent. One important consequence of this is that the duties of those at the ‘sharp end’ of any human institution are dependent on the fulfilment of the duties of many others.
Professionalism is, therefore, contextually dependent. It is not a fixed, abstract essence but a historically situated, evolving and contested concept. Indeed, changes to the social character of professionalism over the last few decades have produced many concerns about the erosion of traditional professional values including the authority of professionals to determine the nature and ends of their work according to standards they see as ‘internal’ to the activity in question. The increasingly managerial culture in healthcare (which we suggest has become heightened through the imposition of austerity) subordinates professional norms to organisational norms, defining professional activity in terms of whatever happens to be relevant to organisational success in a particular policy regime. In such cases professional autonomy and discretionary is replaced by ‘standardization of work procedures and practices and managerialist controls [and] relies on externalized forms of regulation and accountability measures such as target-setting and performance review’ [31]. In practice—in the UK but also in any system where the containment of resource use has become a central principle of healthcare organisation—growing managerialism combined with increased financial pressures have strongly shaped the conditions and possibilities of professional practice.
This institutional cultivation of budgetary and efficiency ‘consciousness’ is obviously a defensible strategy up to a point; however, it also carries clear risks of deleterious effects. The point at which financial constraint substantially undermines the conditions needed for professionalism is both a theoretical and empirical question, and will partly depend upon the conception of professionalism being deployed. However, on any reading of professionalism, there will come a point where financially determined organisational restrictions stifle professionalism and contort professional ethics.
Without being overly idealistic, or ‘starry-eyed’, about healthcare professionals they might, in relatively affluent health systems, reasonably expect conditions to be available that enable them to: (a) routinely provide threshold levels of adequate treatment and care; (b) have some capacity to identify and aim for high standards of treatment and care through, for example, (contributing to or harnessing) research and innovation; (c) work in an environment that supports effective teamwork and enables professional development including peer learning and support, and (d) have some time and space available to them to come to terms with, and help enact, evolving models of good practice. This is a fairly minimal sketch of expectations in which the various elements belong together. Offering effective and safe basic care in a routine way is a valuable thing but it cannot be enough—not least because professional expertise consists, in part, in questioning and reforming our conceptions of what counts as effective care. However, all of this—even the provision of routine basic care—is put under threat if the circumstances in which staff are operating restrict the possibilities of exercising and upholding professionalism.
Here we will briefly summarise three overlapping mechanisms through which the conditions of professionalism can potentially be undermined by financial pressures—intensification of work, practitioner isolation, and organisational alienation. This analysis has been generated by systematically setting the details of the Dr. Bawa-Garba case (and analogous examples) against theorisations of professionalism as a social accomplishment (including our own previous work on this theme [30]). We will outline the mechanisms separately but we are suggesting that they tend to work together in mediating between working conditions and the construction and exercise of professional roles and ethics.
Firstly, the intensification of work pressures is perhaps the simplest means through which standards of professionalism are put at risk. Under financial constraint healthcare systems are continuously asked to deliver ‘more for less’ and this can get translated into an expectation that individual professionals are expected to do more and more. Under conditions of austerity the effect may be to concentrate a more substantial and complex workload into fewer hands. There is obviously a line at which this becomes unsustainable and harmful to both professionals and patients. Though this may be hard to discern, even operating on the ‘right side’ of that line is asking a lot from individual professionals. The sheer quantity of activity—both volume and number of tasks—drains physical and psychological resources and demands stamina and resilience which are not infinite. There is also the continual stress that work may, as a result, be undertaken with inadequate concentration or responsiveness to the particularities of cases or circumstances, especially as exhaustion sets in. These conditions can risk the more personal and subtle aspects of caring becoming ‘crowded out’ of clinical practices and relationships. At an individual level these conditions can lead to ‘burn out’ for individuals and staffing crises for healthcare systems even where there is in principle resource available to fill positions.
The three mechanisms we are discussing, taken together, change the character of professional work. But that possibility is discernible from this first point alone: intensification and the significant reduction in the availability of ‘mental space’ and time not only impairs one’s ability to do a good job but also alters one’s sense of the job being done. If there is insufficient time to engage properly with patients, or to reflect on the strengths and weaknesses of decisions and practices then this is likely to erode interest, motivation and personal fulfilment. It seems plausible to suggest that the pressures and effects of intensification may also undermine the capacity for, and sensitivity of, ethical discernment and reasoning. After all, tired minds are not the best minds.
Secondly, and relatedly, austerity can create conditions of isolation for practitioners which can threaten their work. Financial pressures, including deliberate efficiency measures and recruitment and retention side-effects, can lead to situations in which individuals are often working with much less ‘back up’ and/or in which—because of workload demands—they have much less time to communicate with one another. When and where isolation occurs it is a body blow to professionalism and professional ethics because these critically depend upon teamwork, collegiality and both peer review and support. A healthy professionalism will manifest itself in opportunities for individuals to ‘compare notes’ with one another and to look for informal (as well as formal) moral and technical support from colleagues. Conditions of isolation are therefore a threat to professionalism even before the potential perils of the more individualist, competitive, defensive and self-oriented attitudes that may be encouraged by harsher neo-liberal cultures are considered, though isolation may be amplified by such norms. The quality of ethical deliberation very often depends on creating conditions for dialogue and debate, whether in routine interaction or in more structured opportunities for organisations and professional groups to ‘stand back’ from immediate practical imperatives and mutually reflect on contentious or burdensome issues.
As with intensification, the risks of isolation are not purely on the quality of the work done but on the quality of life of practitioners. Relative isolation, especially when being challenged by growing demands, is liable to have a disastrous effect on mood and wellbeing. Being chronically dismayed, anxious or depressed has serious consequences for the way one sees the worthwhileness and meaningfulness of one’s role and hence poses a substantial cumulative risk to the sustainability and credibility of the system of which one is a part.
Thirdly, the loss of meaning and motivation may be compounded by (and perhaps most acute in relation to) a growing sense of alienation. Being subject to strong organisational norms is always liable to produce a degree of alienation, but the norms of pervasive managerial directives and regimes of ‘efficiency’ can easily introduce a gulf between practitioners’ organisational identities and their vocational identities. This is possible, for example, when priorities are principally shaped by the demands of budgets, targets and algorithms rather than by context-sensitive professional expertise.
Conditions of austerity and its associated management techniques risk professionals feeling that they have become separated from the things that took them into their profession in the first place. Whereas with the first two mechanisms the prevailing sense might be that it has become much harder to do a good job, organisational alienation can create a sense that one’s role has been taken away altogether and replaced by something else. When this happens then disillusionment, severe frustration or depression may not be very far away. It is not unreasonable for professionals to feel that they should be able to derive some fulfilment from performing well in their role. If this possibility is substantially reduced, or completely removed, so that workers can no longer live up to their idea of what it means to occupy and execute their professional role, their thoughts of leaving the profession are understandable, not least as a means of maintaining a vestige of personal (and professional) integrity [32].