The Professions, State and the Market author Mike Saks talks to us about complementary medicine, the differences in the British, American and Russian healthcare systems and more.
Mike Saks is Research Professor in Health Policy at University Campus Suffolk, UK, and Visiting Professor at the University of Lincoln, UK, and the University of Toronto, Canada. He has published over a dozen books with top publishers on professions, health care and research methods.
1. What interested you in researching the development of the medical profession particularly? Why not the legal profession for example?
The medical profession has held a long-term fascination for me because of its particular importance for the wellbeing of human kind. In consequence, although I have studied and been involved in the education of professions generally, including the classic profession of law, I have undertaken numerous research projects and produced many publications on medicine in particular in Britain and internationally. These have given me a strong grasp of the dynamics of this key area both historically and in modern times – along with my own practical involvement in high level health care management and health policy formation in this country and elsewhere.
2.Why did you adopt a Weberian perspective specifically?
For me, neo-Weberianism provides the most incisive theoretical perspective for understanding professional groups at a macro level in the context of the state and the market. The benefits of this approach against others are highlighted in the book. At the heart of neo-Weberianism is the notion of professions being based on exclusionary social closure, which is centred on the creation of legal boundaries that bestow the privileges of income, status and power on a selected group of insiders. The analysis underlines that such state-endowed professional privileges are a sociopolitical creation and need to be justified or otherwise to the broader public by the bodies concerned.
3.What are the key messages of the book about the development of the medical
A key message of the book is that the medical profession has developed in very different ways in the three societies of Britain, the United States and Russia under varying sociopolitical regimes, from the capitalist framework of the former countries to the socialist roots of the latter. These developments are documented in detail over several centuries in each society in relation to the interplay between the state and the market. It is also evident that the development of medicine can only be seen in the context of the holistic division of labour – as it is synergistically linked with the position of other groups, including nurses and midwives, allied health practitioners and complementary and alternative therapists.
4.What was the most surprising thing you discovered through your research?
The most surprising aspect of the research was that the development of the independence or otherwise of the medical profession is not simply related to the public/private axis in the interplay between the state and the market, as is commonly supposed. Instead, its standing varies from the state-regulated independence of the British medical profession and the corporatization of medicine in the United States to its deprofessionalization in Soviet times and the subsequent attempts to reconstruct professionalization in Russia. As such, there is little convergence in medicine in the three societies concerned, notwithstanding the pervasive implementation of New Public Management.
5.Is it possible to summarise briefly the key differences and similarities between British, United States and Russian physicians?
Physicians in Britain generally have a greater degree of autonomy under the shelter of the state than in the United States where they are increasingly subject to greater corporate controls in a more market-oriented society. However, in America the growth of specialization has been particularly rife, which has enabled those operating in the top specialisms in a more privatized economy to earn very high incomes. This contrasts with Russia, where medicine remains female dominated and professionalization is still relatively undeveloped, in which the salaries of doctors are typically low – even in comparison with other occupations.
6.What was it like researching Russia’s health service? It is probably one of the least well-known societies in this regard, so what would you say was the biggest difference?
I have been involved in research into the Russian health service since the late 1990s. At this time I was involved in an INTAS project with the Russian Academy of Sciences in Moscow studying some six hundred physicians in three different areas of Russia. One key research objective was to see if the values of Russian physicians had changed following the demise of the socialist state. This was a fascinating agenda – one of the most interesting aspects of which was the continuity that seems to have been maintained through Tsarist, Soviet and post-Soviet times despite apparent seismic sociopolitical change, not least in relation to the level of centralization and the ongoing existence of a ‘black market’ in health care.
7.You obviously have an interest in the way in which complementary medicine is regarded within the health care landscape – what do you think it can contribute to modern health care?
I have for long been centrally involved with complementary and alternative medicine (CAM) through publishing and serving as a government adviser in this area, including as Chair of the Research Council for Complementary Medicine. As such, it is not surprising that it is a strong strand in the book, especially because I regard orthodox and unorthodox medicine as two sides of the same coin. As regards the potential contribution of CAM to contemporary health care, I think all therapies should be evidence based in terms of quantitative and qualitative methodologies – albeit CAM has laboured under significant disadvantages to biomedicine in all the countries concerned as a result of differential resourcing and political positioning.
8.What would you like medical policy makers to take from your research?
The central point of the book is that the form of professionalization or otherwise of medicine has significant effects in terms of clients and the wider public. This means that medical policy makers in all societies need to consider very carefully how they regulate physicians at a collective level in the public interest. As the book underlines, the models concerned range from complete independent professional self-regulation to ‘top down’ regulation by the state from above – as well as allowing the market to determine medical outcomes, which can be seen as ‘the law of the jungle’.
9.You mention that you would like to see your book being used in medical schools. What would you like trainee doctors to take from your research?
I would indeed like to see the book employed in medical schools, as well as in the training of other health professionals as well as doctors. The reason for this is that its comparative international focus clearly shows how the work of physicians and their organization varies between societies – and thereby highlights both ‘good’ and ‘bad’ practice in specific societal contexts. The book also underlines that medical arrangements are not just reflexively derived from the development of medical technologies and expert knowledge, but are significantly politically inspired. In these terms they are subject to determination by the state and market – including by politicians, users and doctors themselves.
10.In Britain, the National Health Service and the medical professionals who work in it are in an increasingly political relationship. What do you think the future holds?
The relationship between doctors and the British National Health Service has of late been particularly politically inspired – not least with the threat of junior doctors going on strike over pay and conditions. However, as will be seen from the book, it is argued that from its very inception the links between doctors and the National Health Service has been politicised, notwithstanding the interwar medical-Ministry alliance. I would expect the political aspects of this relationship to continue to surface in the future, especially as the British state has increasingly sought to regulate medicine – as most recently epitomised by the enforced introduction of regular medical appraisal and accreditation, albeit by peers.
11.How does the professional role and characteristics impact upon the doctor-patient relationship in each of the societies?
In all of this, the positive role of physicians should not be understated. As the book shows, in different societies at different points in time they may have been prey collectively to the operation of self-interests, influenced by commercial concerns in the market and operated under the yolk of the state. Nonetheless, it is important to distinguish the role of individual doctors from medicine at a wider group level – and none of the analysis in the book should be taken to undermine the altruistic spirit in which many physicians approach their relationship to patients. Indeed, the macro and the micro are particularly strongly connected in medicine from a patient viewpoint through the important role of professional and other forms of ethics.
12.What do you think was the most important insight gained about how the professions, the state and the market interact to influence health policy, and therefore patients?
The most important insight in the book about the professions, state and the market is that – whether in Britain, the United States or Russia – the interaction of all three of these elements affects substantially the way health care is framed and delivered. Accordingly, it is argued that the life chances of patients and the public more generally are significantly shaped in terms of mortality, morbidity and quality of life. The book in this sense is a clarion call for policy makers, practitioners and users to develop a greater understanding from a multidisciplinary neo-Weberian perspective of the many ways in which sociopolitical considerations influence health care at every level.
This unique book enhances our understanding of the links between professions, the state and the market – and their implications for the public in terms of professional practice. In so doing, the book adopts a neo-Weberian perspective, in which professions are seen as a form of exclusionary social closure based on legal boundaries established by the state. | Read More