The language of quality

Journal of Evaluation in Clinical Practice, 2, 2, 87

P E R S P E C T I V E

The language of quality

Michael Loughlin PhD Lecturer in Philosophy, Department of Humanities and Applied Social Studies, Manchester Metropolitan University, Manchester. U K

Correspondence Dr M. Loughlin Department of Humanities and Applied

Manchester Metropolitan University Crewe and Alsager Faculty Alsager Campus Hassall Road Alsager Stoke-on-Trent ST7 2HL UK

Social Studies

Keywords: criteria, evaluation, indoctrination, language, management, philosophy, quality

Accepted for publication: 1 July 1996

Abstract Management theorists have developed a language which, they claim, can be used to evaluate many diverse practices, including practices in health care. This language embodies conceptualizations of practice and an approach to evaluation which treat the concept of quality as foundational and which have links with free market ideology. Despite an extensive literature which attempts to apply this language to various areas of life, its fundamental conceptual assumptions remain largely unexamined. Without adequate philosophical arguments in support of these assumptions, the value of this language and the validity of the approach to practice that i t embodies are unproven. Its imposition in the absence of such arguments therefore represents a form of intellectual imperialism. To understand and develop adequate responses to this situation, i t is necessary to look at Lhe broad political picture which affects the nature of debates in specific areas of practice, such as the health service, and to question the dominant paradigm governing practical debate in contempor:iry society.

The language of quality and the morals of the market

In recent years a great deal of work has gone into the construction of a new language for evaluating practice; a language whose applications now extend far beyond its place of origin in the world of business, into the worlds of health care, education and even the organization of prisons. A key feature of this new language is its use of the word ‘quality’ which, as two skilled users of the language note (Joss & Kogan 1995, p. 5 ) , has changed its connotations since the early part of this century, when it was a term associated with ‘exclusivity’, to become a much more ‘democratic’ word. Where once ‘quality’ was a rare thing, it is now found all over the place, and the word appears in much of the contemporary literature on evaluation almost as frequently as the definite article. ‘Quality’ is indispensable: where once people discussed how to improve services, this phrase now seems somehow incomplete, and they discuss instead how to improve

the qiialify of those services. I t is as if the first form of expression were a sort of shorthand for the second, quite acceptable in casual discourse, but to be replaced by the second phrase whenever one needs to give a full and precise statement of one’s meaning. To evaluate anything is, necessarily, to discuss its quality, so the term is treated as foundational. Authors describe quality as the ‘cornerstone’ of health care (Brooks 1992; Peters 1992; Al Assaff 1993 a.b) and this ‘discovery’ is heralded as a conceptual revolution (Hill el al. 1990; PA Consulting Group 1989; Joss & Kogan 1995, p. 9).

In the new, ‘revolutionary’ language, ‘quality’ is typically treated as a function of management (Loughlin 1993) and is associated with a host of terms taken from religious, economic, psychological and political discourses, including ‘empowerment’, ‘mis- sions’, ‘self-actualization’, ‘personal renewal’, ‘posi- tive focusing’, ‘zero defects’ and ‘vision statements’ (Loughlin 1995a, 1996) along with many terms which take ‘quality’ as their root, such as ‘quality circles’,

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‘quality continua’, ‘quality awareness’, ‘quality shadow structures’, ‘quality loops’ and ‘quality spirals’ (Loughlin 1993; Miles er al. 1995). Another char- acteristic of the new language seems to be a fondness for emphatic words such as ‘total’: so we have ‘total quality’, ‘total cost management’, ‘total service delivery concepts’ and ‘total commitment’ (to total quality) (Al-Assaff & Schmele 1993). Expertise in, and absolute dedication to, Total Quality are often stated as prerequisites for posts advertised in health service management. The subject of ‘Total Quality Manage- ment’ (TQM) is offered by management courses at many universities, and an ever expanding literature exists to support such courses. Since it is assumed that all organized activities share the goal of producing quality, it becomes possible to speak of ‘basic organisational criteria common to all complex organisations’ (IHSM 1993, p. 23), the discovery of which criteria is treated as a scientific enterprise (Loughlin 1994a). Thus there are ‘quality engineers’, the ‘experts’ in the new subject called ‘quality science’ (Berwick 1993). Because ‘organisational quality is a managed process’ (Brookes 1992, p. 18), ‘quality science’ is treated as a species of ‘management science’, and the theorists of this new science call for the use of ‘industrial quality management science’ in all ‘service industries’, including the health service (Laffel & Blumenthal 1993). One recent contribution to this literature is Advancing Quality: Total Quality Man- agement in the National Health Service (Joss & Kogan 1995). Stylistically, this text is atypical of work in the area, since its authors go to some lengths to translate the language of quality management into a form of prose ‘non-specialists’ can digest, with minimal dis- comfort to their intellectual and aesthetic sensibilities. However, the authors strain throughout to disguise the rather unpleasant managerial accent that comes with the territory, at several points breaking into what I have elsewhere described as Qualispeak, ‘a pseudo- intellectual “management-speak” whose quasi-economic ugliness fails to disguise a shocking lack of precision’ (Loughlin 1993, p. 69). Like much of the work in this field, theirs is marked by the appropria- tion of terminology from the field of philosophical ethics, accompanied by a (total) lack of any serious philosophical thought about the meanings of the terms it uses. TQM is described as a ‘paradigm’ (p. 26) and as a ‘philosophy’ (p. 18) with implications for the

relationships between quality and other evaluative concepts, including ‘need’ (p. 20), ‘value’ (p. 27), ‘goals’ (p. 29), ‘well-being’ and ‘equity’ (p. 31). Yet none of these terms is subjected to philosophical analysis, nor is the central assumption, that the concept of quality is somehow basic to evaluation, given any defence whatsoever. In the opening paragraph, the authors assert that:

TQM requires a wholehearted and long-term commitment to a particular approach to quality improvement. It has its origins in private sector manufacturing and has only relatively recently made a somewhat uneasy transition to service industries. The cultural, structural and systems differences between private sector services and public sector health suggest that considerable thought needs to be given to how the principles of TQM could be operationalized in the NHS.

(Joss & Kogan 1995, p. 1) The authors recognize that there are difficulties in applying a management strategy with origins in commercial practice to the health service, but they treat these as difficulties for ‘operationalizing’ the approach. In other words, they treat the problems for applying TQM to the NHS as practical rather than conceptual. They take it as read that the ‘principles of TQM’ are understood, and that they can meaningfully be applied to health care. Just as there are principles in engineering which can be applied to the building of any structure, such that if one knows how to build a supermarket one can apply the same basic principles to the building of a hospital (with the addition of some context-specific information about the requirements of the users of the building), it is assumed that if one knows how to manage a business then the same principles can be applied to the organization of any practice: one simply needs to learn the particular ‘requirements’ of the new area, which in the case of health care means incorporating empirical data about such matters as the costs of particular types of care and about what the ‘consumers’ of care require.

It does not occur to them that the problems may be conceptual in nature, in that the meaningfulness of the application can be called into question. What it meuns for a building to stand up does not change in accor- dance with the purposes for which it is used, but what i t means for an organization to be ‘successful’ does. There need be no general principles of good organi-

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zation, applicable to any and every practice, any more than there need be general principles of ‘doing well’ applicable to every human action (Loughlin 1994, p. 137). The authors assume that ‘doing well’ in health care can be understood in terms of concepts which also define what it is to do well in the world of com- merce. This is a huge assumption, which the vast majority of people working in health care do not share. More importantly, there is no good reason why they shouldshare it, any more than we should assume that knowing how to succeed in chess entails knowing something about success in general, such that one also knows how to win at poker, or that knowing how to build a supermarket entails knowing how to paint a picture of one.

To the untrained eye, business and health care are as alike as engineering and aesthetics. The fact that health care incurs financial costs does not undermine this point, any more than the fact that paintings are physical objects suggests that art is a branch of phy- sics. The onus is surely on those who think i t is meaningful to apply concepts from the one area to the other to explain very clearly why they think this is possible. In other words, why should we train our- selves to see the one activity as ‘basically’ or funda- mentally the same as the other, when they appear at first glance to be so different, and when the effort to see them as the same is indeed a struggle (requiring the construction of a new and unnatural language, and requiring us to dismiss as misguided the instincts of those dedicated to working in the health service, who view the comparison with business as repellant)? Why should we strive to force the practices of health care into a conceptual framework designed for competitive trade - against the resistance of many practitioners?

It is surely incumbent on the advocates of this ‘paradigm shift’ (Joss & Kogan 1995, p. 26) to explain the foundations of their new ‘paradigm’, ‘philosophy’, ‘science’ or whatever else they care to call it, and to justify the claim that by applying it to health care they improve anything. Instead of giving such an explanation, authors in the field think it sufficient to discuss the practical problems in implementing the approach. Joss & Kogan are by no means unusual in this respect. It is standard for management theorists to avoid the discussion of serious conceptual difficulties and to treat philosophical analysis with disdain. When chal- lenged to defend the conceptual foundations of their

discipline, to explain why one should want to imple- ment their approach in the first place, such theorists are dismissive, not only of philosophy but of all rational argument. Thus Wall (1994, p. 318) suggests that ‘it is vain to criticise’ managers for being confused about ‘the concepts which underpin their behaviour’, since ‘such people’ are not ‘expected to rely on the processes of rational thought’, should those processes turn out to be ‘not to our purpose’. It is as if they think that the sheer volume of work in the area should convince us there must be something to it. Heginbo- tham (1994) protests that ‘there is a great deal of management theory’ which has been ‘successfully applied within healthcare as in other industries’. It is of course true that the exponents of ‘management theory’ have been ‘successful’ in getting official backing to apply their approach to the health service. Whether or not they have been ‘successful’ in the more interesting sense, in that the service is better than i t would otherwise have been as a result of their inter- vention, is surely the point at issue. Needless to say Heginbotham defends neither this claim nor the treatment of ‘healthcare’ as an ‘industry’: he takes these points as read. Certainly he is correct in assert- ing that a great deal has been written on the subject (though whether one describes this work as ‘theory’ also begs some philosophical questions) and the existence of this vast literature does call for an explanation.

The explanation need not, however, be one that asserts the validity of ‘management science’ and TQM. Consider the quantity of human energy and resources that, in an earlier age, went into the development of methods for detecting, exposing and pun- ishing witches, who were blamed for causing plagues, for sudden, unexpected deaths and also for crop fail- ures and a host of natural catastrophes. Were Heginbotham the Witchfinder General, he might well have pointed to the numbers of witches ‘successfully’ caught and condemned, and the wealth of literature on the subject, as evidence of the validity of this approach to public health. We would immediately recognize this argument as question begging, since the concept of witchcraft has meaning as part of a conceptual framework which we have been given no good reasons to accept. Similarly, the creation of ever mote layers of management does not constitute an argument that either can or should persuade workers in the

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health service to evaluate their activity in terms of concepts derived from ‘a distinctively managerial perspective’ (IHSM 1993, p. 6) . As the ‘witchcraft’ illustration shows, the very fact that many people are engaged in a project does not demonstrate that the project is worthwhile, or that its conceptual foundations are sound. That they have the approval of the powers that be most certainly does not guarantee this. What is needed is philosophical argument, and this is strikingly absent from ‘management theory’.

Philosophy, retraining and indoctrination

Philosophy is often portrayed as a discipline divorced from practice. I have argued elsewhere that this is a misconception, whose basis lies in a philosophical theory that is now widely believed to have been dis- credited (Loughlin 1994b). The aim of philosophical analysis is to identify the logical structure of arguments. in order to assess their validity and to expose and analyse their key assumptions. Far from being an alternative to practical thinking, i t is essential, if thinking is to provide the basis for coherent practice, that logical confusions about the meanings of terms and the implications of statements are avoided through the use of philosophical method. However, philosophy is not only characterized by its methods. Philosophers typically raise questions of a fundamental nature, since in most discussions, logical analysis of the key terms used leads fairly quickly to the questioning of fundamental assumptions. When con- fronted with the assertion that all decisions should be based on sound evidence, a philosopher is likely to ask what ‘evidence’ means, and how, in the first place, one identifies good evidence and distinguishes i t from bad evidence. If the assertion is so obvious that no sane person could dispute i t , then a straightforward answer will surely be forthcoming. If, however, no clear answer is given, then we might suspect that some sort of trick is being played: perhaps the initial statement is not as innocuous as it first appeared to be - perhaps there are ambiguities worthy of examination (Gra- hame-Smith 1995).

Hostility to this type of question is the intellectual equivalent of putting one’s fingers in one’s ears whenever one’s most cherished assumptions are cri- ticized (Loughlin 1994b, p. 312). I t indicates confu- sion at best: at worst it is associated with arrogance,

bigotry and intellectual repression. I have argued that insofar as ‘objectivity’ is a valuable thing it involves ‘the ability to view the world from perspectives other than one’s own’ and that

a necessary condition of having this ability is being prepared to view one’s own philosophical assumptions with a degree of scepticism, as one set of assumptions amongst others, and thus as potentially false. This makes it possible to view them as in need of support in terms of arguments, intelligible to other rational beings w h o might see the world differently.

(Loughlin 1995b, p. 133) The true ideologue views his or her own assumptions 2s sheer commonsense, too obvious to be worth debating. The only interesting questions for such a person concern how one moves from (his/her own) theory to practice. The activity of spelling out assumptions clearly and subjecting them to analysis is treated as an irritating distraction from the business of turning (one’s own) ideas into reality. The ideologue does not have time for the ‘academic’ and the ‘philosophical’, being too busy implementing beliefs to pause to consider their truth value, and this mentality is supposed to be indicative of a ‘practical’, and therefore serious. mind. The real effect of separating the ‘practical’ from ‘ideas’ is not, of course, to make one’s thinking more ‘practical’: rather il is to protect the set of ideas influencing one’s approach to practice from criticism. One’s approach will still be influenced by a set of ideas and assumptions, even if one refuses to spell out clearly what they are.

I t should not, then, be a surprise that no sustained defence has been given of the assumptions underlying the health service reforms and the rise of ‘management philosophy’ (Al-Assaf & Schmele 1993, p. ix). I t is unsurprising (although it is, nonetheless, remarkable) that the advocates of an approach which insists that every aspect of practice should be examined in detail, evaluated and continually re-evaluated should refuse so bluntly to examine and evaluate their own assumptions.

The defenders of TQM emphasize its revolutionary nature. Workers are expected to conceive of their activities in new ways, with the help of ‘trained managers’ whose ‘role’ it is to ‘change perceptions’ and ‘lead opinions’ (Spiers 1994). This process is viewed as a form of training (or retraining) resulting in a new

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‘quality culture’ (Joss & Kogan 1995, p. 22) -the word ‘culture’ conveying the ideas of a group of persons characterized by a distinctive set of practices and associated beliefs. Barely beneath the surface of the ‘empowerment’ rhetoric is the idea that this new intellectual culture must, in the first instance, be imposed on a hitherto ignorant population, who will become ‘enlightened’ once they have been initiated, and only when ‘enlightened’ can they be said to have reached ‘maturity’ (Crosby 1979, pp. 32-33); Jones & Macilwane 1991, p. 21; Curtis 1993, p. 200). By implication, opposition to TQM indicates lack of maturity, although Merry (1993) also suggests it is symptomatic of decrepitude. What each condition has in common is the suggestion that the sufferer’s objections need not be taken too seriously. Ideas can be dismissed and choices overridden without this in any way threatening the objector’s ‘autonomy’, since by virtue of being an objector s/he is seen as already lacking autonomy.

Managers are cast in the roles of educators, where ‘education’ means changing the I J N I L I ~ S of those who are to be educated. Thus ‘education is about changing attitudes’ with the goal of ‘securing commitment and behdviour change’ (Joss & Kogan 1995. p. 31). As experts on quality, managers speak with ‘particular authority’ on the purpose of any organization, including the health service (IHSM 1993, pp. 8 and 31), and it is therefore their job to organize ‘the management of public understanding’ to ‘correct’ the expectations of the public and the workforce with regard to the nature and purpose of health care (Dare 1994. p. 198). If managers play their part in providing the sort of ‘education’ that is synonymous with ‘transformational leadership’ (Curtis 1993, p. 200), i t is surely only reasonable that others accede to the process of ‘educative change’ (Joss & Kogan 1995, p. 43). However difficult it may be for carers to see the patient as a consumer or a customer, and to see their fellow workers as ‘internal customers’ (Joss & Kogan 1995, p. 23), they are expected to try, just as the ignorant should at least t ry to learn something and the immature should listen to their elders and betters. The coercive flavour of this brand of education is swee- tened by democratic declarations that we are all in it together, that change must come from everyone and be ‘bottom up’ as well as ‘top down’ (Joss & Kogan 1995, pp. 40-44). Declarations such as this, though

meant to reassure us, treat the desirability of the changes as unquestionable, effectively ignoring the possibility that scepticism about the approach may be justzjkd. The sceptic is portrayed as someone with ‘psychological and other needs’ that responsible ‘re- educative initiatives’ should address. Individuals need to be ‘developed’ so that cultures can engage in ‘dynamic self correction’ (Joss & Kogan 1995, p. 43). The use of such terminology suggests that doubt is being treated as a personal problem for the doubter, rather than the legitimate response to a theory that has failed adequately to explain, let alone prove itself.

When training lacks a rationale intelligible to those being trained, it is experienced as indoctrination. Darbyshire (1993) speaks for many working in the health service when he expresses a profound sense of ‘alienation’ and ‘despair’ as he watches the service being ‘transformed into an ideologue’s adventure playground’. If those imposing the new ‘perspective’ know that no such rationale can be given, if they rejcct the very idea that an argument is either possible or necessary (Wall 1994). then they are, indeed, engaged in a process o f indoctrination. In that case their ‘authority’ is ‘rooted in nothing other than the power structure, and their current place within it’ and their job is ‘to impose an alien vocabulary on carers’ giving no honest account of, nor argument for, the ideology which underpins it (Loughlin 1995b. pp. 131-133). Darbyshire is right to call for resistance to this sort of intellectual repression.

Joss & Kogan (1995, p. 43) accept that the cause of resistance to TQM may lie in an inadequate explanation of the approach by management, observing that ‘the different versions of TQM were not fully conceptualized before they were launched’. Were this admission accompanied by an adequate explanation and defence of TQM, it would represent real progress. An adequate account of ‘TQM philosophy’ would explain its basic assumptions in some detail. What do the defenders of TQM mean by ‘quality’? What is ‘quality science’ and how is it that its ‘principles’can be applied apparently universally, to any organized activity whatsoever? What is the basis for management’s claim to be a ‘science’? Why do management theorists sometimes treat quality as a ‘product’ (or ‘output’) of organized activities, and sometimes as a ‘process’ which can be ‘managed’?Can it bc both? Why is this concept taken as fundamental to evaluation,

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such that bringing about quality is taken to be the ‘purpose’ of any worthwhile endeavour, including work that takes place within the health service? Unfortunately, however, while these authors offer a ‘definition’ of TQM, it is not one that clarifies the assumptions of the approach, nor does it provide the basis for a coherent defence of them. They state that:

TQM is an integrated, corporately-led pro- gramme of organizational change designed to engender and sustain a culture of continuous improvement based on customer-oriented definitions of quality

(Joss & Kogan 1995, p. 13) This tells us what we knew already: that the aim of TQM is to create a certain type of ‘culture’ within an organization, via the imposition of certain practices by management which will, in some as yet unspecified way, improve the organization. Clearly the phrase ‘based on customer-oriented definitions of quality’ is key to understanding the authors’ meaning, although the definition does not explain their conception of quality, nor does it indicate why the concept is treated as somehow basic to evaluation. If the concept of quality were conceptually basic, we would surely be able to explain other evaluative concepts in terms of it. However, whenever management theorists attempt to answer the question ‘what is quality?’ they inevitably define it with reference to other evaluative terms which have to be comprehensible independentfy of the concept of quality (suggesting that i t is not, in fact, foundational) for the definition to be understood (Loughlin 1993, pp. 71-72 & 19953, p. 82), or else they move immediately to the question ‘who defines quality?’ As the phrase ‘customer-oriented definitions’ suggests, Joss & Kogan take the latter option, iden- tifying different ‘conceptions of quality’ in terms of which group of persons defines (or ‘drives the definition of‘) quality (pp. 6-8 & 169-171). This shift represents an abuse of the term ‘definition’. To define a term is to say what it means: a good definition would help explain what the term meant to someone who did not already know, and would serve as a guide to future usage, ruling out some uses in advance by distinguishing appropriate uses from inappropriate ones (Loughlin 1993). There is a difference between conducting a conceptual investigation into the meaning of a term, and conducting an empirical sur- vey whereby one invites various people to apply it to

certain services or products. The latter type of inveF- tigation may provide the basis for, or may at least inform, an investigation of the former sort, but there is much more involved in analysing the meaning of a term than simply knowing how certain people would apply it in specific circumstances: particularly when the term’s meaning has an evaluative component. In such a case, a full account of the term’s meaning should include the fact that different people, with opposing attitudes, will apply it to different things, and a proper defence of the claim that one is applying the term correctly would include a defence of the reasonableness of whatever attitudes determined one’s application. To ‘operationalize’ something (and, indeed, to be ‘wholeheartedly committed’ to it) one must first know what it means. There is something very bizarre about an approach which is ‘launched’ before being ‘fully conceptualized’. Joss & Kogan state that ‘The quest for quality is made more testing by the difficulty of defining it.’ (p. 5) If they do not know what ‘quality’ means, then why have they embarked on a ‘quest’ for it? How will they know when they have found it? What definition of quality is implicit in their view that what the ‘customer’ has to say about quality has special significance?

In line with the rest of management theory, the authors have not thought about what sort of word ‘quality’ is before embarking on their ‘quest’ for it. Management theorists are perhaps wise to avoid a philosophical investigation of the concept of quality, since such an investigation exposes the incoherence of their ‘quality science’, the very idea of which places the term ‘quality’ in the wrong logical category. By using ‘quality’ to refer to something which can be measured, whose presence or absence can be detected scientifi- cally and which can enter into causal relationships, they treat the term as if it were a referring expression. The correct analysis of ‘quality’ suggests that it does not, in fact, refer at all. Rather, one predicates the term of something in order to recommend it as a good instance of its kind, and this ‘commendatory function’ is the only common strand of meaning which the term possesses in every context in which it is used (Loughlin 1995, pp. 82-83). The proper criteria for its application to any specific instance of a given kind differ radically according to context. (The criteria for its application in the context of health care, for instance, need have nothing whatsoever to do with the criteria

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for its application in any other context.) This is why it is so easy to be ‘wholeheartedly committed’ to quality in advance of knowing what it is: because one is not, in fact, committing oneself to anything in particular; all one is doing is (artificially) detaching the term’s general commendatory function from any specific criteria of application in any concrete context. To go on to speak as if one has discovered a thing (or ‘entity’; Brookes 1992, p. 18) named ‘quality’, which exists in every context in which one can use the word and whose nature can be the object of a scientific study, is to talk nonsense.

The exponents of ‘quality science’ treat the tautol- ogy that it is always good to have quality as if it were a scientific discovery. They treat the premise that ‘to evaluate anything is to discuss its quality’, which tells us something about the meaning of the word ‘quality’, as if i t represents a substantial truth, since they proceed to search for ‘general principles’ of ‘quality management’ which can be applied in any context whatsoever. So i t is that an entire discipline is founded on a fairly crude philosophical error (Loughlin 1995a, pp. 83-84). Far from being a more complete statement of one’s meaning, the move from discussing how to ‘improve’ a service to discussing how to improve its quality adds nothing to the debate - except, it seems, that our ability to find two ways of saying the same thing has created, for some, the illusion that a new feature of the service has been discovered, and these confused theorists go in search of the elusive ‘quality’ as once the confused sought out witches.

The survival of ‘quality’

Despite the vacuous nature of the debate about quality, the discussion of this concept will continue for two reasons, neither of them good. The first is that the word ‘quality’ has emotive properties such that, other things being equal, the very fact that the word has been applied to something inclines us to view it posi- tively, irrespective of any rational considerations. Hence its importance to the business world, where the need to ‘demonstrate’ quality ‘in the perception of clients or customers’ (Brookes 1992) is stressed (Kelly & Swift 1991; Loughlin 1993). The second reason concerns the word’s place in a philosophy whose time has very much arrived. The defenders of TQM speak

of a ‘paradigm shift’. Their use of this term is significant, and is perhaps related to their appeal to the language of ‘revolution’. In Kuhn’s philosophy of science (Kuhn 1970) a ‘paradigm’ is a set of inter- connected beliefs representing a whole world view. A paradigm shift represents a change in the conscious- ness of members of the scientific community, such that one whole system is replaced by another, and the replacement takes place via a non-rational process, a ‘scientific revolution’. The revolution occurs when the old system is perceived to be inadequate hy the majority of scientists working within it.

Robert Wolff (1986) complains that a similar shift is taking place in our political thinking, as the ideo- logues of free market capitalism urge us to reduce every aspect of human life to a market transaction. Commenting on Robert Nozick’s classic text Anarchy. State and Utopia (1974), Wolff identities its bizarre style as its most disturbing feature. Even compensation for the victims of crime is discussed in the language of market economics, such that the level of compensation paid effectively determines the market price of the injuries suffered. Wolff brings out elo- quently the dehumanizing potential of this conceptual shift. The introduction of TQM into the health service can be seen as part of a wider process, establishing free market thinking as dominant in every significant area of life. While I have said that to speak of ‘improving X’ and of ‘improving the quality of X’ is simply to find two ways to say the same thing, these expressions are not identical in meaning, for although the addition of the word ‘quality’ adds no substantial content to the discussion, it brings with it a host of associations. Contained within the hollow jargon of quality is the mentality of the market.

To return to the above-quoted definition of TQM, offered by Joss & Kogan, there are obvious clues as to the nature of the ‘culture’ TQM aims to create in the use of the words ‘customers’ and ‘corporately led’. To apply TQM to any organization it is necessary to conceive of its users as its customers, reinforcing the idea that all organized activities must be understood on the model of a commercial enterprise. The type of commercial enterprise in question can be envisaged more clearly by considering the authors’ historical account of the rise of TQM thinking. As they explain, ‘scientific methods of management’ developed in the light (or, perhaps more appropriately, the shadow) of

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‘changes in production processes’ leading to greater ‘industrialization’ and ‘automation’, resulting in

a decline in the number of skilled workers who were responsible for a complete production process and an increase in employment of unskilled and semi-skilled workers carrying out high volume repetitive sub-tasks in narrow areas of production.

(Joss & Kogan 1995, pp. 8-9) In these circumstances the ‘sense of individual own- ership of quality for the final product’ proved ‘difficult to maintain’, leading to the development of Quality Control and Quality Assurance mechanisms from which TQM eventually developed. These mechanisms functioned to replace the individual’s engagement with the work that mass production had destroyed. In Marxist terminology, these mechanisms take as their starting point the conditions of alienation created by advanced capitalism.

I t is hardly surprising, then, that some health service workers are expressing a sense of ‘alienation’ as a result of current developments. Increasingly encoun- ters between health care practitioners and patients, which might previously have been conceptualized in terms of unique and often implicit moral commit- ments, are instead being understood in terms of for- mal capitalist transactions, as the language of care is systematically replaced by the language of business (Darbyshire 1993). I t is certainly the case that the reality of health care is changing, but the introduction of the new vocabulary is not functioning, simply, to describe those changes. I t is also helping to shape the new reality.

Perceived inadequacies in our previous conceptions led to their overthrow by market ideology. If these changes are to be resisted, then the development of clear alternatives must accompany work pointing out the shortcomings of current management thinking. The lack of philosophical depth to much of the debate taking place today is as unsurprising as it is striking. The more confused a culture becomes about foundational questions, the more it strives to convince itself that the answers to these questions are already known. Awareness of the ideological implications of the forms of evaluative language in use is a prerequisite to meaningful discussion. There is no need to cut the word ‘quality’ out of the language. However, in the present atmosphere those who wish to oppose the

intellectual imperialism of market ideology should note that there are dangers in the use of this term. A word, like any other symbol, can be appropriated by a cause, and the struggles taking place in the health service cannot be understood independently of wider philosophical and political questions.

References

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Al-Assaf A.F. (1993b) Principles of total quality in health care organisations. In The Textbook of Total Quality in Healthcare (eds A.F. Al-Assaf & J.A. Schmele), pp. 29- 30. St Lucie Press, Florida.

Al-Assaf A.F. & Schemele J.A. (1993), The Textbook of Total Quality in Healthcare. St Lucie Press, Florida.

Bcrwick D.M. (1993) Continuous improvement as an ideal in health care. In The Textbook of Total Quality in Healthcare (eds A.F. Al-Assaf & J.A. Schmele), pp. 31- 39. St Lucie Press, Florida.

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The language of quality

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