by David Benbow
The concept of ideology seems to have been supplanted in contemporary critical theory by the concept of discourse. Postmodernist scholars, such as Michel Foucault and Gilles Deleuze and Felix Guattari, have criticised the concept of ideology. Nonetheless, the two concepts are potentially compatible. I believe that the concept of ideology is superior to the concept of discourse because, as David Hawkes noted, it mediates between the ideal and the material. The work of the Frankfurt School philosopher, Theodor Adorno, and his conceptualisations of ideology, are particularly useful in examining the relationship between the ideal and the material in modern neoliberal societies. The contemporary relevance of Adorno’s work is evident in the burgeoning literature concerning the philosopher—see, for example, Blackwell’s A Companion to Adorno, published in 2020, which contains the largest collection of essays by Adorno scholars in a single volume. I have utilised Adorno’s conceptualisations of ideology, within my own work, to examine different aspects of the law relating to health and healthcare.
Adorno’s distinction between liberal ideology and positivist ideology, and his conceptualisations of reification, informed my analysis of reforms which have marketised and privatised the English National Health Service (NHS). I also made use of Adorno’s method of ideology critique to demonstrate how many public statements regarding the high-profile Charlie Gard and Alfie Evans cases (which involved disputes between parents and clinicians regarding the treatment of young infants), for example by United States (US) politicians (such as Donald Trump and Ted Cruz), were unjustifiably critical of socialised medicine. The cases led to renewed proposals for the best interests test, which is currently determinative in such cases, to be replaced with a significant harm test. I employed Adorno’s notion of the dialectic of enlightenment (the idea that reason can engender unreason) to undermine the argument that parents would make better decisions in these types of cases. I contended that the clinicians in such cases reflexively acknowledged the limits of medicine, in contrast to the parents, who appear to have suffered from false hope. Adorno’s ideas are also informing my current research projects on vaccine confidence (and the influence of anti-vaccination ideology) and the potential of human rights to address health injustices in states within the Global South. In respect of the former, I have employed the psycho-social dialectic methodology that Adorno developed in his research into anti-Semitism to identify the objective social factors which have influenced the increase in vaccine hesitancy. In respect of the latter, Adorno noted that rights may be tacitly critical of existing conditions and thus I am developing a paper regarding how they may be used to articulate present injustices within the Global South (and elsewhere) with a view to their remedy.
In the chapter on the topic of the concept of ideology, published as part of the Frankfurt School’s book Aspects of Sociology, Adorno distinguished between liberal ideology and positivist ideology. In Adorno’s view, positivist ideology, which he thought was becoming more prominent in modern societies, hardly says more than ‘things are the way they are’. By contrast, the emphatic concepts of liberal ideology, such as freedom, equality and rights, are often used, within discourse, to justify certain states of affairs (or changes to them). Such emphatic concepts can also be used to critique existing conditions. There are different modalities of the related concept of reification in Adorno’s work. One modality of reification in Adorno’s work is philosophical reification, which refers to phenomena being treated as fixed. An example of philosophical reification is the exchange principle, which treats unlike things alike. Another modality of reification in Adorno’s work is social reification, which refers to means becoming ends in themselves. Both of these modes are evident in consumerism. Reification may lead to estrangement, whereby people become strangers or enemies to one another. Estrangement is the opposite of solidarity, which Rahel Jaeggi defines as ‘standing up for each other because one recognises one’s own fate in the fate of the other’. Reification may undermine the solidarity which has been pivotal in the creation and continuation of the NHS.
I have analysed the emphatic concepts of freedom and equality and how they have been used within the discourse of successive governments regarding the English NHS. I have also considered the potential reifying effects of the market reforms that successive governments have implemented within the English NHS. When the NHS was established, in 1948, it was to be publicly answerable via ministerial accountability to Parliament. However, this was deemed to be a constitutional fiction. Since the 1970s, there have been efforts to enhance patient and public involvement within the NHS via two types of mechanisms, identified by Albert Hirschman: voice and choice. In the neoliberal era, the preference has been for choice mechanisms (although attenuated voice mechanisms have persisted). This preference is evident in the use of indicators and market mechanisms to facilitate competition among NHS providers. The internal market introduced by the Conservatives, in the 1990s, was justified on the basis of enhancing patient choice, although evidence indicates that it reduced the choices available to patients. The mimic-market established in the English NHS by the New Labour governments, in the 2000s, afforded private healthcare companies increasing opportunities to deliver NHS services and gradually extended patient choice to any willing provider. New Labour sought to naturalise the relationship between patients and the NHS as a consumerist one. However, studies indicate that many patients were recalcitrant in this regard and often did not utilise the opportunity to exercise choice when it was available to them.
The latest English NHS market was introduced by the Health and Social Care (HSC) Act 2012. This statute places duties on commissioners to act with a view to enabling patients to make choices. Such commissioners are also required to comply with regulations passed pursuant to S.75 of the statute, and, prior to Brexit, with European Union (EU) public procurement law, in tendering services. Such laws have coaxed many commissioners into tendering services in circumstances where they did not think that it was best for patients,  which is symptomatic of social reification, as the market has become an end in itself. New methods for enabling patients to compare providers, such as friend and family test (FFT) scores, have also been introduced. These are symptomatic of philosophical reification, as the process of reducing quality (patient experiences) into quantity (a number) is one of abstraction, which is unlikely to capture the complexity of patient experiences. In any event, patient choice, which was used to justify the coalition’s reforms, has taken a backseat, and the market created by the HSC Act 2012 has primarily involved providers competing for tenders. The intention of many of the policymakers who designed the market reforms to the English NHS thus seems to have been to get private providers into the NHS, rather than to extend patient choice. I contend that voice mechanisms are a preferable method of empowering patients by allowing them to convey the complexity of their experiences and to influence clinical practices.
Adorno was critical of the concept of equality, on the basis that it could obscure important differences. Nonetheless, equality of access to the NHS (based on need) and the reduction of health inequalities are principles which, I contend, are compatible with an Adornian perspective. The Welsh Marxist theorist, Raymond Williams, helpfully distinguished between dominant, residual, and emergent norms within his work.  I have conceptualised neoliberal norms (such as competition and choice) as dominant norms, the founding principles of the NHS (such as equality of access, comprehensiveness, and universality) as residual norms (as they are remnants from the era of the social democratic consensus, which preceded the neoliberal era) and the reduction of health inequalities as an emergent norm. In the neoliberal era, different UK governments have all articulated their support for the residual norm of equality of access. However, this has been undermined, for example, by the ability of foundation trusts to earn 49% of their income from private patients. The other residual norms, such as comprehensiveness, have also been undermined by successive governments, within the neoliberal era, thereby extending the exchange principle (as patients are now required to pay for some health services). The issue of health inequalities was not a priority of the Conservative governments between 1979 and 1997, which sought to bury the Black Report and which rebranded such inequalities, in a positivistic manner, as health variations. In contrast, both the New Labour governments between 1997 and 2010 and the Conservative-led governments since 2010 have adopted the goal of reducing health inequalities. The HSC Act 2012 created statutory duties for different actors to have regard to the need to reduce such inequalities. However, the impact of the main economic policy (austerity) pursued by governments since 2010, has increased such inequalities. Austerity negatively affected NHS capacity and resources, as well as population health, rendering the NHS less resilient to the current Covid-19 pandemic. The reduction of health inequalities requires alternative economic policies to austerity.
Ultimately, I have identified both liberal and positivistic elements in the discourse of successive governments, in the neoliberal era, in relation to the English NHS. Consequently, government discourse pertaining to the English NHS has not become completely positivistic. Rather, there are liberal elements which provide members of the public and scholars with a basis for critique. The statements of successive governments that they were desirous of empowering patients, respecting the NHS’ founding principles and reducing health inequalities can be used to critique their policies (which have not empowered patients, have undermined the NHS’ founding principles and are likely to exacerbate health inequalities) and to conceive alternative policies. The development of sustainability and transformation plans (STPs), integrated care systems (ICSs) and integrated care providers (ICPs), and the increased emphasis on integration in the discourse of the government and NHS England (a non-departmental body which oversees the day-to-day operation of the NHS in England and commissions primary care and specialist services) has been interpreted by many as a move away from the competition that has dominated the English NHS in the neoliberal era. A recent Kings Fund report found that there has been a move away from procurement to collaboration within the English NHS (with the former being used as a method of last resort). However, some fear that the new structures being established within the English NHS may undermine its founding principles and afford new opportunities for private companies.
I have argued elsewhere that the policies of successive governments pertaining to the English NHS were indicative of market fetishism. The recent award of many contracts to private companies under special powers that circumvent normal tendering rules, during the Covid-19 pandemic, suggests a fetishism for private companies and not necessarily with competitive processes. I have identified the corporate influence on the reforms to the English NHS of successive governments. Such corporate influence has ostensibly also affected the current government’s response to the pandemic. Although I have identified several potential reifying effects of government reforms to the NHS, which could undermine the solidarity which led to its creation and continuation, the adherence of the public to unprecedented rules, such as national lockdowns, during the Covid-19 pandemic, to ‘Protect the NHS’ (as government slogans state), is a palpable contemporary manifestation of such solidarity. The pandemic has also exposed the impact of persistent health inequalities. If efforts to undermine the founding principles of the NHS continue, the slogan ‘Protect the NHS’ will persist as a powerful means of providing an immanent critique of government policies. Additionally, growing awareness of health inequalities may lead to increased clamour for more action than government promises and statutory duties.
 Rahel Jaeggi, ‘Rethinking Ideology’, in Boudewijn de Bruin and Christopher F. Zurn (eds.), New Waves in Political Philosophy (Basingstoke: Palgrave Macmillan, 2009), 63.
 Michel Foucault, Power/Knowledge: Selected Interviews and Other Writings, 1972–1977 (Brighton: Harvester Press, 1980), 118.
 Gilles Deleuze and Felix Guattari, A Thousand Plateaus (London: Continuum, 1987), 76.
 Trevor Purvis and Alan Hunt, ‘Discourse, Ideology, Discourse, Ideology, Discourse, Ideology...’, The British Journal of Sociology, 44(3) (1993), 498.
 David Hawkes, Ideology: 2nd Edition (London: Routledge, 2003), 156.
 See, for example, Charles A. Prusik, Adorno and Neoliberalism: The Critique of Exchange Society (London: Bloomsbury Academic, 2020); Deborah Cook, Adorno, Foucault and the Critique of the West (London: Verso, 2018).
 Peter E. Gordon, Espen Hammer, and Max Pensky (eds.), A Companion to Adorno (Hoboken, NJ: Wiley, 2020).
 See Theodor Adorno, ‘Ideology’, in Frankfurt Institute of Social Research (ed.), Aspects of Sociology, (London: Heinemann, 1973), 202.
 David Benbow, ‘An Adornian Ideology Critique of Neo-liberal Reforms to the English NHS’, Journal of Political Ideologies 26(1) (2021), 59–80.
 Great Ormond Street Hospital v Constance Yates, Chris Gard and Charles Gard (A Child by his Guardian Ad Litem)  EWHC 972 (Fam) .
 Alder Hey Children’s NHS Foundation Trust v Mr Thomas Evans, Ms Kate James, Alfie Evans (A Child by his Guardian CAFCASS Legal)  EWHC 308 (Fam) .
 David Benbow, ‘An Analysis of Charlie’s Law and Alfie’s Law’, Medical Law Review 28(2) (2020), 227.
 Children Act 1989, S.1(1).
 See Theodor Adorno, and Max Horkheimer, Dialectic of Enlightenment (Stanford: Stanford University Press, 2010), xvi.
 Benbow, ‘An Analysis’, 237–8.
 Theodor Adorno, The Psychological Technique of Martin Luther Thomas' Radio Addresses (Stanford, CA: Stanford University Press, 2010).
 The World Health Organisation (WHO) declared this to be a global health threat in 2019. See WHO, ‘Ten threats to global health in 2019’, available at https://www.who.int/news-room/feature-stories/ten-threats-to-global-health-in-2019 (accessed 29 October 2020).
 Adorno and Horkheimer, Dialectic of Enlightenment, 141.
 Adorno, ‘Ideology’, 202.
 Deborah Cook, ‘Adorno, Ideology and Ideology Critique’, Philosophy & Social Criticism 27(1) (2001), 10.
 Anita Chari, A Political Economy of the Senses: Neoliberalism, Reification, Critique (New York, NY: Columbia University Press, 2015), 144.
 David Held, Introduction to Critical Theory: Horkheimer to Habermas (Cambridge: Polity, 2004), 220.
 Chari, Political Economy of the Senses, 144.
 John Torrance, Estrangement, Alienation and Exploitation: A Sociological Approach to Historical Materialism (Basingstoke: Macmillan, 1977), 315.
 Rahel Jaeggi, ‘Solidarity and Indifference’, in Ruud ter Meulen et al (eds.), Solidarity and Health Care in Europe (London: Kluwer, 2001), 291.
 Alec Merrison, Report of the Royal Commission on the National Health Service, Cmnd 7615. (London: HMSO, 1979), 298.
 Albert O. Hirschman, Exit, Voice and Loyalty: Responses to Decline in Firms, Organisations and States (Cambridge, MA: Harvard University Press, 1970).
 Via the National Health Service and Community Care Act 1990.
 Department of Health, Working for Patients (London: Stationery Office, 1989), 3–6.
 Marianna Fotaki, ‘The Impact of Market-Oriented Reforms on Choice and Information: A Case Study of Cataract Surgery in Outer London and Stockholm’, Social Science & Medicine 48(100 (1999), 1430.
 Department of Health (DOH), Principles and Rules for Co-operation and Competition (London: DOH, 2007), 10.
 For example, the word consumer appeared more in Labour’s health policy documents than in its policy documents for other policy areas. See Catherine Needham, The Reform of Public Services under New Labour: Narratives of Consumerism (Basingstoke: Palgrave, 2007), 115.
 John Clarke, Janet Newman, and Louise Westmarland, ‘Creating Citizen-Consumers? Public Service Reform and (Un)willing Selves’ in Sabine Maasen and Barbara Sutter (eds.), On Willing Selves: Neoliberal Politics vis-à-vis the Neuroscientific Challenge (Basingstoke: Palgrave, 2007), 136.
 Anna Dixon, Patient Choice: How Patient’s Choose and How Providers Respond (London: Kings Fund, 2010), 20.
 NHS Act (2006), S.13I and S.14V as amended by HSC Act (2012), S.23 and S.25.
 National Health Service (Procurement, Patient Choice and Competition) Regulations (No.2) (S.75 Regulations), SI 2013/500.
 Directive 2014(24) EU of the European Parliament and of the Council of 26 February 2014 on Public Procurement and repealing directive 2004/18/EC, OJ L. 94, 28 March 2014. This was implemented in the UK via the Public Contracts Regulations, SI 2015/102. Such regulations are still in force.
 D. West, ‘CCGs open services to competition out of fear of rules’, Health Services Journal, 4 April 2014.
 Theodor Adorno, Lectures on Negative Dialectics: Fragments of a Lecture Course 1965–1966 (Cambridge: Polity, 2008), 127.
 Chris Ham et al., The NHS under the Coalition government part one: NHS Reform (London: Kings Fund, 2015), 18.
 Theodor Adorno, Negative Dialectics (New York: Continuum, 1973), 309.
 Raymond Williams, Marxism and Literature (Oxford: Oxford University Press, 1977), 122.
 David Benbow, ‘The sociology of health and the NHS’, The Sociological Review 65(2) (2017), 416.
 NHS Act (2006), S.43(2A) as amended by Health and Social Care (HSC) Act (2012), S.164(1).
 Department of Health and Social Service (DHSS), Inequalities in Health: Report of a Research Working Group (London: DHSS, 1980).
 Clare Bambra, Health Divides (Bristol: Policy Press, 2016), 185.
 For example, the Secretary of State for Health is required to have regard to the need to reduce health inequalities in exercising their functions (NHS Act (2006), S.1C as amended by the HSC Act (2012), S.4.) and NHS England and CCGs are required to have regard to the need to reduce inequalities in respect of access (NHS Act (2006), S.13G(A) and S.14T(A) as amended by HSC Act (2012), S.23 and S.25) and outcomes (NHS Act (2006), S.13G(B) and S.14T(B) as amended by HSC Act (2012), S.23 and S.25).
 Clare Bambra, ‘Conclusion: Health in Hard Times’ in Clare Bambra (ed.), Health in Hard Times: Austerity and Health Inequalities (Bristol: Policy Press, 2019), 244.
 Chris Thomas, Resilient Health and Care: Learning the Lessons of Covid-19 in the English NHS (London: Institute for Public Policy Research, 2020), 3.
 Hugh Alderwick et al., Sustainability and Transformation Plans in the NHS: How are they being developed in practice? (London: Kings Fund, 2016), 7.
 Ruth Robertson and Leo Ewbank, Thinking Differently about Commissioning (London: Kings Fund, 2020).
 Allyson M. Pollock and Peter Roderick, ‘Why we should be concerned about Accountable Care Organisations in England’s NHS’. British Medical Journal 360 (2018).
 Benbow, ‘The sociology of health and the NHS’, 420.
 British Medical Association (BMA), The role of private outsourcing in the Covid-19 response (London: BMA, 2020), 4.
 Benbow, ‘An Adornian Ideology Critique’, 66, 68.
 Peter Geoghegan, ‘Cronyism and Clientelism’, London Review of Books 42 (2020).
 Abi Rimmer, ‘Covid-19: Tackling health inequalities is more urgent than ever, says new alliance’. British Medical Journal 371 (2020).