Table Of ContentCare in the Iron Cage
This book explores two public sector scandals in the UK, drawing on
Max Weber’s thought on ‘the iron cage’ to understand how these cases of
patient-neglect in NHS hospitals and failures by police and social workers
to address the organised sexual exploitation of young girls occurred.
Through examination of the management failures and institutional
vulnerabilities, and with attention to the trends of bureaucratisation and
rationalisation that characterised both scandals, it reveals the explanatory
power of Weber’s thought, developing a theoretical model that updates
and extends Weber’s work in light of the cases discussed. The final chapter
examines the response to the COVID-19 pandemic and highlights how the
focus on a rational techno-medical solution to the pandemic offered by the
vaccines together with bureaucratic expansion has created an authoritarian
and totalitarian society which represents the ultimate realisation of Weber’s
iron cage.
Showing that ordinary people, including professionals, are still trapped
in the ‘iron cage’, it will appeal to scholars of sociology and social theory, as
well as those providing training and working within the caring and service
professions of policing, social work and nursing.
Rowena Slope is a Senior Lecturer in adult nursing based in the UK. Her
clinical experience includes working as an Emergency Nurse in an Emergency
Department while her doctorate analysed handover communication between
prehospital and hospital receiving staff.
Classical and Contemporary Social Theory
Classical and Contemporary Social Theory publishes rigorous scholarly
work that re-discovers the relevance of social theory for contemporary
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without being confined to a single discipline. As such, work from across the
social sciences is welcome, provided that volumes address the social con-
text of particular issues, subjects or figures and offer new understandings
of social reality and the contribution of a theorist or school to our under-
standing of it.
The series considers significant new appraisals of established thinkers or
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retical approaches. Contributions are welcome that assess broad strands of
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ings of social issues and contexts.
Series Editor:
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Titles in this series:
Masculinity from the Inside
Gender Theory’s Missing Piece
Bruce Fleming
Care in the Iron Cage
A Weberian Analysis of Failings in Care
Rowena Slope
For more information about this series, please visit: https://www.routledge.
com/sociology/series/ASHSER1383
Care in the Iron Cage
A Weberian Analysis of
Failings in Care
Rowena Slope
First published 2023
by Routledge
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© 2023 Rowena Slope
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British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
Names: Slope, Rowena, author.
Title: Care in the iron cage: a Weberian analysis of failings in care /
Rowena Slope.
Description: Abingdon, Oxon; New York, NY: Routledge, 2023. |
Series: Classical and contemporary social theory | Includes
bibliographical references and index.
Identifiers: LCCN 2022025187 (print) | LCCN 2022025188 (ebook) |
ISBN 9781032154084 (hbk) | ISBN 9781032182957 (pbk) |
ISBN 9781003253907 (ebk)
Subjects: LCSH: Social sciences--Philosophy. | Child sexual abuse--
Great Britain. | Weber, Max, 1864-1920.
Classification: LCC H61 .S5875 2023 (print) | LCC H61 (ebook) |
DDC 300.1--dc23/eng/20220906
LC record available at https://lccn.loc.gov/2022025187
LC ebook record available at https://lccn.loc.gov/2022025188
ISBN: 9781032154084 (hbk)
ISBN: 9781032182957 (pbk)
ISBN: 9781003253907 (ebk)
DOI: 10.4324/9781003253907
Typeset in Times NR MT Pro
by KnowledgeWorks Global Ltd.
Contents
List of Tables vi
Introduction 1
1 Life, Times and Works of Max Weber (1864–1920) 16
2 Relevant Applications of Max Weber’s Work 23
3 New Managerialism at Mid Staffordshire and Rotherham 35
4 Professional Indoctrination 54
5 Regulatory Compromise 71
6 Acts of Violence 84
7 Human Fragility 97
8 Sensory Deprivation 109
9 Going Forward 118
10 Conclusion 131
COVID-19 Afterword 136
References 152
Bibliography 169
Index 172
List of Tables
4.1 Preventing and Dealing with Dual Loyalty 58
9.1 A Summary of Common Factors between Rotherham and
Mid Staffordshire, Identifying Possible Improvements 129
A.1 Yellow Card Data by COVID-19 Vaccines and Associated
Reactions 143
Introduction
Personal and Professional Biography
I am a Registered General Nurse with the Nursing and Midwifery Council
(NMC) and have worked in a range of clinical settings and higher education
in the UK. The inspiration for writing this book came from working as an
Emergency Nurse in a National Health Service (NHS) Foundation Trust
hospital. At that time, a report had been released concerning poor care
and neglect by healthcare professionals in a hospital in Mid Staffordshire,
England, which was estimated in media reports to have led to 800–1200
deaths. Upon reading the report, I could relate to the vulnerabilities and
hazards faced by patients caught up in these difficult circumstances and
wondered how healthcare professionals could have been implicated in
treating patients so poorly. At the same time, I recognised the pressures
faced by staff trying to deliver care in the context of new managerialism,
especially, performance management tasks. These targets were set by
central government and were designed to improve patient care and save
costs. The most recognisable target was the four-hour target whereby a
certain percentage of patients attending an Emergency Department (ED)
or Accident and Emergency (A&E) Department (known as the Emergency
Room in the USA) had to be seen, treated, discharged or admitted within
four hours. Hospitals were incentivised to meet these targets in order to
gain the coveted Foundation Trust status and the financial independence
that accompanied it whilst hospitals that failed to meet the targets faced
financial penalties.
The introduction of new managerialism led to unintended consequences
as some hospitals cut frontline staff members to unsustainable numbers and
huge pressure was brought on frontline healthcare professionals to meet
the targets. This produced constant moral dilemmas about who to treat
and when, exacerbated by the chronic staff shortages, and the ever clicking
clock. I could relate to the suffering of patients and staff caught up in an
institutional setting that was not conducive to promoting health and well-
being, or the delivery of holistic nursing care, and the acute vulnerability of
dementia patients in particular in such institutionalised settings.
DOI: 10.4324/9781003253907-1
2 Introduction
Hospitals can be a potentially hazardous place for any patient. Every day
spent on a hospital ward increases risks associated with muscle atrophy,
blood clots, hospital acquired infections, gastrointestinal disruptions, med-
ical and nursing errors, and institutionalisation. Hospital routines disrupt
circadian rhythms whilst patient identity and autonomy are eroded by a lack
of personal effects and access to individual grooming routines. A variety of
environmental hazards and architectural constraints exacerbate a sense of
disorientation. These include fixtures, fittings, ward layout, excessive noise
and a lack of natural light. Privacy and dignity is constantly challenged
by proximity to other beds, thin curtains and revealing hospital gowns.
Combining these factors together, hospital wards can be a dehumanising
place even with great nursing and medical care. However, the risks asso-
ciated with admission increase when organisational cultures are focused
on targets introduced by new managerialism rather than delivering quality
care, defined here as care that is safe, effective, individualised and holistic. A
focus on quantitative targets compromises quality care and leaves staff and
patients at risk of dehumanisation. Hospitals are essentially hierarchical
bureaucratic organisations and when managers far removed from frontline
services focus on quantitative outputs then dysfunctional and bullying cul-
tures can emerge.
Around the same time as the report into Mid Staffordshire was released,
a journalist called Andrew Norfolk published an investigation in the Times
newspaper on organised Child Sexual Exploitation (CSE) by criminal gangs
in Rotherham, England. Child Sexual Exploitation is defined as:
a form of sexual abuse. It occurs where an individual or group takes
advantage of an imbalance of power to coerce, manipulate or deceive a
child or young person under the age of 18 into sexual activity (a) in
exchange for something the victim needs or wants, and/or (b) the finan-
cial advantage or increased status of the perpetrator or facilitator. The
victim may have been sexually exploited even if the sexual activity
appears consensual. Child sexual exploitation does not always involve
physical contact; it can also occur through the use of technology.
(HM Government, 2018, p. 107)
An independent report was commissioned by Rotherham Metropolitan
Borough Council known as the Jay Report (2014) which identified repeated
failure by public sector services including the criminal justice system, social
services and local councils to disrupt the activities of these gangs or to pro-
tect vulnerable young people and their families from sexual exploitation,
intimidation and violence. It was estimated that around 1400 children and
young people were victims of this organised abuse between 1997 and 2013
(Jay, 2014, p. 1).
At first glance, there seems nothing obvious linking patient neglect at
Mid Staffordshire and CSE in Rotherham. However, closer examination of
Introduction 3
the multitude of reports into these two cases reveals striking similarities in
regard of organisational dysfunction and the failure of caring profession-
als. Victims of CSE faced similar hazards as patients at Mid Staffordshire
hospital in relation to dehumanisation, and vulnerability increasing on
contact with state institutions. Moreover, a common theme appeared to
be new managerialism which was introduced into the public sector by cen-
tral government in order to make services more efficient and business like.
Performance management targets were not just introduced to the NHS but
also the police service, Crown Prosecution Service (CPS) (responsible for
prosecuting criminal cases in England and Wales) and social services. The
result was that these services were primarily focused on meeting quanti-
tative targets over care delivery or public protection. At Rotherham, new
managerialism and performance management targets left victims unpro-
tected from criminal gangs whilst essentially placing the blame on victims.
The impact of new managerialism on organisations, the individuals
working for them, and the care and protection that they were tasked with
delivering, can be illuminated by the theories of Max Weber, a sociologist,
particularly his theories on rationalisation and bureaucracy. Max Weber
(1864–1920) is credited as one of the founders of modern day sociology. The
original intention of this book was to provide a comparative analysis of Mid
Staffordshire and Rotherham inspired by a Weberian approach but it soon
became apparent that Weber’s core ideas needed updating to reflect changes
brought about by modernity. This book also owes a profound debt of grat-
itude to the work of other distinguished sociologists such as Bauman and
Ritzer who developed Weber’s work to account for such diverse phenomena
as the holocaust and the McDonalds restaurant franchise.
The update on Weber’s theories to emerge from this comparative anal-
ysis of Mid Staffordshire and Rotherham are based around five themes:
Professional Indoctrination; Regulatory Compromise; Acts of Violence;
Human Fragility; and Sensory Deprivation. A chapter is devoted to each
theme and informed by relevant practical examples. The theoretical update
to Weber’s work presented in this book has explanatory value beyond
Rotherham and Mid Staffordshire, and can be used to examine the response
by governments around the world to the SARS-CoV-2 (COVID-19) pan-
demic declared by the World Health Organisation (WHO) in March 2020.
Since the emergence of this new novel virus in the human population, gov-
ernments have responded with lockdowns, masks and vaccine mandates
based on a limited evidence base but supported by technological organisa-
tions and media outlets. Despite an Infection Fatality Rate of less than 0.2%
(ONS, 2021) authoritarian actions have become more entrenched leading to
increased totalitarian and authoritarian responses. Other casualties have
been parliamentary democracy, the rule of law, medical ethics and quality
care. Therefore, a supplementary chapter has been included as an afterword
to demonstrate the utility of this theoretical update to Weber’s work reflect-
ing on these events.
