by Es Will
Contents
In his 1998 ‘Seeing like a State’, James C Scott examined the historical features of attempts to transform societies by intransigent central authority, like Bolshevism in post World War 1 Russia.1 Leaving aside the philosophical idealisations of such attempts, and the social/economic crises that permitted them, he emphasised the need to describe populations, as a preliminary to their subjugation by irresistible policies. He examined how the structures of the populations to be reorganised were standardised to allow political control. Their Description had to go hand in hand with prescribed change, or non-medical Prescription. He gave two historical examples.
A quote from the late 17th century French polymath and prolific military architect of Louis XIV, Vauban, relates to Description.2 We can assume that in planning a fortification, Vauban will have scrutinised the strategic sites minutely, and this habit of description carried over into his even-handed social perspective. He was well aware of the importance of description as a basis of prescription, but unfortunately, his subsequent recommendations of census and class-indifferent taxes were not to the taste of the pre-Enlightenment French court!
The other example was of Prescription to standardise, using the attempts at a predictable wood supply to be achieved through regimented tree planting in commercial forestry. Standardisation permits much simpler imposition of any prescribed processes, in commerce or human affairs. The price turns out to be a loss of resilience.
Scott identified that sustained coercive political policies will create populations that reflect the initial ideal descriptions in detail, but pari passu, that typically narrow prescriptions left a residue of parallel, multidimensional civic cultures. The attempt to simplify social roles to make them readable (‘legible’) for political and practical management exposed ‘illegible’ social elements at an intermediate level. For typically incomplete political prescriptions those elements, like private plots on collective farms, could allow a submission to authority by offering an alternative effectiveness. They also offered subtle opportunities to resist political models, without dire consequences. The inefficacy of a ‘work to rule’, the rule being a prescribed modus operandi, is a case in point, or the observation that the NHS ‘works’ despite, not through, its formal structures. Patterns of organisation are not necessarily the critical factors in ensuring performance and may need to be rescued by hidden skills.
Less radical transformations are being attempted all the time in peacetime civic cultures, for example in the professions. The formal bodies representing clinical subspecialties have periodically to lead their constituencies into novel processes and relationships. In the UK such moulding is necessarily in tandem with NHS management and government policy. It is of interest to examine the trajectory of Renal Medicine in the late twentieth century in the light of Scott’s work, since major changes were wrought, involving description and prescription, to both stabilise clinical practice and then shift clinical attitudes towards idealised, high-level, academic and professional goals.
The analogy of ‘seeing like a specialty’ with ‘seeing like a state’ needs caveats. The largely voluntary nature of professionals is in obvious contrast to dependent national populations. The specialty central authority, in this case the Renal Association (RA), has a foot in both legible and illegible camps, being responsible for development of the specialty through forms of prescription but also serving the vital interests of its constituency of nephrologists, its kith. The ability of professional bodies to prescribe change depends on a range of contingencies, including clinical consensus and perceptions of desirable development. There is obvious potential to influence professional beliefs and attitudes from a central perspective, ‘seeing like a specialty’. In general, their proposals need to be acceptable to a constituency through a brokerage, to appear to offer strong recommendations rather than impositions. The initial RA ambivalence about Standards versus Guidance in their compiled clinical suggestions illustrated the point.3 Also, professional and governmental interests always need reconciliation. There are multiple ‘constituencies’ to assuage in voluntary systems.
The core functional (standard) entity of renal replacement in UK healthcare was the renal unit, analogous to the hamlets of a predominantly agrarian state. They were uniform in the overall clinical function of renal replacement and nephrological provision, and so were partly ‘legible’. However, each UK unit was burdened with historical, often intractable, issues regarding resources, NHS relationships, accommodation, and so on. Not all were in the same state of development and staffing was not nationally determined. What is more, the historical piecemeal establishment around a core of nephrologists had created heterogeneity in day-to-day processes, through necessary improvisation and parochial preferences. The interests motivating senior staff were varied and variously pursued. Despite commonality of clinical IT, information infrastructures were locally determined, by topography and intuition. These factors leant an illegibility to each unit and their staff complement, which justified my label elsewhere of an ‘archipelago’ of clinical units in the ocean of the UK NHS.4
It is relevant to examine the timing and interactions of the incidental descriptions and prescriptions in the development of the specialty, to clarify the strengths and weaknesses of the historical consensus approaches and their consequences. It turns out that there were two, at least, uncharacterised responses to specialty prescription, which are the subject of further associated essays.
Unlike historical populations that were vulnerable, through crises, to radical political solutions, renal unit clinical staff went into the 1990s from a position of frustrated dissatisfaction with inadequate resources. In fact, patient demand for renal replacement had been managed (albeit uncomfortably) across the 1980s but the RA was drawn finally to express concern politically. The workloads and unit expansions prompted RA-sponsored epidemiological surveys of the status quo, to create a quantitative ‘situational awareness’ for both the RA and the NHS. That snapshot enabled the successful recruitment of further government resources after 1990.5 Thus, one version of (professionally-initiated) description had indeed preceded and subsequently served desirable (governmental) prescription!
[Both the specialty and government seemed to need the confidence of numerical certainty before promoting an expensive investment. The phrase situational awareness seems to have developed especially from modern aerial combat but has many cultural ties. It is a crucial function of vision and the biological basis of human ocularcentrism.6,7]
The predominant professional focus had then shifted, towards establishing the quality and outcomes of renal replacement treatment and wider nephrological management. It was serving that perspective that introduced elements of prescription to within the axis of the RA and profession.
I previously explored the introduction of high-level cultural prescriptions, like Evidence-based Medicine (EBM) and Continuous Quality Improvement (CQI), into UK renal units as a reversal of academic ethnographic methods applied to the notional renal archipelago of the NHS.4,8 A particular example was the insistence on the local rehearsal of a medical audit culture in the early 1990s. This centrally imposed diktat, by the Royal Medical Colleges and government, was absorbed largely as a manageable gale in the NHS weather. It was followed by a lower pressure, but sustained, climate for change in the processes of CQI, latterly in the post-millennial National Service Framework (NSF). The information necessary for these prescribed activities arrived with the building of the UK Renal Registry (UKRR) after 1995, a cornucopia of reported data, which advertised a situational awareness of national renal replacement to clinical renal practitioners. That awareness was inserted into the pursuit of the prescribed, high level, cultural novelties of EBM and CQI.8 By the millennium then, the national specialty description was catching up with maturing official prescriptions.
The questions posited by EBM and CQI suited the academic aspirations of clinicians, being irresistible in clinical logic (until experience exposed the conundrum of group vs individual clinical management, for example). The specialty consensus allowed the government to use academic idealisations, then and subsequently, to hold professional ‘noses to the grindstone’. That manoeuvre served as the organisational diversion desired by government and the NHS, at a time of another ideological upheaval of healthcare (the Purchaser-Provider split), easing clinicians out of critical management/leadership. However, the voluntary nature of nephrological organisation remained in contrast to a vulnerable citizenry of a nation state example, since any medical specialty might have reacted quite differently to central diktat than a civil population. Indeed, subsequent specialty-derived descriptive collaborations, like surveys of vascular access and infection control, were clinical in origin (albeit prompted, again, from international epidemiological observations).
It is possible to adopt the perspective of the political transformation of a state to clarify the trajectories of clinical specialties, for example Renal Medicine in the 1990s. “Seeing like a specialty” is moot. The two basic components are description and prescription. There must be caveats about the nature of the prescribers (those ‘doing’) and the populations (the ‘done-to’), especially the careful management of voluntary involvement as opposed to the prescriber carte blanche of irresistible political coercion. There are standardisations involved in each case. A division between what can be known, as ‘legible’, and a complex residue of prescription that is not apparent, as ‘illegible’, is inevitable.
The potential for novel professional relationships and tacit discontent can be inferred for Renal Medicine. They will be the topics of a further discussion.
Last Updated on May 16, 2026 by John Feehally