Sociology of Health & Illness Vol. 21 No.6 1999 ISSN 0141–9889, pp.

759–777

The gaze and visibility of the carer: a

Foucauldian analysis of the discourse of informal
care
Janet Heaton
Social Policy Research Unit, University of York

Abstract Working from a Foucauldian perspective, this paper examines

the discourse of informal care and addresses three questions.
When was it first possible to speak of ‘the informal carer’? What
are the characteristics of the discourse of informal care? And,
what are the conditions of the possibility of the informal carer’s
recognition? Following an analysis of the appearance and
conceptualisation of the informal carer in policy and related
discourse since the 1970s, the visibility of this figure is situated in
the context of the historical transformation of the medical gaze.
It is argued that two broad axes of the gaze’s ongoing transfor-
mation—its devolution to ‘relays’ and its extension to the whole
population and the ‘whole person’—underpinned the shift in
emphasis from care in the community to care by the community
in the 1970s, and the associated development of the discourse of
informal care.

Keywords: Foucault, medical gaze, discourse, informal care

Introduction

Thirty years ago ‘informal carers’, or ‘carers’ as they are now more gener-
ally known, were unheard of. Following their emergence in the 1970s, it was
only in the 1980s and 1990s that individuals, usually family members, who
provide unpaid assistance for their dependant relatives living in the commu-
nity, became widely recognised and defined by a discourse of informal care.
In particular, carers became established as a prominent group on the health
and social care policy agenda, culminating in 1996 when they were made the
exclusive object of policy for the first time with the implementation of the
Carers (Recognition and Services) Act 1995 (Department of Health 1995a).
While there is an extensive literature documenting the prevalence, nature
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Oxford OX4 1JF, UK and 350 Main Street, Malden MA 02148, USA.
760 Janet Heaton

and experience of informal caring (see, for example, Green 1988, Parker
1990, 1993, Twigg 1992, Parker and Lawton 1994, Twigg and Atkin 1994),
the rise of the carer figure on the policy agenda has not been examined to
the same degree. As Prior has noted, theories of the development of commu-
nity care have also failed to explain why the discourse of informal care
‘made a pronounced appearance’ at this time (1991: 485).
In this paper, I apply a Foucauldian perspective to examine the enigma of
the carer’s emergence as an object of health and social care policy and prac-
tice. Unlike much empirical work focused upon this group, which typically
discovers previously unrecognised carers or exposes hidden dimensions of
informal caring, this perspective emphasises the ways in which such figures
are constructed by the discourses surrounding them (Fairclough 1992).
While the present study focuses mainly on the discourse of informal care in
policy, the relationship between this and the wider set of discourses on
and/or by carers themselves is also considered. Use of the term ‘the dis-
course of informal care’ is therefore not meant to imply that there is only
one, homogeneous form of this discourse; on the contrary, attention will be
drawn to its varied and contested nature.
Three questions are addressed which variously emerge from applications
of Foucault’s archaeological and genealogical methods (Dreyfus and
Rabinow 1982, Armstrong 1990, Fairclough 1992). When was it first pos-
sible to speak of ‘the carer’? What are the characteristics of the discourse of
informal care? And, what are the circumstances, or conditions of possibility,
of the unfolding of this discourse? These questions are addressed through an
empirical analysis of the discourse of informal care, focusing mainly on the
policy discursive domain. The analysis draws upon and amplifies previous
work by Foucauldian analysts, particularly David Armstrong (1983, 1995),
on the historical development and operation of the medical gaze in the 20th
century.
By adopting this approach I hope to develop recent work which has
begun to explore the ways in which carers are socially constructed (see for
example, Fox 1995, Keith and Morris 1995, Dean and Thompson 1996) as
well as add to the corpus of Foucauldian analyses of 20th-century medical
knowledge and practice (see, for example, Silverman 1987, Bloor and
McIntosh 1990, May 1992, Nettleton 1992, Cheek and Rudge 1994,
Armstrong 1983, 1995). In particular, I hope to add to our understanding of
the ways in which the transformation of the gaze has facilitated the visibility
of the informal carer—not in a deterministic sense—but in terms of provid-
ing the necessary mode of perception which allowed this figure to be made
manifest. The effects of the use of the discourse of informal care, for exam-
ple how it serves to engender, maintain and undermine particular figures
and configurations of care, are also considered.

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 The gaze and the visibility of the carer 761

From care in the community to care by the community

Since the turn of the century, there has been an ongoing shift in the locus of
care from the hospital to the community. This is reflected in the closure of
hospitals, reductions in the number of hospital beds, and shortening lengths
of stay in hospital (Marks, 1994), together with the parallel development of
care in the community. While early policy focused on transferring in-
patients from large scale institutions to smaller residential homes in the
community, since the 1970s the emphasis has shifted toward enabling
people to live in their own homes. Thus, services were developed which
focused upon supporting people in their domestic settings: relevant statu-
tory services included community nursing, home helps, and meals on
wheels. Voluntary services also flourished, including the Crossroads Care
Attendant Schemes which began in 1974, as well as sitting services, care
attendant, and family support schemes. In addition, Local Authorities,
Social Services Departments and Housing Departments increasingly became
involved in adapting homes and, together with District Health Authorities,
supplying aids, equipment and wheelchairs. Voluntary organisations also
became engaged in providing communication systems, such as telephones
and alarms.
The development of a mixed economy of community care has not only
been characterised by the provision of statutory and voluntary care in
people’s own homes but it has also enshrined the role of ‘the community’ as
providers of care for people living in the community. To use a phrase coined
by Bayley (1973), ‘community care’ came to mean not only care in the com-
munity but also care by the community. This shift was clearly evident in pol-
icy by the 1980s, as the following statement from the White Paper Growing
Older indicates:

Whatever level of public expenditure proves practicable, and however it is

distributed, the primary sources of support and care are informal and
voluntary. These spring from the personal ties of kinship, friendship and
neighbourhood. They are irreplaceable. It is the role of public authorities
to sustain and, where necessary, develop—but never displace—such
support and care. Care in the community must increasingly mean care by
the community (original emphasis) (Department of Health and Social
Security 1981: 3, para 1.9).

In this revised philosophy of community care particular emphasis is placed

on the role of family members, as well as friends and neighbours, as the
providers of community care; together, they are defined as ‘informal and
voluntary’ sources of support and care. Thus, it is in the context of this shift
in philosophy from care in the community to care by the community that
the discourse of informal care first emerged in health and social care policy
in the 1970s. For example, there was an early reference to carers in the
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762 Janet Heaton

White Paper Better Services for the Mentally Handicapped (Department of

Health and Social Security 1971). However, it was in the 1980s and 1990s
that the discourse flourished and the carer figure became particularly promi-
nent in policy and other related discursive domains.

The discourse of informal care

An indication of the expansion of the discourse of informal care is provided

by a simple count of references to ‘informal care’ in bibliographic databases
covering health and social care policy and practice (see Table 1). Of the
three databases examined, the earliest reference occurred in 1976 (Medline).
The table shows a limited number of references to informal care in each
database in the first half of the 1980s, followed by a large increase in the
remainder of the decade and the first half of the 1990s. The ways in which
policy makers, informal carers and researchers respectively adopted the dis-
course of informal care in the 1980s and 1990s is further considered below.

Table 1: References to ‘informal care’ in three bibliographic databases, 1976–1998

DHdata
Sociological (*only available
Medline Abstracts 1983–1998
1976–1980 1 2 —
1981–1985 3 4 27*
1986–1990 29 45 127
1991–1995 46 70 69
1996–1998 27 12 7

In policy, the discourse of informal care expanded with the publication of

various health and social care policies promoting the new philosophy of
community care. Thus, carers are recognised in Sir Roy Griffiths’ influential
report Community Care: Agenda for Action (Griffiths 1988), in the White
Paper Caring for People (Department of Health 1989a), and in the NHS and
Community Care Act (Department of Health 1990). In related policies and
guidelines on hospital discharge procedures, developed in order to facilitate
the implementation of community care, such as Discharge of Patients from
Hospital (Department of Health 1989b, 1989c), the Hospital Discharge
Workbook (Henwood 1994), and the patients’ charter standard on hospital
discharge (Department of Health 1991, Andrews et al. 1993), carers are fur-
ther recognised as key ‘stakeholders’. This view has been reiterated in the
more recent NHS guidance on meeting continuing health care needs
(Department of Health 1995b). Finally, as already noted, in 1996 carers
were for the first time made the object of policy in their own right with the
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enactment of the Carers Act, which gives specified carers the right to request
that they be assessed (Department of Health 1995a, 1996, Department of
Health and Social Services Inspectorate 1996).
With the development of the discourse of informal care in policy,
patients’ relatives, friends and neighbours are increasingly referred to, and
defined as, ‘carers’. For example, in early policy the terms ‘relatives’ and
‘carers’ were sometimes used interchangeably, as in the following example
from hospital discharge guidance:

The patient, and if appropriate, the family or carer(s) must be at the

centre of the planning process (Department of Health 1989b: para 3).

However, in the following quotation from the later Hospital Discharge

Workbook the term ‘carer’ is first defined and thereafter used as a generic
term to refer to all these individuals:

In using the term ‘carer’ we are referring to any individual who provides
informal regular help and support to another person. Often this will be a
spouse or partner, or another relative with whom they live, but on
occasions it might be a friend or neighbour (Henwood 1994: 3).

Similarly, in the more recent policy guidance to the Carers Act individuals
who care are generally referred to as ‘carers’ following the statement that:

For the purposes of the Act the term carer includes people who may or
may not be a relative and who may or may not be living with the person
for whom they are caring . . . (Department of Health 1996: 3, para 7).

In these ways, carers have become the object of policy as patients’ social
contacts have been transformed into, and made visible as, ‘carers’ by the
discourse of informal care.
Over the same period, patients’ social contacts were being re-defined as
carers by political pressure groups and organisations run by individuals who
cared for relatives. For example, in 1981, the Spinal Injuries Association
(SIA), formed by wives of men with spinal cord injuries, became the
Association of Carers. Likewise, in 1981, the National Council for the
Single Woman and her Dependants (NCSWD), established in 1965 initially
for single and later for married women looking after elderly parents, became
the National Council for Carers and their Elderly Dependants (NCCED).
Later, the two groups merged in 1988 to form the Carers National
Association (CNA) (Morris 1993). The redesignation of these groups as
organisations for carers further promoted the visibility of the carer in policy
(the CNA was, for example, instrumental in the formulation of the Carers
Act), and more generally through campaigns for carers’ needs to be better
recognised and addressed by health and social care services.
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764 Janet Heaton

In the 1980s and 1990s there was also an expansion in the informal care
research genre, which originated in the 1970s. This research has investigated
the prevalence of informal caring, developed classifications of types of caring
activities and types of carers, documented the experiences of carers, and high-
lighted the needs and preferences of particular carers (see, for example, Green
1988, Parker 1990, 1993, Parker and Lawton 1994, Twigg 1992, Twigg and
Atkin 1994). Knowledge of the carer’s situation produced through this work
has informed policy and, together with carer pressure groups, has helped to
promote and establish carers on the policy agenda. While the discourse of
informal care has been employed by policy makers, carer groups and
researchers since the 1970s, the ways in which carers have been defined
through it has varied over time, as well as within and across these different
discursive domains. This is explored further in the next section which focuses
mainly on conceptualisations of carers in policy, although how this varies
from conceptualisations employed by health and social care practitioners,
researchers and carers themselves, is also briefly considered.

Conceptualisations of the carer in policy

Dean and Thompson (1996) have drawn attention to the relatively narrow
and limiting way in which carers have been defined in policy. They argue that
the contemporary policy discourse of new public management (NPM) has
reinforced an ideology of welfare which places a moral imperative on fami-
lies, and women in particular, to function as carers. In their analysis, atten-
tion is drawn to the complex and contradictory nature of this ‘doctrine’. On
the one hand, NPM normalises the role of informal carers as the basic
providers of community care while, on the other hand, it promotes a general
philosophy in favour of user choice yet fails to offer carers a real choice over
whether or not to care. This is epitomised by the Griffiths report (1988)
which, according to Dean and Thompson, ‘stresses the key role informal car-
ers provide in welfare provision’ but does not ‘address carers as potential con-
sumers through offering alternative choices to caring’ (1996: 154).
As the subsequent analysis indicates, this conceptualisation of carers in
policy as the primary providers of care in the community still prevails.
However, in the recent policy and practice guidance accompanying the
Carers Act (Department of Health 1996, Department of Health and Social
Services Inspectorate 1996) two different conceptualisations of carers as
users or consumers of services are also apparent, one of which reinforces the
normalisation of carers as providers, while the other recognises that there
are situations in which these individuals are not best placed to care and, fur-
ther, that this role should not simply be assumed of relatives but that they
should have a say in whether or not they act as carers.

Carers as providers
The development of the discourse of informal care has been characterised
by the differentiation of the new figure of the informal carer from the estab-
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lished figure of the formal carer. Informal carers have, for example, been
distinguished as unpaid care-givers who provide care out of love and filial
piety. This is illustrated by the definition of carers in the policy guidance to
the Carers Act which explicitly omits from its remit not only paid carers but
also voluntary workers who are contracted to care:

The Act excludes from the definition of carer volunteers who provide care
as part of their work for a voluntary organisation and anyone who is
providing care by virtue of a contract of employment or any other con-
tract. This would exclude anyone who is providing personal assistance for
payment, either in cash or kind (Department of Health 1996: 3, para 7).

In addition, informal and formal carers have also been differentiated in

terms of their respective roles, with the former conceptualised as the pri-
mary providers of care in the community and the latter distinguished as the
sustainers and developers of an informal network of care provision. This is
exemplified by the following extract from the Griffiths report in which the
statutory services are positioned as secondary support services:

Publicly provided services constitute only a small part of the total care
provided to people in need. Families, friends, neighbours and other local
people provide the majority of care in response to needs which they are
uniquely well placed to identify and respond to. This will continue to be
the primary means by which people are enabled to live normal lives in
community settings. The proposals take as their starting point that this is
as it should be, and that the first task of publicly provided services is to
support and where possible strengthen these networks of carers. Public
services can help by identifying such actual and potential carers, consult-
ing them about their needs and those of the people they are caring for,
and tailoring the provision of extra services (if required) accordingly
(1988: 5, para 3.2).

This is also evident in the following statement from Discharge of Patients

from Hospital which suggests that in just a ‘minority of cases’:

the patient will need care and support on a continuing basis which cannot
be provided by family and carers without some additional help
(Department of Health 1989c: 1, para 4).

In these ways, the normalisation of patients’ social contacts as primary

providers of community care is accomplished through the polarisation of
informal and formal carers’ roles; that is, informal carers are conceptualised
as the mainstay of community care provision while formal carers are posi-
tioned as the overseers of the informal care network, providing back-up
during times of crisis or when carers are in need of coverage of relief.
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Moreover, the fact that the Carers Act is called just that, and not the
Informal Carers Act, indicates the extent to which the term ‘carer’ is now
synonymous with informal, rather than formal, carers.

Carers as users
While the emphasis of contemporary community care policies has been on
supporting dependent people in their own homes via a network of informal
care provision, increasingly services have also been directed at carers them-
selves (Morris 1993). Indeed, carers have been described as ‘the fifth user
group’ (Audit Commission 1992: 17). This conceptualisation of carers as
users or consumers of services, with needs of their own, has taken two forms
both of which are discernable in the guidance to the Carers Act. The first
and more common form recognises carers to have needs qua care-givers; for
example, where assessments are directed at carers this is primarily in order
to ascertain the viability of the caring relationship. This is exemplified by
the emphasis in the practice guide accompanying the Carers Act on the
carer’s assessment as a means of preventing the caring relationship from
breaking down (rather than, say, empowering individuals to choose whether
or not to be carers):

When undertaking a carer assessment it is important to recognise the

value of early intervention and on-going support in preventing deteriora-
tion in the carer’s and user’s welfare. In many instances, early access to
advice and practical help can minimise the subsequent need for increased
levels of service. A swift response to requests for emergency, short-term
care can alleviate carers’ anxieties and avoid a possible breakdown in the
caring arrangements and need for long term care (Department of Health
and Social Services Inspectorate 1996: 4–5, para 9.6)

Similarly, where carers are provided with support, the aim of this is to sus-
tain the caring relationship, perhaps thereby averting crises of care and so
preventing the dependent person being admitted to hospital, or deferring
the need for increased intervention from formal community care services for
as long as possible.
In contrast, the second conceptualisation of carers as users recognises
that these individuals may have health and social care needs of their own
which are separate from, and even at odds with, their role as carers. For
example, in the policy guidance to the Carers Act it is recognised that:

Carers may have community care needs in their own right by reason of
their old age, physical or mental health, physical or learning disability
(Department of Health 1996: 6, para 17).

In the following quotation from the same source both conceptualisations of

carers as users are reflected in the account of the purpose of the carer’s
assessment:
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The focus of the carer’s assessment for the purposes of this Act should be
on the carer’s ability to care and to continue caring [first conceptualisa-
tion]. The assessment should take account of the carer’s circumstances,
their age, views and preferences, the amount of support available to them.
It should not automatically assume a willingness by the carer to continue
caring, or to continue providing the same level of support [second concep-
tualisation] (Department of Health 1996: 6, para 2.1).

Thus, whereas the first part of the statement is premised on carers’ prior
conceptualisation as providers of health and social care in the community,
and so reflects the ideology of welfare outlined by Dean and Thompson, the
second recognises that not all carers will be able or willing to act in this
capacity.
To date, the recognition that carers may have needs which conflict with,
and exonerate them from, the caring role has been mainly evident in rela-
tion to carers who are children. Thus, in the policy guidance to the Carers
Act, the developmental needs of these individuals is highlighted as a matter
of particular concern. In the following quotation, the possibility that caring
could have adverse effects and conflict with their ‘normal’ role as children is
explicitly acknowledged:

Where the carer is a child the impact of caring may be different as it may
affect the child’s health and development by the restrictions that provid-
ing regular and substantial care might place on the child’s educational
and leisure opportunities. This should be carefully considered as part of
the assessment (Department of Health 1996: 7, para 22).

More generally, carers have increasingly been recognised as users on a par

with patients. For example, whereas hospital discharge policy has tended to
prioritise the latter’s needs by requiring patients to consent to carers’
involvement in discharge planning (Department of Health 1989b), the
advent of the Carers Act has given carers the right to request a separate
assessment of their needs. However, this right only extends to carers with
heavy responsibilities, namely those who ‘are either providing or intending
to provide a substantial amount of care on a regular basis’ (Department of
Health 1996: 1, para 4). In addition, the option of requesting a carer’s
assessment is only available if and when patients are assessed and it cannot
be requested at other times. Thus, while carers’ status in policy has begun to
approach that of patients, the former’s needs are still regarded as secondary
to those of the latter: patients remain the primary users of health and social
care in the community.

Conceptualisations of carers in other discursive domains

Just as these alternative conceptualisations of carers are manifest in health
and social care policy, so in other discursive domains related formulations
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768 Janet Heaton

may be discerned. For example, health and social care practitioners have
been found to conceptualise carers in four different ways (Twigg and Atkin
1994). As ‘resources’, informal carers are regarded by agencies as a free and
largely taken-for-granted primary resource of care, with the main focus on
the needs of the cared-for rather than the carer. As ‘co-workers’, informal
carers are seen more as joint providers of care alongside other agencies.
Here there is a greater emphasis on carers’ needs, albeit on an ‘instrumental’
basis. As ‘co-clients’, carers are regarded by agencies as having needs of
their own. In this model, attitudes to carers are less instrumental and they
may be the main target of interventions. Finally, in the ‘superseded’ model
of carers, agencies aim to promote and maximise the independence of both
carers and those they care for, thereby removing their status as people who
are ‘carers’ or ‘cared-for’. While these are ideal types, Twigg and Atkin
show how certain models dominate and are used by particular agencies to
different effects.
Similarly, a review of the informal care research genre suggests that
increasingly sophisticated classifications of carers have been developed as
researchers have documented different types of caring activities and differ-
ent types of carers. Thus, new or hidden groups of carers, such as children
and men have been identified (Morgan 1996). Moreover, investigations of
the experiences of these groups have revealed that the subjects of the
research—so called ‘carers’—may not define themselves as such. For exam-
ple, Beresford (1994) found that parents of disabled children did not see
themselves as ‘carers’. This finding has been acknowledged in policy to the
extent that this group are not referred to as ‘carers’ in the policy guidelines
for the Carers Act (Department of Health 1996: 3, para 6 footnote).
Similarly, Arksey et al. (1997) found that those who participated in a study
of carers’ perspectives on hospital discharge arrangements mostly did not
identify with the carer label, despite being the main provider of care for
individuals discharged home from hospital for at least four weeks post-
discharge. Rather, they preferred to think of themselves as a mother, father,
daughter or son who cared for their relatives. Thus, the discourse of informal
care mundanely employed by practitioners, researchers and carers appears
to vary within and across different discursive domains and may even be con-
tested by those to whom the category putatively applies. This includes dis-
abled people, some of whom believe that the policy focus on carers is to
their detriment in terms of restricting their choice of care arrangements and
therefore their ability to lead an autonomous lifestyle (Morris 1993).
The emergence of the discourse of informal care in the 1970s, the concep-
tualisation of carers as both providers and users of community care in pol-
icy, and the contested nature of this discourse, raises a number of issues
which are explored in the remainder of the paper. Why did the discourse of
informal care blossom at this particular historical juncture? What is the
social basis of carers’ manifold conceptualisation? What is the relationship
between the discourse of informal care and the contemporary configuration
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 The gaze and the visibility of the carer 769

of health and social care provision? And, what are the practical implications
of the discursive practices surrounding the carer figure? The subsequent
analysis draws on Foucauldian analyses of the medical gaze to address these
issues.

The medical gaze and the visibility of the carer

From a Foucauldian perspective, ‘carers’ did not exist as such prior to the
development of the discourse of informal care in policy and other discursive
domains. To understand, therefore, the emergence of the carer, one has to
examine the discursive practices through which the figure is produced. These
practices, and the structures they engender, form the conditions of possibil-
ity of the carer’s realisation. Accordingly, the emergence of the discourse of
informal care in the 1970s, and its entrenchment in the late 1980s and 1990s,
can be placed in the context of the development of the medical gaze and
associated changes in the historical configuration of health and social care
provision. Following a brief outline of the concept of the medical gaze I
shall argue first, that the shift in emphasis from care in to care by the com-
munity and the associated appearance and definition of the informal carer
was made possible by the devolution and extension of the gaze. Secondly, I
shall suggest that the manifold conceptualisation of the carer is characteris-
tic of the operation of the gaze in the 20th century.

The medical gaze in the 20th century

Foucault’s notion of the gaze has been widely discussed elsewhere (for
example, see Sheridan 1980, Armstrong 1983, Simons 1995) and hence is
only briefly summarised here. Translated from the French ‘le regard’, the
gaze is defined as a way of looking at or, indeed, hearing, smelling and
otherwise sensing or comprehending the world (Foucault 1976, 1979,
1980a). While the gaze is not a prescriptive mode of perception, it does pro-
vide historically discrete fields of view. In this way it facilitates the identifi-
cation and definition of particular subjects at certain times, which are
accomplished through associated discursive practices.
Focusing on the operation of the gaze in institutions such as the hospital
and the prison during the 19th century, Foucault describes how individuals
contained therein have been subjected to various techniques of monitoring
or surveillance since the birth of the human sciences in the late 18th century.
The exercise of the gaze is conceptualised as an act of ‘discipline’ or power,
a way of defining and regulating subjects; hence it is also broadly referred to
as the ‘disciplinary gaze’. As a variant of the gaze, the ‘medical’ or ‘clinical’
gaze refers to the ways in which the objects of medical knowledge and prac-
tices have been viewed and understood.
While Foucault’s work is mainly concerned with the operation of the gaze
in the 19th century, his analysis suggests that the gaze is not a fixed way of
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770 Janet Heaton

looking at the world; rather it is malleable and dynamic, capable of identify-

ing and redefining new objects of scrutiny as alternative methods of surveil-
lance are developed. Thus, at the end of Discipline and Punish he compares
and contrasts the exercise of disciplinary power epitomised by Bentham’s
design of the Panopticon with that of the Mettray colony, suggesting that
the latter is a more ‘effective’ form of the former, owing to its ‘diffused’
state (Foucault 1979, Driver 1994). Similarly, in their more specific studies
of the development of medical knowledge and practices in the late 19th and
early 20th centuries, Armstrong (1983, 1995) and other analysts (for exam-
ple, Arney and Bergen 1984, Nettleton and Burrows 1994) have pointed to
the emergence of a distinctively new medical gaze.
In The Political Anatomy of the Body, Armstrong (1983) argues that the
shift from hospital to community health care was associated with the decline
of the Panoptic regime and the rise of the Dispensary (named after a clinic
set up in the late 19th century to monitor, treat and act as a clearing house
for people with tuberculosis). He later described this as the decline of
Hospital Medicine and the rise of Surveillance Medicine (Armstrong 1995).
Whereas one of the key characteristics of Hospital Medicine was the place-
ment, investigation and treatment of sick bodies within hospitals,
Surveillance Medicine is characterised by a new ‘spatialisation of illness’
whereby not only sick but also healthy bodies are the subjects of attention
in an ‘extracorporeal space’. With this ‘problematisation of the normal’ the
gaze is turned outward on to the general population (Armstrong 1995: 395).
Drawing on these various analyses of the development of the medical gaze,
two particular aspects of the gaze’s transformation in the 20th century are
described below which, I shall argue, form the conditions of possibility for
the shift in emphasis from care in to care by the community, and hence the
development of the discourse of informal care.

The devolution of the gaze

In Discipline and Punish Foucault (1979) argues that the exercise of the
modern disciplinary gaze depends on both its interiorisation by, and devolu-
tion to, the objects of surveillance. In this way, the gaze is not uni-direc-
tional, imposed by some over others, but circulates through a network of
pyramidal social relations. Thus, in his view, the functioning of modern
methods of surveillance is:

. . . that of a network of relations from top to bottom, but also to a

certain extent from bottom to top and laterally; this network ‘holds’ the
whole together and traverses it in its entirety with effects of power that
derive from one another: supervisors, perpetually supervised (1979:
176–77).

However, as Foucault implies in the above quotation, although power does

tend to flow in different directions, it does so more strongly in some direc-
© Blackwell Publishers Ltd/Editorial Board 1999
 The gaze and the visibility of the carer 771

tions than others. Within this disciplinary matrix, people can exert power, be
the subjects of power, and may resist it, for in this model individuals are nei-
ther ‘empowered’ nor ‘disempowered’ but are active mediators of the gaze.
By operating through more generalised networks of surveillance, such as
the family, rather than more structured hierarchies of observation, such as
the state, the vicarious authority of the medical gaze has allowed individuals
increasingly to become implicated in the monitoring of their own bodies
and, more importantly from the point of view of this paper, engaged as
‘relays’ of the medical gaze in overseeing the health of those around them
(Foucault 1979: 174, see also 1980b: 177). While the devolution of the med-
ical gaze to the family was evident as early as the 18th century when parents
were identified as the guardians of their children’s health (Donzelot 1977,
Foucault 1980b), this role has become more established in the 20th century
with the development of welfare services to monitor, support and, where
necessary, cover the role of parents and, in particular, the mother. For
example, in a study of the operation of the dental gaze in the 20th century,
Nettleton (1991, 1992) has shown how mothers have been recruited by the
dental profession to help govern or watch over the health of the child’s
teeth, thereby creating a ‘network for dental productivity between the den-
tist, the teacher, the health visitor, and the mother and infant’ (Nettleton
1992: 58). This network forms the basis for a more participatory style of
government or regulation of the social body in which the subjects of the
gaze will ideally ‘exercise power over themselves’ (Nettleton 1991: 101).
With the ongoing devolution of the medical gaze in the 19th century, fam-
ilies were involved in caring for their dependent relatives in the community
in local, ad hoc networks of private and public welfare provision (Horden
and Smith 1998). However, it was only with the advent of community care
and, in particular, the emphasis in the 1980s and 1990s on care by the com-
munity, that this care came to be provided under the tutelage of formal
carers in a complex, integrated network of community care provision. At
the same time, the caring relationship between the cared-for person and the
care-giver in the community became the object of the medical gaze, and ‘the
carer’ was discovered (of which more below).
The establishment of the carer as a relay of the medical gaze is reflected in
their conceptualisation in health and social care policy as the primary
providers of community care. As noted earlier in the paper, formal carers
have been distinguished as the facilitators of this care network while infor-
mal carers have been defined as the direct, ‘hands on’ providers of this care.
So positioned, informal carers’ relationships with, on the one hand,
patients, and, on the other, formal service providers, exemplify contempo-
rary disciplinary practices using relays: the informal carer is the supervisor
of the person they care for, in turn supervised by the statutory health and
social care services. In the next section, the circumstances that enabled this
caring relationship to become the object of the medical gaze, and the carer
to be perceived as a user as well as a provider of care, are further examined.
© Blackwell Publishers Ltd/Editorial Board 1999
772 Janet Heaton

The extension of the gaze

According to Armstrong (1983, 1995) the transformation of the medical
gaze since the late 19th century has been marked by a new conceptualisation
of disease. Whereas in the 18th century the medical gaze was concerned with
the anatomy of the individual diseased body, by the late 19th century it
‘identified disease in the spaces between people, in the interstices of relation-
ships, in the social body itself’ (Armstrong 1983: 8). Related to this, medical
subjects were no longer divided or classified according to whether they were
‘ill’ or ‘healthy’; rather, they existed in a state of ‘precarious normality’
where, if not ill, they were still regarded as having the potential to so
become (Armstrong 1995: 403). Accordingly, not only patients located in
hospitals, but the population in general became the objects of an extended
medical gaze.
The extension of the medical gaze into the community was accompanied
by new methods of investigating the health of the population as a whole and
the health status of individual subjects. Through surveys of the population
(Armstrong 1983) it became possible to identify and define particular
groups and individuals as being ‘at risk’ from socially or genetically
acquired diseases. In addition, Armstrong (1983) and Arney and Bergen
(1984) have pointed to a more recent shift in medical practices since the sec-
ond world war, moving from a relatively narrow concern with the physically
impaired body to a wider interest in the psycho-social status of individuals
as well. Thus, whereas in the course of the old clinical examination patients
were treated as ‘docile’ objects, today patients’ subjective health status is a
matter of interest, and, now encouraged to speak, they have become more
active participants in the medical encounter. This is reflected in the growing
emphasis in health and social care policy on the need for users’ views to be
given more regard in the planning and delivery of health service provision
(Nettleton and Burrows 1994).
The concomitant development of these new methods of surveillance
enabled those who provided care, as well as those who received it, to be
recognised as the co-object of health and social care practices in various
ways. First, in focusing on patients located in the community, their
domestic and social relationships were made visible to practitioners. Thus,
according to Armstrong the extension of the medical gaze promoted a
growing:

. . . emphasis on the close scrutiny of details of patients’ contacts and

relationships, and the creation of a thorough record of family networks,
friends and acquaintances through which to co-ordinate home visits,
checks and follow ups (1983: 8).

In this way, patients’ social contacts increasingly became the object of for-
mal care providers’ practices, as provision became centred on the home. The
closer relations and liaison between patients’ families and community-based
© Blackwell Publishers Ltd/Editorial Board 1999
 The gaze and the visibility of the carer 773

practitioners confirmed them as allies in the new system of provision of

health and social care for patients cared for in the community.
Secondly, reflecting the new outlook of the medical gaze upon the whole
population, the health of patients and their social contacts were, for the first
time, regarded as inter-related concerns. This is reflected in the ways in
which carers have been conceptualised as users in health and social care pol-
icy. Thus, as described earlier in this paper, the main emphasis of policy has
been on supporting carers in their role as the primary providers of commu-
nity care, and preventing the caring relationship from breaking down for as
long as possible. In addition, more recently it has also been recognised in
policy that carers may have health and social care needs of their own which
may allow them to be relieved from becoming, or continuing to act as, pri-
mary care-givers.
Finally, contemporary interest in the health of all individuals, not just the
sick, is reflected in the proliferation since the 1970s of quantitative and qual-
itative research techniques for assessing the health and wellbeing of carers.
Thus, the impact of caring on the health status of care-givers has been mea-
sured using tools specifically designed for this purpose, such as the Carers’
Assessment of Difficulties Index, the Caregiver Strain Index, and the
Relatives’ Stress Scale (Nocon and Qureshi 1996). These scales focus on lev-
els of distress or perceived strain among carers, and the impact of caring on
their psychological wellbeing. Similarly, the commissioning of qualitative
studies which place priority on describing carers’ first-hand experiences of
care-giving reflects the wider expectation that, as consumers, their views
need to be determined and incorporated in the design of contemporary
health and social care policy and practice.

Conclusion

In this paper I have suggested that the development of the discourse of

informal care in policy and other related discursive domains since the 1970s
can be understood in the context of the historical transformation of the
medical gaze. From this Foucauldian perspective, the appearance of the
informal carer figure is viewed as a manifestation of the devolution and
extension of the gaze in the 20th century. These two axes of the gaze’s trans-
formation provided the conditions of possibility for the shift in emphasis
from care in to care by the community in the 1970s, and the emergence of
the carer figure with the development of the discourse of informal care. In
addition, it has been argued that the manifold conceptualisation of the carer
as both a provider and a user of community care in policy, and the con-
tested nature of this discourse, reflects the multifarious operation of the gaze
in the 20th century. In this way carers are simultaneously established as a
‘relay’ of the gaze caring for others under the tutelage of formal carers, and
also as an object of the gaze whose own wellbeing is a matter of concern.
© Blackwell Publishers Ltd/Editorial Board 1999
774 Janet Heaton

It might be objected that by concentrating on discursive practices in this

way, other relevant social processes and imperatives have been neglected
(for a discussion of this issue see, for example, Dreyfus and Rabinow 1982,
Cain 1993). However, while discursive practices are viewed as the key means
through which social relationships and structures are produced and repro-
duced, this is not to say that the relationships and structures thus engen-
dered are immaterial. Rather, they continue to be realised, sustained and
sometimes undermined by discursive practices. Hence the emphasis in this
paper on the variable and contested nature of the discourse of informal care
which, whilst it underpins the current philosophy of community care, may
equally come to be revised, and so promote a new order of health and social
care. Indeed, as noted above, parents’ classification as ‘carers’ has been
quashed in the policy guidance to the Carers Act as a result of their resis-
tance to the label, raising questions about the very sustainability of the dis-
course of informal care.
The effects of the discourse of informal care, then, are real. The ways
in which carers are conceptualised and classified in policy can have far-
reaching implications for individuals thus defined. For example, individuals
may be included or excluded from certain rights or opportunities or benefits
which apply to carers but not non-carers, or to some but not all carers.
Thus, an understanding of the discourse of informal care is not just a ques-
tion of semantics but has significant social consequences. Accordingly,
understanding the operation of discourses of care is central to comprehend-
ing the dynamics of care-related policies and their practical consequences
for individuals.
This analysis also has implications for understanding the changing nature
of the medical gaze and its wider application. Given that the medical gaze is
no longer the sole prerogative of experts, but the shared responsibility of all,
it is questionable whether it is any longer appropriate to speak of an unal-
loyed medical gaze. Perhaps the term para-medical gaze better describes its
modus operandi in the 20th century, a gaze which operates in an increasingly
complex network, extending through and linking institutions and communi-
ties, in formal and informal circuits of surveillance.
Address for correspondence: Janet Heaton, Social Policy Research Unit,
University of York, Heslington, York YO10 5DD
e-mail: jh35@york.ac.uk

Acknowledgements

I would like to thank Sarah Nettleton and Andrew Tudor for their encouragement
and advice on this paper, as well as the anonymous referees for their comments.

© Blackwell Publishers Ltd/Editorial Board 1999

 The gaze and the visibility of the carer 775

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